What is the treatment for hypertriglyceridemia?

Treatment for Elevated Triglycerides

Fibrates are the first-line pharmacological treatment for isolated hypertriglyceridemia, while statins are first-line when LDL is also elevated or when cardiovascular risk is present. 1

Classification and Initial Assessment

• Severity classification:

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

• Target goals:

  • Triglycerides: <150 mg/dL
  • Non-HDL cholesterol: 30 mg/dL higher than LDL goal 1

Step 1: Address Secondary Causes and Lifestyle Modifications

• Identify and treat secondary causes:

  • Uncontrolled diabetes mellitus
  • Hypothyroidism
  • Renal or liver disease
  • Excessive alcohol intake
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 1, 2

• Dietary modifications:

  • For TG 500-999 mg/dL: Limit fat to 20-25% of calories, reduce refined carbohydrates
  • For TG ≥1,000 mg/dL: Restrict total fat to 10-15% of calories, eliminate added sugars completely
  • Reduce saturated fat to <7% of total calories
  • Increase omega-3 fatty acids in diet
  • Increase soluble fiber to 10-25g/day
  • Add plant stanols/sterols (2g/day) 1

• Lifestyle changes:

  • Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity
  • Target 5-10% weight reduction for overweight/obese patients
  • Completely avoid or significantly limit alcohol consumption 1

Step 2: Pharmacological Treatment

For Isolated Hypertriglyceridemia:

1. Fibrates (first-line):

   • Fenofibrate: Initial dose 54-160 mg daily with meals, maximum 160 mg daily
   • Gemfibrozil: Alternative option
   • Expected reduction: 30-50% in triglycerides 1, 2
   • Adjust dose based on renal function (start at 54 mg/day for mild-moderate renal impairment) 2

2. Prescription omega-3 fatty acids (add-on therapy):

   • Dosage: 4g/day
   • Expected reduction: 25-35% in triglycerides 1

3. Niacin (alternative option):

   • Gradually titrated to therapeutic dose
   • Caution: May worsen insulin resistance 1

For Mixed Dyslipidemia (Elevated TG + Elevated LDL):

1. Statins (first-line):

   • Options: Pravastatin (20-40 mg daily) or Atorvastatin (10 mg daily)
   • Expected reduction: 10-30% in triglycerides 1

2. Combination therapy for refractory cases:

   • Statin plus improved glycemic control
   • Statin plus fibrate (monitor for myositis risk)
   • Statin plus omega-3 fatty acids
   • Statin plus niacin 1

Special Considerations

For Severe Hypertriglyceridemia (≥1,000 mg/dL):

• Urgent treatment needed to prevent pancreatitis
• Fenofibrate dosing: 54-160 mg daily, individualized according to response
• Monitor lipid levels every 4-8 weeks initially 2
• Consider referral to lipid specialist for TG >2,000 mg/dL 1

For Diabetic Patients:

• Optimize glycemic control as first priority for triglyceride lowering
• Effective insulin therapy is crucial 1

Safety Monitoring:

• Monitor for myositis risk with statin-fibrate combinations (fenofibrate has lower risk than gemfibrozil)
• Monitor liver and renal function with pharmacological therapy
• Contraindications for fenofibrate: severe renal impairment, active liver disease, preexisting gallbladder disease 1, 2
• Monitor triglyceride response after 8-12 weeks of treatment 1

Treatment Algorithm

1. For TG 150-499 mg/dL with low cardiovascular risk:

   • Lifestyle modifications alone

2. For TG 150-499 mg/dL with elevated LDL or cardiovascular risk:

   • Statin therapy + lifestyle modifications

3. For TG 500-999 mg/dL:

   • Fibrate therapy + lifestyle modifications
   • Add omega-3 fatty acids if inadequate response

4. For TG ≥1,000 mg/dL:

   • Urgent fibrate therapy + strict dietary fat restriction
   • Consider combination therapy if inadequate response

5. For refractory cases:

   • Combination therapy based on lipid profile
   • Consider referral to lipid specialist

The treatment approach should be adjusted based on monitoring lipid levels every 4-8 weeks initially, with the goal of reducing triglycerides to <150 mg/dL 1, 2.