What is the treatment for patients with hypertriglyceridemia (high triglycerides) and hypercholesterolemia (high cholesterol)?

Treatment for Hypertriglyceridemia and Hypercholesterolemia

The treatment of hypertriglyceridemia and hypercholesterolemia requires a stepwise approach, with statins as first-line therapy for most patients, followed by targeted additional therapies based on triglyceride levels and cardiovascular risk. 1, 2

Initial Assessment and Classification

• Obtain at least two fasting lipid panels (2 weeks apart) to confirm diagnosis 2
• Classify triglyceride severity:
  • Mild: 150-199 mg/dL
  • Moderate: 200-999 mg/dL
  • Severe: 1,000-1,999 mg/dL
  • Very severe: ≥2,000 mg/dL 2
• Evaluate for secondary causes:
  • Obesity, metabolic syndrome, diabetes
  • Liver or kidney disease
  • Hypothyroidism
  • Medications (corticosteroids, estrogens, retinoids)
  • Alcohol consumption 2

Treatment Algorithm Based on Triglyceride Levels

For TG <500 mg/dL with elevated cholesterol:

1. Intensive lifestyle modifications (foundation of treatment):

   • Weight reduction (target 5-10% weight loss)
   • Regular aerobic exercise (150 minutes/week)
   • Dietary changes:
     • Eliminate added sugars and refined carbohydrates
     • Increase soluble fiber (>10g/day)
     • Consume fatty fish twice weekly 2

2. Statin therapy (first-line pharmacological treatment):

   • Provides 10-30% dose-dependent reduction in triglycerides
   • Target LDL-C <100 mg/dL (or <70 mg/dL with cardiovascular disease)
   • For primary prevention patients with 10-year ASCVD risk ≥7.5% to <20%, moderate-intensity statin therapy is recommended 1, 2

3. Add-on therapy for persistent elevated triglycerides despite statin:

   • Prescription omega-3 fatty acids (4g/day) - reduces TG by 25-35%
   • Icosapent ethyl for patients with ASCVD or other CV risk factors on statin with controlled LDL-C but persistent TG 150-499 mg/dL 2

For TG ≥500 mg/dL (primary goal is to prevent pancreatitis):

1. Very low-fat diet (10-15% of calories from fat)

   • For TG ≥1,000 mg/dL, restrict fat to <5% of total calories until TG <1,000 mg/dL 2

2. Fibrate therapy (e.g., fenofibrate 54-160 mg daily):

   • Provides 35-50% triglyceride reduction
   • Fenofibrate clinical trials showed significant reductions in triglycerides (46-54%) 2, 3
   • Caution: increased risk of myopathy, especially when combined with statins 2

3. High-dose omega-3 fatty acids (4g/day) 2

4. Combination therapy with fibrate plus omega-3 fatty acids for inadequate response 2

Monitoring and Follow-up

• Assess response to therapy after 8-12 weeks
• Monitor for potential increases in LDL-C levels with some treatments
• Check liver and renal function with pharmacological therapy, especially with fibrates
• Target goals:
  • Triglycerides <150 mg/dL
  • LDL cholesterol <100 mg/dL
  • Non-HDL cholesterol <130 mg/dL 2

Special Considerations

• Diabetic patients: Prioritize glycemic control alongside lipid management
• Pregnancy: Statins are contraindicated; women of childbearing age should use reliable contraception 2
• Severe hypertriglyceridemia: Urgent treatment needed due to high risk of acute pancreatitis 2

Common Pitfalls to Avoid

1. Focusing only on LDL-C: Both elevated triglycerides and cholesterol contribute to cardiovascular risk
2. Inadequate lifestyle intervention: Lifestyle changes are the foundation of treatment and should be emphasized before and during pharmacological therapy
3. Overlooking secondary causes: Treating underlying conditions can significantly improve lipid profiles
4. Insufficient monitoring: Regular follow-up is essential to assess response and adjust therapy
5. Ignoring drug interactions: Particularly important when combining statins with fibrates

The 2021 ACC Expert Consensus emphasizes that lifestyle intervention remains the foundation of management for all patients with hypertriglyceridemia, with pharmacological therapy added based on triglyceride levels and cardiovascular risk 1.