What is the treatment for severely elevated triglycerides (hypertriglyceridemia)?

Treatment for Severely Elevated Triglycerides (Hypertriglyceridemia)

For severe hypertriglyceridemia (≥500 mg/dL), implement aggressive dietary modifications, eliminate alcohol and added sugars, and initiate fibrate therapy to prevent pancreatitis and reduce cardiovascular risk. 1

Classification and Risk Assessment

• Moderate hypertriglyceridemia: 150-499 mg/dL - associated with increased cardiovascular disease risk 1
• Severe hypertriglyceridemia: 500-999 mg/dL - increased risk of pancreatitis and cardiovascular disease 1
• Very severe hypertriglyceridemia: ≥1,000 mg/dL - high risk for acute pancreatitis 1

First-Line Management for Severe Hypertriglyceridemia (≥500 mg/dL)

Dietary Modifications

• For triglycerides 500-999 mg/dL: Restrict dietary fat to 20-25% of total calories 1
• For triglycerides ≥1,000 mg/dL: Implement very low-fat diet (10-15% of total calories) 1
• For extremely severe cases: Consider extreme dietary fat restriction (<5% of total calories) until triglycerides are <1,000 mg/dL 1
• Eliminate added sugars completely for triglycerides ≥1,000 mg/dL 1
• Eliminate alcohol consumption 1

Pharmacological Management

• Fibrates (fenofibrate) are first-line therapy for severe hypertriglyceridemia to prevent acute pancreatitis 1, 2
• Initial fenofibrate dosing: 54-160 mg per day, individualized according to patient response 2
• Maximum fenofibrate dose: 160 mg once daily 2
• Fenofibrate has demonstrated 46-54% reduction in triglyceride levels in clinical trials 2

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

• For acute management with imminent risk of pancreatitis: Consider insulin therapy, especially in patients with poor glycemic control 3
• Insulin counteracts insulin resistance and improves triglyceride metabolism 3
• In acute pancreatitis due to hypertriglyceridemia: Rapidly lower triglycerides below 1,000 mg/dL initially, with target of <500 mg/dL 3, 4
• For patients with diabetes and severe hypertriglyceridemia: Address glycemic control first, then re-evaluate triglyceride levels 1
• Consider prescription omega-3 fatty acids (icosapent ethyl or omega-3 acid ethyl esters) as adjunctive therapy 1

Addressing Secondary Causes

• Identify and treat secondary causes of hypertriglyceridemia 1, 5:
  • Poorly controlled diabetes mellitus 5
  • Obesity and metabolic syndrome 5
  • Hypothyroidism 5
  • Chronic kidney disease 5
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 2

Long-term Management

• Monitor lipid levels every 4-8 weeks initially, then adjust therapy accordingly 2
• Maintain triglyceride levels <500 mg/dL to prevent recurrent pancreatitis 4
• Continue lifestyle modifications indefinitely 1
• For patients with cardiovascular risk factors and hypertriglyceridemia, consider adding statin therapy 1

Common Pitfalls to Avoid

• Focusing only on fat restriction without addressing refined carbohydrate intake 5
• Using statins alone for severe hypertriglyceridemia (≥500 mg/dL), as they typically reduce triglycerides by only 10-30% 5
• Overlooking glycemic control in patients with diabetes 5
• Failing to identify medications as potential causes of hypertriglyceridemia 5
• Delaying treatment in patients with triglycerides >1,000 mg/dL due to high risk of acute pancreatitis 6, 4