What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with lifestyle modifications, followed by pharmacological therapy based on triglyceride severity levels, with fibrates being the first-line drug therapy for severe hypertriglyceridemia (≥1,000 mg/dL) to prevent pancreatitis. 1

Classification of Hypertriglyceridemia

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

Step 1: Address Secondary Causes

Before initiating specific therapy, identify and address secondary causes:

• Optimize glycemic control in diabetes patients
• Treat hypothyroidism
• Manage liver and kidney disease
• Review medications that can elevate triglycerides:
  • Beta-blockers
  • Thiazide diuretics
  • Retinoids
  • Antipsychotics
  • Estrogens/oral contraceptives 1
• Reduce or eliminate alcohol consumption 1

Step 2: Lifestyle Modifications

Lifestyle modifications are the foundation of treatment for all patients:

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

Step 3: Pharmacological Therapy Based on TG Levels

For Severe Hypertriglyceridemia (≥1,000 mg/dL)

• First-line: Fibrates (e.g., fenofibrate 54-160 mg daily) to reduce pancreatitis risk 1, 2
  • Initial dose: 54-160 mg daily with meals
  • Adjust dose based on response after 4-8 weeks
  • Maximum dose: 160 mg once daily 2
  • Provides 35-50% triglyceride reduction 1
• Alternative/Add-on: Prescription omega-3 fatty acids (4g/day) providing 25-35% TG reduction 1

For Moderate Hypertriglyceridemia (200-999 mg/dL)

• First-line: Statins if elevated LDL-C or cardiovascular risk is present (10-30% TG reduction) 1
• Add-on therapy (if inadequate response):
  • Fibrates (fenofibrate preferred over gemfibrozil when combined with statins due to lower myopathy risk) 1
  • Prescription omega-3 fatty acids 1
  • Icosapent ethyl for patients with ASCVD or cardiovascular risk factors on statin with controlled LDL-C but persistent TG 150-499 mg/dL 1

For Diabetic Patients with Hypertriglyceridemia

Treatment algorithm:

1. Improved glycemic control plus high-dose statin
2. If inadequate response: Add fibric acid derivative
3. If statin contraindicated: Consider resin plus fibric acid derivative 1

Special Considerations

Renal Impairment

• For mild to moderate renal impairment: Start fenofibrate at 54 mg/day
• Avoid fenofibrate in severe renal impairment 2

Pregnancy

• Statins are contraindicated in pregnancy
• Women of childbearing age should use reliable contraception 1

Monitoring

• Check triglyceride response after 8-12 weeks of therapy
• Monitor liver and renal function with pharmacological therapy, especially with fibrates
• Treatment goals:
  • Primary goal: Reduce TG <500 mg/dL to prevent pancreatitis
  • Final goal: TG <150 mg/dL, LDL-C <100 mg/dL, non-HDL-C <130 mg/dL 1
• Consider discontinuing therapy if inadequate response after two months at maximum dose 2

Common Pitfalls

• Failing to identify and address secondary causes before initiating pharmacotherapy
• Not emphasizing the importance of lifestyle modifications as the foundation of treatment
• Underestimating the risk of pancreatitis with severe hypertriglyceridemia (≥1,000 mg/dL)
• Overlooking potential drug interactions, particularly statin-fibrate combinations which increase myopathy risk 1
• Inadequate monitoring of liver and renal function during pharmacological therapy