What are the treatment options for hypertriglyceridemia?

Treatment Options for Hypertriglyceridemia

The first-line treatment for hypertriglyceridemia is comprehensive lifestyle modification, followed by pharmacologic therapy with fibrates for severe hypertriglyceridemia (≥500 mg/dL) or prescription omega-3 fatty acids, statins, and niacin based on triglyceride levels and cardiovascular risk factors. 1

Classification of Hypertriglyceridemia

Hypertriglyceridemia is classified by severity:

• Normal: <150 mg/dL
• Mild: 150-199 mg/dL
• Moderate: 200-499 mg/dL
• Severe: 500-999 mg/dL
• Very severe: ≥1000 mg/dL 1

Initial Assessment

Before initiating treatment:

• Evaluate for secondary causes: excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, medications (thiazides, beta-blockers, estrogen, corticosteroids) 1
• Assess cardiovascular risk factors: family history, central obesity, hypertension, abnormal glucose metabolism 1
• Determine risk of pancreatitis (particularly with triglycerides ≥500 mg/dL) 1

Treatment Algorithm

1. Lifestyle Interventions (First-Line for All Patients)

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

• Weight loss: Target 5-10% of body weight; can reduce triglycerides by 20% 1
• Dietary modifications:
  • Restrict added sugars to <6% of total daily calories 1
  • Limit total fat to 30-35% of total daily calories 1
  • Reduce refined carbohydrates and increase fiber intake 2
• Physical activity: At least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Alcohol restriction: Limit or avoid alcohol consumption 1

For Severe Hypertriglyceridemia (500-999 mg/dL):

• Further restrict added sugars to <5% of total daily calories 1
• Reduce total fat to 20-25% of total daily calories 1
• Complete abstinence from alcohol 1
• Same physical activity recommendations as above 1

For Very Severe Hypertriglyceridemia (≥1000 mg/dL):

• Eliminate added sugars completely 1
• Restrict total fat to 10-15% of total daily calories 1
• Complete abstinence from alcohol 1
• Consider medium-chain triglyceride oil for additional calories 1

2. Pharmacologic Therapy

For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL):

• Fibrates (first-line drug therapy): Reduce risk of pancreatitis 1
  • Fenofibrate: Initial dose 54-160 mg daily, maximum 160 mg daily 3
  • Adjust dose based on renal function and response 3

For Moderate Hypertriglyceridemia (200-499 mg/dL):

• Statins: If elevated LDL-C or increased cardiovascular risk; provide 10-30% reduction in triglycerides 1
• Prescription omega-3 fatty acids:
  • Icosapent ethyl (IPE): 4g daily for patients with established cardiovascular disease or diabetes with ≥2 additional risk factors 1
  • Omega-3 acid ethyl esters: For severe hypertriglyceridemia 1
• Fibrates: Consider for persistent hypertriglyceridemia despite statin therapy 1
• Niacin: Consider for patients with low HDL-C and hypertriglyceridemia 4, 5

Combination Therapy

For refractory cases:

• Statin + fibrate (monitor for myopathy) 5
• Statin + omega-3 fatty acids 1, 5
• Statin + niacin 5

Monitoring and Follow-up

• Assess response to lifestyle interventions after 4-12 weeks 1
• Monitor lipid levels periodically and adjust therapy as needed 3
• For pharmacologic therapy, evaluate response after 2 months; discontinue if inadequate response 3

Special Considerations

• Diabetes: Optimize glycemic control, which can significantly improve triglyceride levels 1
• Renal impairment: Reduce fibrate dose in mild to moderate renal impairment; avoid in severe renal impairment 3
• Atrial fibrillation risk: Monitor for increased risk with prescription omega-3 fatty acids 1
• Pancreatitis risk: Prioritize aggressive triglyceride lowering in patients with levels ≥500 mg/dL 1

Treatment Efficacy

• Lifestyle modifications can reduce triglycerides by 20-50% 1, 2
• Fibrates can reduce triglycerides by 30-50% 6, 4
• High-dose omega-3 fatty acids can reduce triglycerides by 20-30% 4, 5
• Statins typically reduce triglycerides by 10-30% 1, 7

Remember that treatment should be tailored based on triglyceride levels, cardiovascular risk, and risk of pancreatitis, with lifestyle modifications forming the foundation of all treatment approaches 1, 7.