What are the treatment options for hypertriglyceridemia?

Treatment Options for Hypertriglyceridemia

Lifestyle modifications are the foundation of hypertriglyceridemia treatment, with medication therapy added based on triglyceride levels and cardiovascular risk factors. 1, 2

Classification of Hypertriglyceridemia

Hypertriglyceridemia is categorized based on fasting triglyceride levels:

• Mild: 150-199 mg/dL (1.7-2.3 mmol/L) 1
• Moderate: 200-999 mg/dL (2.3-11.3 mmol/L) 1
• Severe: 1,000-1,999 mg/dL (11.3-22.6 mmol/L) 1
• Very severe: ≥2,000 mg/dL (≥22.6 mmol/L) 1

First-Line Approach: Lifestyle Modifications

Dietary Interventions

• Reduce total fat intake to 20-25% of total daily calories for moderate hypertriglyceridemia 2
• Further restrict fat to 10-15% of calories for severe hypertriglyceridemia (≥500 mg/dL) 1
• For very severe hypertriglyceridemia (≥1,000 mg/dL), implement extreme dietary fat restriction (<5% of total calories) until triglycerides decrease below 1,000 mg/dL 1
• Limit added sugars to <6% of total daily calories 2
• Completely eliminate added sugars and alcohol for severe hypertriglyceridemia 1, 2

Physical Activity and Weight Management

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity 2
• Target 5-10% weight loss, which can reduce triglycerides by up to 20% 2
• Regular endurance exercise can reduce triglyceride levels by up to 30% 2

Address Secondary Causes

Before initiating pharmacotherapy, identify and treat secondary causes:

• Uncontrolled diabetes (prioritize glycemic control) 1, 2
• Hypothyroidism 1, 2
• Excessive alcohol intake 1
• Medications (estrogens, thiazides, beta-blockers, corticosteroids, retinoids, protease inhibitors) 1, 3
• Renal or liver disease 1, 2

Pharmacological Treatment

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins are first-line therapy if 10-year ASCVD risk ≥7.5% 1
  • Provide 10-30% dose-dependent reduction in triglycerides 1, 2
  • Consider moderate-intensity statin for patients with 10-year ASCVD risk 5-7.5% 1

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line therapy to prevent pancreatitis 1
  • Fenofibrate starting dose: 54-160 mg daily, adjusted based on response 3
  • Maximum dose: 160 mg once daily 3
  • Monitor lipid levels every 4-8 weeks to adjust dosage 3
• Prescription omega-3 fatty acids can be added if triglycerides remain elevated 1
• Consider combination therapy with fibrates, niacin, and omega-3 fatty acids for refractory cases 1, 4

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

• Immediate aggressive dietary fat restriction (<5% of calories) 1
• Fibrate therapy to reduce risk of pancreatitis 1
• Complete elimination of alcohol and added sugars 1
• If diabetes present, prioritize glycemic control before addressing hypertriglyceridemia 1, 2

Treatment Goals and Monitoring

• For moderate hypertriglyceridemia: Target non-HDL cholesterol level 30 mg/dL higher than LDL goal 1
• For severe hypertriglyceridemia: Primary goal is to reduce triglycerides below 500 mg/dL to prevent pancreatitis 1
• Monitor lipid levels periodically and adjust therapy accordingly 3
• Consider discontinuing therapy if inadequate response after two months at maximum dose 3

Special Considerations

• Avoid fibrate-statin combinations when possible due to increased myositis risk 2
• In patients with renal impairment, start fenofibrate at lower dose (54 mg daily) 3
• Fenofibrate is contraindicated in severe renal impairment, active liver disease, preexisting gallbladder disease, and nursing mothers 3
• Low-carbohydrate diets may be more effective than low-fat diets for triglyceride reduction in some patients 2, 5