What medications decrease triglycerides?

Medications That Decrease Triglycerides

Fibrates are the most potent triglyceride-lowering medications, followed by omega-3 fatty acids, niacin, and statins, with each having specific indications based on triglyceride levels and cardiovascular risk profiles. 1

First-Line Medications for Triglyceride Lowering

Fibrates

• Most potent triglyceride-lowering class, with reductions of 35-54% in patients with hypertriglyceridemia 1, 2
• First-line treatment for severe hypertriglyceridemia (triglycerides >500 mg/dL) 1
• Two main options:
  • Fenofibrate (54-160 mg daily) - preferred when combined with statins 1, 3
  • Gemfibrozil (600 mg twice daily) - more potent but higher risk of interactions 1, 4
• Additional benefits include increasing HDL cholesterol by 8-23% 2
• Caution: May increase LDL cholesterol, especially when triglycerides are very high 2, 1

Omega-3 Fatty Acids

• Prescription-strength formulations at doses of 2-4 g/day effectively lower triglycerides 1
• Two main types:
  • Icosapent ethyl (IPE) - purified EPA formulation with demonstrated cardiovascular benefits beyond triglyceride reduction 1
  • Combination EPA/DHA formulations - reduce triglycerides but without proven cardiovascular outcome benefits 1
• Prescription formulations preferred over over-the-counter supplements due to consistent potency and purity 1
• Can be added to fibrates when triglycerides remain elevated despite fibrate therapy 1

Second-Line Medications

Niacin

• Effectively reduces triglycerides and modestly reduces LDL cholesterol 1
• Dosage typically 1-2 g daily 1
• Limitations include:
  • Flushing and pruritus (can affect compliance) 1
  • May worsen insulin resistance and glucose control 1
  • Should be avoided as first-line therapy in patients with insulin resistance or diabetes 1

Statins

• Primarily used for LDL cholesterol reduction but also lower triglycerides by 10-30% 5, 6
• Triglyceride-lowering effect is proportional to LDL-lowering potency 5
• Most effective in patients with combined dyslipidemia (elevated LDL and triglycerides) 2
• Not generally recommended as first-line therapy for isolated severe hypertriglyceridemia (>500 mg/dL) 1

Combination Therapy Approaches

• For mixed dyslipidemia with elevated LDL and triglycerides (200-500 mg/dL):

  • Start with statin therapy, then add fibrate if triglycerides remain elevated 1
  • Fenofibrate preferred over gemfibrozil when combined with statins due to lower myopathy risk 3, 1

• For severe hypertriglyceridemia (>500 mg/dL):

  • Start with fibrate therapy 1
  • Add omega-3 fatty acids if response is inadequate 1, 6
  • Consider adding niacin as a third agent in refractory cases 1

Special Considerations and Precautions

• Risk of myopathy with fibrate-statin combinations:

  • Higher with gemfibrozil than fenofibrate 3, 1
  • Gemfibrozil is contraindicated with simvastatin 1
  • When combining fibrates with statins, take fibrates in the morning and statins in the evening 1
  • Monitor for muscle symptoms (myalgia) 1

• Non-pharmacological approaches should always accompany medication:

  • Weight reduction, exercise, smoking cessation 1
  • Dietary modifications (reduced alcohol, simple sugars, and long-chain fats) 1
  • Glycemic control in patients with diabetes 1

• For very severe hypertriglyceridemia (>1000 mg/dL):

  • Immediate combined drug and non-drug therapies to prevent pancreatitis 1
  • Absolute restriction of alcohol and severe restriction of dietary fat 1

Emerging Therapies

• Newer agents being studied include:
  • Pemafibrate - a selective PPAR-α modulator 7
  • Vupanorsen - an antisense oligonucleotide targeting triglyceride synthesis 7
  • Combination therapies like fenofibrate plus ezetimibe for mixed dyslipidemia 8