What is the management for elevated triglycerides?

Management of Elevated Triglycerides

The management of elevated triglycerides should prioritize lifestyle modifications first, followed by appropriate pharmacotherapy based on triglyceride levels, with specific interventions tailored to the severity of hypertriglyceridemia. 1

Classification of Hypertriglyceridemia

• Moderate hypertriglyceridemia: 150-499 mg/dL 1
• Severe hypertriglyceridemia: ≥500 mg/dL 1
• Very severe hypertriglyceridemia: ≥1,000 mg/dL 1

First-Line Management: Lifestyle Interventions

Weight Management

• 5-10% weight reduction can result in up to 20% reduction in triglycerides 1
• Weight loss of 1 kg per week can decrease triglycerides by 30-40% 1
• More modest weight loss of 0.25-0.5 kg per week can still reduce triglycerides by 10-20% 1

Physical Activity

• Recommend at least 150 minutes per week of moderate-intensity or 75 minutes of vigorous aerobic activity 1
• Regular endurance exercise is most effective when baseline triglycerides are elevated (≥150 mg/dL) 1
• Moderate to high-intensity physical activity can lower triglyceride levels by improving body composition 2

Dietary Modifications (Based on Triglyceride Levels)

For triglycerides <500 mg/dL:

• Restrict added sugars to <6% of daily calories 1
• Limit total fat to 30-35% of daily calories 1
• Restrict alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 1

For triglycerides 500-999 mg/dL:

• Further restrict added sugars to <5% of daily calories 1
• Reduce total fat to 20-25% of daily calories 1
• Completely abstain from alcohol 1
• Avoid refined carbohydrates 1

For triglycerides ≥1,000 mg/dL:

• Eliminate added sugars completely 1
• Restrict total fat to 10-15% of daily calories 1
• In extreme cases, consider <5% of total calories from fat until triglycerides are <1,000 mg/dL 1
• Complete abstention from alcohol 1

Specific Dietary Recommendations

• Replace saturated fats with polyunsaturated fatty acids (PUFAs) to lower triglycerides by about 0.4 mg/dL for each 1% energy substitution 1
• Replace carbohydrates with monounsaturated fatty acids (MUFAs) to lower triglycerides by 1.7 mg/dL for each 1% energy substitution 1
• Higher-protein, lower-carbohydrate diets are associated with greater triglyceride reduction 1
• Mediterranean diet has consistent evidence for efficacy in hypertriglyceridemia 3

Pharmacological Management

For Moderate Hypertriglyceridemia (150-499 mg/dL)

• Statins are first-line therapy, particularly for patients with cardiovascular risk factors or established ASCVD 1, 2
• Consider statins for patients with 10-year ASCVD risk of 5-7.5% and persistent hypertriglyceridemia 1
• For patients with 10-year ASCVD risk ≥7.5%, at least moderate-intensity statin therapy is recommended 1

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line pharmacological treatment for patients at risk of pancreatitis 1, 4, 5
• Prescription omega-3 fatty acids (4 g/day) can reduce triglycerides by ≥30% 1, 6
• Icosapent ethyl (IPE) is FDA-approved for cardiovascular risk reduction in patients with triglycerides ≥150 mg/dL with established cardiovascular disease or diabetes plus ≥2 additional risk factors 1
• Omega-3 acid ethyl esters are indicated as adjunct to diet for severe hypertriglyceridemia 1

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

• Aggressive dietary fat restriction (<5-10% of calories) is crucial 1
• Fibrates are recommended to prevent acute pancreatitis 1, 5
• Consider combination therapy with fibrates and omega-3 fatty acids if needed 7
• Treat any underlying hyperglycemia first in patients with diabetes, then reassess triglyceride levels 1

Special Considerations

Secondary Causes to Address

• Evaluate and treat diabetes/insulin resistance 1, 8
• Review medications that may increase triglycerides (e.g., corticosteroids, estrogens, antipsychotics) 1, 8
• Assess and treat hypothyroidism 8
• Address excessive alcohol consumption 1

Combination Therapy Considerations

• When using fibrates with statins, monitor for increased risk of myositis 8, 4
• For patients with persistent hypertriglyceridemia despite statin therapy, consider adding IPE for cardiovascular risk reduction 1, 6

Common Pitfalls to Avoid

• Using statins alone for severe hypertriglyceridemia (≥500 mg/dL) is insufficient 1, 2
• Failing to address underlying causes before initiating pharmacotherapy 8
• Overlooking the importance of aggressive dietary intervention in severe hypertriglyceridemia 1
• Neglecting to individualize dietary fat restriction based on triglyceride levels 1