What is the first line of treatment for hypertriglyceridemia?

First-Line Treatment for Hypertriglyceridemia

Lifestyle modifications are recommended as the initial treatment for hypertriglyceridemia, including weight reduction, exercise, and dietary changes. 1

Understanding Hypertriglyceridemia

Hypertriglyceridemia can be classified by severity:

• Mild: 150-199 mg/dL
• Moderate: 200-999 mg/dL
• Severe: 1,000-1,999 mg/dL
• Very severe: ≥2,000 mg/dL 1

The clinical significance varies by severity:

• Mild/Moderate levels (150-999 mg/dL): Associated with cardiovascular disease risk
• Severe/Very Severe levels (≥1000 mg/dL): Significant risk for acute pancreatitis 1

First-Line Treatment Approach

1. Lifestyle Modifications

• Weight reduction: Target 5-10% weight reduction, which can achieve a 20% reduction in triglycerides 1
• Exercise: Regular aerobic exercise (150 minutes/week of moderate-intensity activity) 1
• Dietary changes:
  • Eliminate added sugars and refined carbohydrates
  • Increase soluble fiber (>10g/day)
  • Consume fatty fish twice weekly
  • Reduce alcohol consumption (complete cessation for severe hypertriglyceridemia) 1, 2

2. Address Secondary Causes

Before initiating pharmacological therapy, identify and manage secondary causes:

• Optimize glycemic control in diabetic patients
• Treat hypothyroidism if present
• Review medications that may exacerbate hypertriglyceridemia:
  • Beta-blockers
  • Thiazide diuretics
  • Retinoids
  • Antipsychotics
  • Estrogens (oral contraceptives, hormone replacement therapy) 1

Pharmacological Treatment

If lifestyle modifications are insufficient after 2-3 months:

For Moderate Hypertriglyceridemia with Elevated LDL-C or CV Risk:

1. Statins: First-line pharmacological therapy, providing 10-30% dose-dependent reduction in triglycerides 1

For Severe Hypertriglyceridemia (≥1000 mg/dL):

1. Fibrates: Initial pharmacological therapy (e.g., fenofibrate 54-160 mg daily)
   • Can reduce triglycerides by 35-50%
   • Dosage should be individualized based on response and renal function
   • Initial dose for severe hypertriglyceridemia: 54-160 mg daily 1, 3

Add-on Therapies:

• Prescription omega-3 fatty acids (4g/day): Can reduce triglycerides by 25-35% 1
• Icosapent ethyl: Consider in patients with cardiovascular risk factors on statin with controlled LDL-C but persistent triglycerides 150-499 mg/dL 1

Treatment Goals and Monitoring

• Primary goal: Reduce triglyceride levels below 500 mg/dL to prevent pancreatitis
• Final goal: Reduce triglycerides to <150 mg/dL 1
• Monitor triglyceride response after 8-12 weeks of therapy
• Monitor liver and renal function with pharmacological therapy, especially when using fibrates 1

Special Considerations

• Renal impairment: Start with lower doses of fenofibrate (54 mg) in mild to moderate renal impairment; avoid in severe renal impairment 3
• Pregnancy: Statins are contraindicated; women of childbearing age should use reliable contraception 1
• Elderly patients: Dose selection should be based on renal function 3
• Combination therapy: Use caution when combining fibrates with statins due to increased risk of myopathy 1

Treatment Algorithm

1. Implement comprehensive lifestyle modifications for all patients
2. If triglycerides remain ≥1000 mg/dL despite lifestyle changes → Fibrate therapy
3. If triglycerides <1000 mg/dL with elevated LDL-C or CV risk → Statin therapy
4. If inadequate response to monotherapy → Consider add-on therapy with omega-3 fatty acids
5. Monitor response and adjust therapy accordingly