What is the treatment for severely elevated triglycerides?

Treatment of Triglycerides Level 616 mg/dL

For severe hypertriglyceridemia with a level of 616 mg/dL, immediate implementation of intensive lifestyle modifications plus fibrate therapy is recommended to reduce the risk of acute pancreatitis and cardiovascular disease. 1

Initial Management

• Implement dietary fat restriction to 20-25% of total calories, as this level falls in the 500-999 mg/dL range of severe hypertriglyceridemia 2, 3
• Completely eliminate added sugars and alcohol consumption, as these significantly worsen hypertriglyceridemia 3, 1
• Initiate fibrate therapy (fenofibrate) as first-line medication for severe hypertriglyceridemia to prevent acute pancreatitis 3, 4
• The recommended initial dose of fenofibrate is 54 mg to 160 mg per day, with dosage individualized according to patient response 4
• Address and treat any secondary causes of hypertriglyceridemia, including uncontrolled diabetes, hypothyroidism, and chronic kidney disease 2, 1

Dietary Modifications

• Implement a diet low in simple and refined carbohydrates and saturated fats 2, 3
• Include high amounts of soluble fiber (>10 g/day) in the diet 2
• Replace refined carbohydrates with unsaturated fats and protein 1
• For patients with triglyceride levels between 500-999 mg/dL, total fat should generally be restricted to 20-25% of the diet 2

Addressing Secondary Causes

• If diabetes is present, address glycemic control first, as hyperglycemia can worsen hypertriglyceridemia 2, 5
• Evaluate for other secondary causes including hypothyroidism, chronic kidney disease, and medications that increase triglycerides (such as estrogens, beta-blockers, thiazide diuretics) 2, 1
• Discontinue any medications that may be contributing to hypertriglyceridemia when possible 2

Pharmacologic Management

• Fenofibrate is indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia 4
• Gemfibrozil is an alternative fibrate option for patients with very high triglyceride levels who present a risk of pancreatitis 6
• For patients with cardiovascular risk factors and hypertriglyceridemia, adding statin therapy may be considered once triglyceride levels are controlled 2, 3
• Prescription omega-3 fatty acids may be considered as adjunctive therapy for patients with severe hypertriglyceridemia 3, 7

Monitoring and Follow-up

• Monitor lipid levels at 4-8 week intervals and adjust fibrate dosage if necessary 4
• The primary goal for triglyceride levels ≥500 mg/dL is to reduce triglycerides below 500 mg/dL to prevent acute pancreatitis 1, 8
• Continue lifestyle modifications indefinitely to maintain triglyceride levels <500 mg/dL 3, 5

Important Cautions

• The combination of statin plus fibrate therapy has not been shown to improve cardiovascular disease outcomes and generally is not recommended due to increased risk of myositis 1, 5
• If triglyceride levels continue to rise despite treatment, consider more aggressive intervention to prevent acute pancreatitis 9, 10
• In cases where triglycerides exceed 1,000 mg/dL despite initial management, more extreme dietary fat restriction (<5% of total calories as fat) may be necessary 2, 5