What is the treatment for elevated triglyceride (hypertriglyceridemia) levels?

Treatment of Hypertriglyceridemia

The first-line treatment for elevated triglycerides is lifestyle modification, followed by pharmacological therapy with statins, fibrates, and/or prescription omega-3 fatty acids based on triglyceride severity and cardiovascular risk. 1, 2

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 2

Treatment Algorithm Based on Triglyceride Levels

Step 1: Lifestyle Modifications (All Patients)

• Weight reduction: 5-10% weight loss can reduce triglycerides by approximately 20% 2
• Exercise: 150 minutes/week of moderate-intensity aerobic activity 2
• Dietary changes:
  • Reduce refined carbohydrates
  • Increase soluble fiber
  • Consume fatty fish twice weekly
  • Limit alcohol intake
  • Reduce total fat intake, particularly saturated fats 1, 2

Step 2: Address Secondary Causes

• Optimize glycemic control in diabetes
• Treat hypothyroidism
• Address liver or kidney disease
• Review medications that may elevate triglycerides
• Reduce or eliminate alcohol consumption 2

Step 3: Pharmacological Therapy Based on TG Level

For TG 150-499 mg/dL with elevated cardiovascular risk:

• Statin therapy as first-line treatment (provides 10-30% TG reduction) 2
• Target LDL-C <100 mg/dL (or <70 mg/dL if cardiovascular disease is present)

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

1. Fibrates (e.g., fenofibrate 54-160 mg daily)

   • Reduces TG by 35-50% 2, 3
   • Dosage should be individualized based on response
   • Monitor for potential increases in LDL-C 3

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

   • Reduces TG by 25-35% 2, 4
   • Options include:
     • Icosapent ethyl (EPA only) - preferred for patients with established ASCVD or risk factors 2
     • Omega-3 carboxylic acid or omega-3-acid ethyl esters (EPA+DHA) 1

3. Combination therapy may be necessary for refractory cases:

   • Statin + fibrate (monitor for increased risk of myopathy)
   • Statin + omega-3 fatty acids 5

Monitoring and Follow-up

• Check lipid panel after 8-12 weeks of therapy 2
• Monitor liver and renal function with pharmacological therapy, especially with fibrates 2
• Treatment goals:
  • Primary goal: Reduce TG to <500 mg/dL to prevent pancreatitis
  • Final goal: Reduce TG to <150 mg/dL 2

Special Considerations

Severe Hypertriglyceridemia (≥500 mg/dL)

• Immediate intervention is crucial to prevent pancreatitis
• Consider hospitalization for very severe cases (>1000 mg/dL) with risk of pancreatitis
• Restrict fat and simple carbohydrates in diet
• Fibrates are typically first-line therapy 3, 6

Diabetic Patients

• Glycemic control is the first priority
• Consider combination of improved glycemic control plus high-dose statin
• Add fibrate if TG remains elevated despite statin therapy 2

Potential Pitfalls

• Fibrates may increase LDL-C levels, especially in patients with very high TG 3
• Omega-3 products containing DHA may raise LDL-C 2
• Combination of statins and fibrates increases risk of myopathy 2
• Statins are contraindicated in pregnancy 2
• Fenofibrate should be used with caution in patients with renal impairment 3

By following this structured approach to treating hypertriglyceridemia, clinicians can effectively reduce triglyceride levels and minimize associated risks of pancreatitis and cardiovascular disease.