What are the management options for elevated triglycerides (hypertriglyceridemia)?

Management of Hypertriglyceridemia

Lifestyle modifications are the first-line treatment for all levels of hypertriglyceridemia, with pharmacotherapy reserved for severe cases or those with persistent elevations despite lifestyle changes. 1

Classification of Hypertriglyceridemia

• 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, 2

Initial Assessment

• Evaluate for secondary causes: uncontrolled diabetes, excessive alcohol intake, hypothyroidism, renal disease, liver disease, pregnancy, and medications (thiazides, beta-blockers, estrogen, corticosteroids, antiretrovirals) 1, 2
• Assess cardiovascular risk factors and calculate 10-year ASCVD risk to guide treatment decisions 1, 3
• Determine risk of pancreatitis, particularly with triglycerides ≥500 mg/dL 2

Lifestyle Interventions

Weight Management

• Target 5-10% weight loss, which can reduce triglycerides by 20-70% 1
• A dose-response relationship exists between weight loss and triglyceride reduction 1

Dietary Modifications

• For mild-moderate hypertriglyceridemia (150-499 mg/dL):

  • Restrict added sugars to <6% of total daily calories 1, 2
  • Limit total fat to 30-35% of total daily calories 1, 2
  • Increase consumption of omega-3 fatty acids through fatty fish (salmon, rainbow trout) 1
  • Increase soluble fiber intake (>10g/day) 1, 4

• For severe hypertriglyceridemia (500-999 mg/dL):

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

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

  • Eliminate added sugars 1
  • Restrict total fat to 10-15% of daily calories 1
  • Medium-chain triglyceride oil can be added gradually for additional calories 1
  • Complete alcohol abstinence is mandatory 1

Physical Activity

• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1, 2
• Regular aerobic exercise can reduce triglycerides by approximately 11%, while resistance training reduces them by about 6% 1
• The greatest effect is observed when baseline triglycerides are elevated and activity is at least moderate intensity 1

Alcohol Reduction

• For mild-moderate hypertriglyceridemia: limit alcohol consumption 1, 2
• For severe-very severe hypertriglyceridemia: complete abstinence from alcohol 1
• Alcohol consumption can increase triglycerides by 5-10% and exacerbates postprandial lipemia, especially when combined with high-fat meals 1

Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates (fenofibrate) are first-line drug therapy to reduce pancreatitis risk 1, 5
• Initial dose of fenofibrate is 54-160 mg daily, adjusted based on response 5
• Prescription omega-3 fatty acids at 4 g/day can reduce triglycerides by 45% 6, 7

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins if there is elevated LDL-C or increased cardiovascular risk (10-15% triglyceride reduction) 1, 2
• Icosapent ethyl (purified EPA) 4 g/day for patients with established cardiovascular disease or diabetes with ≥2 additional risk factors 1, 7

Special Considerations

• Optimize glycemic control in patients with diabetes, as it significantly improves triglyceride levels 1, 2
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 2
• For patients with triglycerides ≥1000 mg/dL, aggressive treatment is needed to prevent acute pancreatitis 1, 3
• Combination therapy may be necessary for refractory cases 8

Treatment Algorithm

1. All patients: Implement lifestyle modifications (diet, exercise, weight loss, alcohol reduction)
2. Triglycerides 150-499 mg/dL: Continue lifestyle modifications; add statin if elevated ASCVD risk
3. Triglycerides ≥500 mg/dL: Continue aggressive lifestyle modifications; add fibrate or prescription omega-3 fatty acids
4. Triglycerides ≥1000 mg/dL: Immediate very low-fat diet, complete alcohol abstinence, and pharmacotherapy with fibrates or omega-3 fatty acids 1, 2