How are elevated triglycerides managed?

Management of Elevated Triglycerides

Lifestyle interventions are the first line of therapy for all patients with persistent hypertriglyceridemia, with specific recommendations based on triglyceride levels. 1

Classification of Hypertriglyceridemia

• Normal: <150 mg/dL 2
• Mild: 150-199 mg/dL 2
• Moderate: 200-499 mg/dL 2
• Severe: 500-999 mg/dL 2
• Very severe: ≥1000 mg/dL 2

Initial Assessment

• Evaluate for secondary causes: excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and certain medications 2
• Assess cardiovascular risk factors and determine risk of pancreatitis, particularly with triglycerides ≥500 mg/dL 2
• Review medications that may contribute to hypertriglyceridemia (estrogen therapy, thiazide diuretics, beta-blockers) 3

Lifestyle Interventions

Weight Loss

• Target 5-10% reduction in body weight, which can decrease triglycerides by up to 20% 1, 2
• A dose-response relationship exists between weight loss and triglyceride reduction, with some patients experiencing up to 70% reduction 1

Dietary Modifications

• For mild to 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
  • Reduce intake of refined carbohydrates and saturated fats 1

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

  • Further restrict added sugars to <5% of total calories 1
  • Reduce total fat to 20-25% of total daily calories 1
  • Restrict alcohol consumption 1

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

  • Eliminate added sugars 1
  • Severely restrict total fat to 10-15% of daily calories 1
  • Completely abstain from alcohol 1
  • Consider extreme dietary fat restriction (<5% of total calories) until triglyceride levels are ≤1000 mg/dL 1

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous aerobic activity 1, 2
• Regular endurance exercise training is most effective when baseline triglycerides are elevated (≥150 mg/dL) 1

Alcohol

• For triglycerides 500-999 mg/dL: restrict alcohol 1
• For triglycerides ≥1000 mg/dL: complete abstinence 1

Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line drug therapy to reduce the risk of pancreatitis 2, 3

  • Initial dose of fenofibrate is 54-160 mg per day, individualized according to patient response 3
  • Maximum dose is 160 mg once daily 3
  • Monitor lipid levels at 4-8 week intervals and adjust dosage as needed 3

• Prescription omega-3 fatty acids are indicated as adjunct to diet 1

  • Icosapent ethyl (EPA only) is FDA-approved for cardiovascular risk reduction 1
  • Omega-3 carboxylic acid and omega-3-acid ethyl esters (containing both EPA and DHA) are approved for severe hypertriglyceridemia 1

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Consider statins if there is elevated LDL-C or increased cardiovascular risk 2
• If triglycerides remain elevated after 3 months of optimized lifestyle modifications, consider adding prescription omega-3 fatty acids or fenofibrate 2

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 2
• In patients with markedly elevated triglycerides and insulin insufficiency, treat hyperglycemia first, then re-evaluate hypertriglyceridemia 1
• For patients with severe renal impairment, avoid fenofibrate or use with caution at reduced doses 3
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 2

Follow-up

• Monitor lipid levels periodically, typically at 6-12 weeks after implementing interventions 2, 3
• Consider reducing medication dosage if lipid levels fall significantly below target range 3
• Withdraw therapy if there is inadequate response after two months of treatment with maximum recommended dose 3

Common Pitfalls

• Failing to address secondary causes before initiating pharmacologic therapy 3
• Using lower-fat, higher-carbohydrate diets, which may lessen triglyceride reduction compared to higher-fat, lower-carbohydrate weight loss diets 1
• Not individualizing dietary fat content based on triglyceride levels 1
• Overlooking the importance of registered dietitian nutritionists in providing individualized Medical Nutrition Therapy for optimal lipid lowering 1