Treatment of Hypertriglyceridemia
The first-line treatment for hypertriglyceridemia is comprehensive lifestyle modification, followed by pharmacological therapy with statins, fibrates, or prescription omega-3 fatty acids based on triglyceride severity and cardiovascular risk factors.
Classification of Hypertriglyceridemia
Hypertriglyceridemia can be classified into four severity levels 1:
- Mild: 150-199 mg/dL
- Moderate: 200-999 mg/dL
- Severe: 1,000-1,999 mg/dL
- Very severe: ≥2,000 mg/dL
Treatment Algorithm
Step 1: Lifestyle Modifications (First-Line for All Patients)
Lifestyle interventions are the foundation of hypertriglyceridemia management 2, 1:
Diet modifications:
- Reduce saturated fat to <7% of total calories
- Limit trans-fatty acids
- Replace saturated fats with monounsaturated fats
- Increase soluble fiber (10-25g/day)
- Add plant stanols/sterols (2g/day)
- Reduce or eliminate alcohol consumption
- Control carbohydrate intake, especially refined carbohydrates
Physical activity:
- At least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes of vigorous activity
- Regular endurance exercise training
- Simple strategies to increase daily activity (taking stairs, standing more)
Weight management:
- Target 5-10% weight reduction if overweight or obese
Address secondary causes:
- Optimize glycemic control in diabetes
- Treat hypothyroidism if present
- Evaluate medications that may increase triglycerides (estrogen therapy, thiazide diuretics, beta-blockers)
Step 2: Pharmacological Therapy Based on Severity
For Severe Hypertriglyceridemia (≥500 mg/dL)
Primary goal is to reduce triglyceride levels below 500 mg/dL to prevent pancreatitis 1, 3:
Fibrates (First-line):
Prescription omega-3 fatty acids (Alternative or add-on):
For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL) with Elevated LDL-C or Cardiovascular Risk
Statins (First-line):
- Pravastatin (20-40 mg daily) or Atorvastatin (10 mg daily) 1
- Expected TG reduction: 10-30%
- Target LDL-C <100 mg/dL (or <70 mg/dL if cardiovascular disease is present)
Combination therapy (If goals not achieved with statin alone):
- Statin + fibrate (monitor for myopathy)
- Statin + prescription omega-3 fatty acids
- Statin + extended-release niacin (especially with low HDL-C)
Special Considerations
For Diabetic Patients
- Effective insulin therapy and glycemic control are crucial first steps 1
- Treatment priority: improved glycemic control plus high-dose statin 1
Monitoring and Treatment Goals
- Assess response to lifestyle modifications after 8-12 weeks 1
- Monitor triglyceride response to pharmacological therapy after 4-8 weeks 3
- Primary goal: reduce triglycerides to <500 mg/dL to prevent pancreatitis
- Final goal: reduce triglycerides to <150 mg/dL 1
- Monitor for potential side effects:
- Fibrates: liver and renal function
- Omega-3 fatty acids: atrial fibrillation risk
- Statin-fibrate combinations: increased risk of myopathy
Important Cautions
- Statins are contraindicated in pregnancy 1
- Fibrates should be used with caution in patients with renal impairment 3
- Nonprescription fish oil supplements have not demonstrated cardiovascular outcomes benefits and are not recommended for ASCVD risk reduction 2
- Prescription omega-3 fatty acids containing DHA may increase LDL-C levels 1
Treatment Response Evaluation
- If inadequate response after two months of maximum therapy, consider reevaluation of secondary causes or referral to lipid specialist 3
- For patients with familial chylomicronemia syndrome (rare genetic disorder), referral to specialized clinics is recommended 4
By following this structured approach to hypertriglyceridemia management, clinicians can effectively reduce triglyceride levels and associated risks of pancreatitis and cardiovascular disease.