How is hypertriglyceridemia managed?

Management of Hypertriglyceridemia

Fenofibrate (160 mg daily with meals) is the first-line pharmacological therapy for severe hypertriglyceridemia (≥500 mg/dL), along with extreme dietary fat restriction (<5% of total calories) until triglycerides are <1000 mg/dL. 1

Classification of Hypertriglyceridemia

• Normal: <150 mg/dL
• Mild to moderate: 150-499 mg/dL
• Severe: 500-999 mg/dL
• Very severe: ≥1000 mg/dL 1

Treatment Algorithm Based on Triglyceride Levels

For Severe Hypertriglyceridemia (≥500 mg/dL)

1. Primary goal: Reduce triglycerides to prevent pancreatitis

2. Initial therapy:

   • Fenofibrate 160 mg daily with meals 1, 2
   • Extreme dietary fat restriction (<5% of total calories) 1
   • Complete elimination of alcohol and added sugars 1
   • Dosage can be started at 54-160 mg daily and adjusted based on response 2

3. Monitoring:

   • Check triglyceride levels every 4-8 weeks until stabilized 1
   • Evaluate renal function before starting fenofibrate, within 3 months after initiation, and every 6 months thereafter 1
   • Target triglyceride level: <500 mg/dL 1

4. Additional pharmacological options:

   • Omega-3 fatty acids (4 g/day) alone or in combination with fibrates 1
   • Niacin as a second-line option (use with caution in patients with diabetes) 1

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

1. Primary goal: Reduce cardiovascular risk

2. Initial approach:

   • Lifestyle modifications (see below)
   • Statin therapy if LDL-C is elevated 1
   • Consider adding ezetimibe if LDL goal not achieved with statin alone 1

3. For patients with diabetes:

   • Consider SGLT2 inhibitor for glycemic control, cardiovascular risk reduction, and renal protection 1
   • Consider GLP-1 receptor agonist for additional glycemic control and weight reduction 1

Lifestyle Modifications (Essential for All Patients)

1. Dietary changes:

   • Very low-fat diet (<5% of calories from fat) until triglycerides <500 mg/dL 1
   • Transition to heart-healthy diet with <30% calories from fat, <7% from saturated fat 1
   • Reduce added sugars and fructose (can reduce triglycerides by 10-20%) 1
   • Consider carbohydrate restriction (<10% of calories from carbohydrates) 1
   • Increase dietary fiber to >10g/day 1
   • Incorporate fatty fish, vegetables, legumes, fiber-rich whole grains, and nuts 1

2. Physical activity:

   • At least 150 minutes per week of moderate-intensity or 75 minutes of vigorous aerobic activity 1

3. Weight management:

   • Target 5-10% weight reduction (can reduce triglycerides by approximately 20%) 3

4. Eliminate alcohol consumption 1, 2

5. Address secondary causes:

   • Optimize glycemic control in diabetes 1, 2
   • Treat hypothyroidism if present 2
   • Review medications that may increase triglycerides (estrogen therapy, thiazide diuretics, beta-blockers) 2

Management of Acute Hypertriglyceridemic Pancreatitis

1. For triglycerides >1000 mg/dL despite 48-hour fasting:

   • IV insulin therapy (with or without heparin) as first-line treatment 1
   • Consider plasmapheresis when triglycerides remain significantly elevated despite insulin therapy 1

2. Nutritional support:

   • Early enteral nutrition (within 24-72 hours from admission) 1
   • Begin oral feeding when pain has ceased, amylase and lipase values are decreasing 1
   • Diet composition: high in carbohydrates and protein, low in fat (<30% of total energy) 1

3. Transition from IV to subcutaneous insulin:

   • Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin 1
   • Calculate dose at 60-80% of daily IV insulin infusion rate 1
   • Continue dextrose infusion as needed to maintain euglycemia during transition 1

Special Considerations

1. Renal impairment:

   • For mild to moderate renal impairment: Start fenofibrate at 54 mg daily 2
   • Avoid fenofibrate in severe renal impairment 1, 2

2. Elderly patients:

   • Dose selection based on renal function 2

3. Drug interactions:

   • Avoid combination of statins with gemfibrozil due to increased risk of myositis 1
   • Use caution when combining statins with fenofibrate 1

Monitoring and Follow-up

• Monitor lipid levels periodically 2
• Consider reducing fenofibrate dosage if triglyceride levels fall significantly below target range 2
• Withdraw therapy if inadequate response after two months of maximum dose (160 mg daily) 2
• Long-term monitoring: Every 3 months once stabilized 1