What medications are used to treat hypertriglyceridemia?

Medications for Hypertriglyceridemia

Fibrates are the first-line pharmacological treatment for severe hypertriglyceridemia (≥500 mg/dL), while statins, omega-3 fatty acids, and niacin are additional options depending on triglyceride levels and cardiovascular risk factors. 1, 2

Classification of Hypertriglyceridemia

Hypertriglyceridemia is classified by severity:

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

Medication Selection Algorithm

For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)

1. Fibrates (First-line)

   • Fenofibrate (54-160 mg daily) 1, 2
   • Gemfibrozil (600 mg twice daily) 1, 2
   • Expected reduction: 35-50% in triglycerides 2
   • Primary goal: Reduce triglycerides below 500 mg/dL to prevent pancreatitis 2

2. Prescription Omega-3 Fatty Acids (Add-on or alternative)

   • Dosage: 4g/day 2
   • Expected reduction: 25-35% in triglycerides 2
   • Particularly useful when combined with fibrates for severe cases 1

3. Niacin (Alternative option)

   • Dosage: Gradually titrated up to therapeutic dose
   • Indicated for severe hypertriglyceridemia unresponsive to diet 3
   • Expected reduction: 20-50% in triglycerides 4
   • Caution: May worsen insulin resistance 1

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

1. Statins (First-line when LDL is also elevated or with cardiovascular risk)

   • Pravastatin (20-40 mg daily) or Atorvastatin (10 mg daily) preferred 1, 2
   • Expected reduction: 10-30% in triglycerides 2, 4
   • Fluvastatin (20-40 mg daily) is a reasonable alternative 1

2. Fibrates (When statins are not appropriate or as add-on)

   • Same dosing as above
   • Particularly useful when triglycerides remain elevated despite statin therapy 1, 2

3. Icosapent Ethyl (For patients with controlled LDL but elevated triglycerides)

   • Consider for patients with ASCVD risk factors on statins with triglycerides 135-499 mg/dL 2
   • Can reduce cardiovascular mortality (NNT = 111 over five years) 5

Combination Therapy

For refractory cases with combined hyperlipidemia:

1. High-dose statin plus improved glycemic control 1
2. Statin plus fibrate (avoid gemfibrozil with statins due to increased myopathy risk) 1
3. Statin plus omega-3 fatty acids 2, 4
4. Statin plus niacin (with caution due to flushing side effects) 1

Important Considerations

Drug Interactions and Safety

• Avoid combining gemfibrozil with statins due to increased myopathy risk 1
• If combining fibrates with statins, prefer fenofibrate over gemfibrozil 1, 6
• Take fibrates in the morning and statins in the evening to minimize peak dose concentrations 1
• Monitor for myalgia symptoms with combination therapy 1
• Monitor liver and renal function, especially with fibrate therapy 2

Special Populations

• HIV patients: Gemfibrozil (600 mg twice daily) or fenofibrate (54-160 mg daily) are options; niacin may worsen insulin resistance 1
• Diabetic patients: Improved glycemic control is crucial for triglyceride reduction; insulin therapy may be particularly effective 1, 2
• Pregnant women: Statins are contraindicated; women of childbearing age should use reliable contraception 2

Treatment Goals

• Primary goal: Reduce triglycerides below 500 mg/dL to prevent pancreatitis 2
• Secondary goal: Reduce triglycerides to <150 mg/dL 2
• For moderate hypertriglyceridemia: Target non-HDL cholesterol level of 30 mg/dL higher than LDL goal 1

Monitoring

• Assess triglyceride response after 8-12 weeks of therapy 2
• Monitor for potential increases in LDL-C levels, particularly with omega-3 products containing DHA 2
• Regular monitoring of liver and renal function with pharmacological therapy 2

Hypertriglyceridemia management should always begin with lifestyle modifications (diet, exercise, weight loss, alcohol restriction), but pharmacological therapy is essential for severe cases to prevent pancreatitis and may be necessary for moderate cases to reduce cardiovascular risk.