What is the treatment for hypertriglyceridemia?

Treatment for Hypertriglyceridemia

For hypertriglyceridemia, the first-line treatment is improving glycemic control and implementing lifestyle modifications, followed by fibric acid derivatives (gemfibrozil or fenofibrate) for persistent elevations, with dosage individualized based on triglyceride levels and patient response. 1

Initial Assessment and Classification

• Classify hypertriglyceridemia 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

• Obtain at least two fasting lipid panels, preferably 2 weeks apart, to confirm diagnosis 1

• Evaluate for secondary causes:

  • Diabetes mellitus
  • Hypothyroidism
  • Liver disease
  • Kidney disease
  • Medications (beta-blockers, thiazides, estrogens, retinoids, antipsychotics)
  • Alcohol consumption 1, 2

Treatment Algorithm

Step 1: Lifestyle Modifications (All Patients)

• Weight reduction (target 5-10% weight loss can reduce TG by ~20%) 1
• Regular aerobic exercise (150 minutes/week of moderate-intensity activity) 1
• Dietary modifications:
  • For TG <1,000 mg/dL: Eliminate added sugars and refined carbohydrates, increase soluble fiber (>10g/day), consume fatty fish twice weekly 1
  • For TG ≥1,000 mg/dL: Very low-fat diet (10-15% of calories from fat) 1
  • For extremely high levels: <5% of total calories as fat until TG <1,000 mg/dL 1
• Alcohol reduction or elimination 1, 2

Step 2: Address Secondary Causes

• For diabetic patients: Glycemic control is first priority 3, 1
• Discontinue medications that may elevate triglycerides when possible 2
• Treat underlying conditions (hypothyroidism, liver disease, etc.) 1

Step 3: Pharmacologic Therapy Based on TG Levels

For TG 150-499 mg/dL with elevated ASCVD risk (≥7.5%):

• Consider statin therapy 1

For TG 500-999 mg/dL:

• Fibric acid derivatives (gemfibrozil or fenofibrate) 3, 1
  • Fenofibrate initial dose: 54-160 mg daily, maximum 160 mg daily 2
  • Adjust dose based on response at 4-8 week intervals 2

For TG ≥1,000 mg/dL (severe hypertriglyceridemia):

• Urgent treatment to prevent pancreatitis 1
• Fibric acid derivatives (gemfibrozil or fenofibrate) 3, 2
• Consider hospitalization if symptomatic or lipase elevated 1

Step 4: Combination Therapy for Inadequate Response

For combined hyperlipidemia:

1. First choice: Improved glycemic control plus high-dose statin 3
2. Second choice: Improved glycemic control plus statin plus fibric acid derivative 3
3. Third choice: Improved glycemic control plus resin plus fibric acid derivative 3

• Prescription omega-3 fatty acids (4g/day) can reduce TG by 25-35% as add-on therapy 1
• Combination of fibrate plus omega-3 fatty acids may be considered for inadequate response 1

Special Considerations

• Caution: The combination of statins with fibrates carries increased risk of myositis 3, 1
• For patients with renal impairment: Start fenofibrate at 54 mg daily and adjust based on response and renal function 2
• Avoid fenofibrate in patients with severe renal impairment 2
• Fenofibrate is contraindicated in patients with preexisting gallbladder disease 2
• Monitor liver and renal function with pharmacological therapy, especially when using fibrates 1

Treatment Goals

• Primary goal: Reduce TG levels below 500 mg/dL to prevent pancreatitis 1
• Final goal: Reduce TG to <150 mg/dL 1
• For patients with diabetes or cardiovascular disease: LDL cholesterol <100 mg/dL (or <70 mg/dL if cardiovascular disease is present) 1

Monitoring

• Check lipid levels after 8-12 weeks of therapy 1
• Monitor for potential increases in LDL-C levels, especially with certain medications 1
• Assess treatment efficacy and adjust therapy as needed 2
• Withdraw therapy if inadequate response after two months of maximum dose 2