What is the treatment for high triglycerides?

Treatment for High Triglycerides

The treatment for high triglycerides should begin with lifestyle modifications, followed by pharmacological interventions based on triglyceride levels, with prescription omega-3 fatty acids (4g/day) being the preferred medication for severe hypertriglyceridemia (≥500 mg/dL) and fenofibrate for moderate hypertriglyceridemia. 1

Classification of Hypertriglyceridemia

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

Step 1: Identify and Address Secondary Causes

• Assess for:

  • Diabetes and poor glycemic control
  • Obesity and metabolic syndrome
  • Excessive alcohol consumption
  • Hypothyroidism
  • Chronic liver or kidney disease
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 1, 2

• Improving glycemic control in diabetic patients with fasting chylomicronemia will often reduce the need for pharmacological intervention 2

Step 2: Lifestyle Modifications (First-Line Therapy)

Dietary Changes

• For triglycerides 150-499 mg/dL:

  • Restrict added sugars to <6% and total fat to 30-35% of daily calories 1
  • Increase soluble fiber intake to 10-25g/day 1
  • Add plant stanols/sterols (2g/day) 1

• For triglycerides 500-999 mg/dL:

  • Reduce total fat to 20-25% of calories
  • Eliminate refined carbohydrates and added sugars 3, 1

• For triglycerides ≥1,000 mg/dL:

  • Implement a very-low-fat diet (10-15% of calories)
  • Eliminate alcohol consumption 3, 1, 4

Physical Activity and Weight Management

• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Target 5-10% weight reduction for overweight or obese patients 1, 5
• Regular endurance exercise can reduce triglycerides by approximately 50% when combined with caloric restriction 5

Step 3: Pharmacological Interventions

For Severe Hypertriglyceridemia (≥500 mg/dL)

1. Prescription omega-3 fatty acids (4g/day) as adjunct to diet 1

   • Icosapent ethyl (IPE) is preferred if concerned about LDL-C elevation
   • Omega-3 carboxylic acids (OM3CA) are also FDA-approved for this indication

2. Fenofibrate (54-160 mg daily)

   • Initial dose: 54-160 mg/day, adjusted based on response
   • Maximum dose: 160 mg once daily
   • Dosage should be individualized and adjusted after 4-8 weeks 2
   • Use with caution in renal impairment (start at 54 mg/day) 2

For Moderate Hypertriglyceridemia (200-499 mg/dL)

1. Statins - First-line therapy, especially if LDL-C is also elevated

   • Provides 10-30% dose-dependent reduction in triglycerides 3

2. Combination therapy may be considered:

   • Statin + fibrate for combined hyperlipidemia 1, 6
   • Statin + omega-3 fatty acids 6

For Patients with ASCVD or Diabetes with Risk Factors

• For patients with established cardiovascular disease or diabetes with ≥2 risk factors and triglycerides ≥150 mg/dL:
  • Icosapent ethyl (4g/day) as adjunct to maximally tolerated statin therapy 1

Monitoring and Follow-up

• Monitor triglyceride response after 8-12 weeks of therapy 1
• Check for potential increases in LDL-C levels 1
• Monitor liver and renal function with pharmacological therapy, especially with fibrates 1
• Target goals:
  • Triglycerides: <150 mg/dL
  • LDL cholesterol: <100 mg/dL
  • Non-HDL cholesterol: <130 mg/dL 1

Important Considerations

• Non-prescription fish oil supplements should not be substituted for prescription products 1
• Evaluate potential net benefit of prescription omega-3 fatty acids in patients at high risk of atrial fibrillation 1
• Withdraw therapy if inadequate response after two months of treatment with maximum recommended dose 2
• Fenofibrate has not been shown to reduce coronary heart disease morbidity and mortality in patients with type 2 diabetes 2