What medications are used to reduce triglycerides?

Medications for Triglyceride Reduction

Fibrates (fenofibrate and gemfibrozil) are the first-line pharmacological treatment for elevated triglycerides, with fenofibrate being preferred due to its lower risk of myositis when combined with statins. 1

Primary Medication Options

First-Line Medications

1. Fibric Acid Derivatives

   • Fenofibrate: 54-160 mg once daily 2, 1

     • Reduces triglycerides by 35-54% 2, 3
     • Increases HDL-C by 12-22% 3
     • Preferred over gemfibrozil when combined with statins due to lower myopathy risk 1

   • Gemfibrozil: 600 mg twice daily 2

     • Reduces triglycerides by approximately 18% 2
     • Should not be initiated alone in diabetic patients with undesirable triglyceride levels 2
     • Higher risk of myositis when combined with statins 2

Second-Line Medications

1. Omega-3 Fatty Acids (Fish Oils)

   • Prescription-strength formulations are preferred 2
   • Two types:
     • Icosapent ethyl (purified EPA): Reduces triglycerides and confers cardiovascular benefits 2
     • Combination EPA/DHA: Reduces triglycerides but without proven cardiovascular risk reduction 2

2. Niacin

   • Dosage: Up to 2g daily 2
   • Reduces triglycerides and modestly reduces LDL-C 2
   • Caution: May worsen insulin resistance 2, 4
   • Side effects: Flushing, pruritus, nausea, and glucose increases 2, 4

3. High-Dose Statins

   • Moderately effective for triglyceride reduction in patients with levels >300 mg/dL 2
   • Consider when patient also has elevated LDL-C 2, 1

Treatment Algorithm Based on Triglyceride Levels

For Triglycerides 150-200 mg/dL

• Focus on lifestyle modifications:
  • Improved glycemic control (for diabetic patients) 2
  • Weight reduction if overweight 2
  • Regular aerobic exercise 2
  • Decreased saturated fat intake 2
  • Reduced alcohol consumption 2
  • Smoking cessation 2

For Triglycerides 200-400 mg/dL

• Clinician judgment on whether to start pharmacological therapy 2
• If medication needed, start with fenofibrate 54-160 mg daily 2, 1

For Triglycerides 400-500 mg/dL

• Strong consideration for pharmacological treatment to minimize pancreatitis risk 2
• First choice: Fenofibrate 54-160 mg daily 2, 1
• Alternative: Gemfibrozil 600 mg twice daily 2

For Triglycerides >500 mg/dL (Severe Hypertriglyceridemia)

• Immediate pharmacological intervention required 2, 3
• First choice: Fibrate (preferably fenofibrate) 2, 3
• Consider combination therapy for triglycerides >1000 mg/dL 2
• Very low-fat diet, avoidance of simple sugars, and elimination of alcohol intake 2

Special Considerations

For Diabetic Patients

• First optimize glycemic control, which can significantly reduce triglycerides 2
• Insulin therapy may be particularly effective in lowering triglyceride levels 2
• After optimizing glycemic control, consider adding fibrate therapy 2, 1

For Patients with HIV on Antiretroviral Therapy

• Fibrates are first-line for triglycerides >500 mg/dL 2
• Fish oils may be tried but have limited data in this population 2

Combination Therapy

• For combined hyperlipidemia (elevated LDL-C and triglycerides):
  1. Improved glycemic control plus high-dose statin 2
  2. If needed, add fibric acid derivative (preferably fenofibrate) 2, 1
  3. Third option: Add niacin (with caution) 2

Monitoring

• Check lipid levels 4-6 weeks after initiating or changing therapy 1
• Monitor liver enzymes at baseline and 8-12 weeks after starting therapy 1
• Monitor for muscle symptoms and check CK if symptoms develop 1

Common Pitfalls to Avoid

1. Drug Interactions: The combination of statins with fibrates increases myopathy risk, particularly with gemfibrozil 2
2. Niacin in Diabetics: Use niacin cautiously in diabetic patients due to potential worsening of insulin resistance 2
3. Over-the-counter Fish Oils: These may have impurities or inconsistent quantities of EPA/DHA; prescription formulations are preferred 2
4. Ignoring Lifestyle Modifications: Dietary changes, exercise, and weight loss are essential components of triglyceride management 2
5. Gemfibrozil with Statins: This combination significantly increases myositis risk; fenofibrate is safer when statin combination is needed 2, 1