What are the treatment options for lowering elevated triglycerides?

Management of Hypertriglyceridemia

The treatment of elevated triglycerides should begin with comprehensive lifestyle modifications, followed by pharmacological therapy with statins, fibrates, and/or prescription omega-3 fatty acids based on triglyceride severity and cardiovascular risk. 1

Classification of Hypertriglyceridemia

Hypertriglyceridemia can be classified into four severity levels:

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

First-Line Treatment: Lifestyle Modifications

Dietary Changes

• Reduce refined carbohydrates and added sugars to <6% of total daily calories 1
• Limit total fat to 30-35% of total daily calories 1
• Reduce intake of trans-fatty acids and saturated fat (to less than 7% of total calories) 2
• Increase consumption of:
  • Soluble fiber (10-25 g/day) 2, 1
  • Fatty fish (twice weekly) for omega-3 fatty acids 1
  • Plant proteins 1
  • Plant stanols/sterols (2 g/day) 2

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes of vigorous activity 1
• Incorporate regular endurance exercise training for maximum triglyceride reduction 1

Weight Management

• Target 5-10% weight reduction if overweight or obese 1
• Assess response to lifestyle modifications after 8-12 weeks 1

Dietary changes alone can reduce triglycerides by 20-50% when properly implemented 1. In some cases, lifestyle modifications alone can dramatically reduce severely elevated triglycerides, as demonstrated in case reports showing reduction from >40 mmol/L to 3.28 mmol/L with lifestyle changes alone 3.

Pharmacological Therapy

The choice of medication depends on triglyceride levels and cardiovascular risk:

For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL)

1. Statins: First-line pharmacological therapy when there's elevated LDL-C or cardiovascular risk

   • Pravastatin (20-40 mg daily) or atorvastatin (10 mg daily) are preferred options 1
   • Provides 10-30% reduction in triglycerides 1
   • Target LDL cholesterol level of <100 mg/dL (or <70 mg/dL if cardiovascular disease is present) 1

2. Add-on therapy if triglycerides remain elevated despite statin therapy:

   • Fibrates: Gemfibrozil (600 mg twice daily) or fenofibrate (54-160 mg daily)

     • Provides 35-50% reduction in triglycerides 1
     • In clinical trials, fenofibrate reduced triglycerides by 46.2% in patients with moderate hypertriglyceridemia and by 54.5% in patients with severe hypertriglyceridemia 4
     • Caution: Increased risk of myopathy when combined with statins 1

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

     • Reduces triglycerides by 25-35% 1
     • Icosapent ethyl can be considered in patients with ASCVD or other cardiovascular risk factors on statin with controlled LDL-C but persistent triglycerides 150-499 mg/dL 1

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Primary goal is to reduce triglyceride levels below 500 mg/dL to prevent pancreatitis 1
• Fibrates are first-line therapy 1, 5
• Prescription omega-3 fatty acids (4g/day) can be added 1, 5
• Niacin can be considered as an additional option 1

Treatment Algorithm Based on Triglyceride Levels

Mild Hypertriglyceridemia (150-199 mg/dL)

1. Implement lifestyle modifications for 8-12 weeks
2. If inadequate response and elevated cardiovascular risk, consider statin therapy

Moderate Hypertriglyceridemia (200-499 mg/dL)

1. Implement lifestyle modifications
2. Add statin therapy if elevated cardiovascular risk or LDL-C
3. If inadequate response after 8-12 weeks, consider adding fibrate or prescription omega-3 fatty acids

Severe Hypertriglyceridemia (≥500 mg/dL)

1. Immediate implementation of strict dietary fat restriction
2. Initiate fibrate therapy
3. Consider adding prescription omega-3 fatty acids
4. For acute pancreatitis with triglycerides ≥1,000 mg/dL, consider insulin infusion or plasmapheresis 5

Monitoring and Follow-up

• Monitor triglyceride response after 8-12 weeks of therapy 1
• Check for potential increases in LDL-C levels, especially with DHA-containing omega-3 products 1
• Monitor liver and renal function with pharmacological therapy, especially when using fibrates 1
• Target goals:
  • Triglycerides <150 mg/dL
  • LDL cholesterol <100 mg/dL
  • Non-HDL cholesterol <130 mg/dL 1

Special Considerations

• For diabetic patients, glycemic control is the first priority 1
• Statins are contraindicated in pregnancy; women of childbearing age should use reliable contraception 1
• For patients with genetic hypertriglyceridemia (e.g., familial chylomicronemia syndrome), referral to specialized lipid clinics is recommended 6