What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia requires a stepwise approach beginning with lifestyle modifications, followed by pharmacologic therapy based on triglyceride severity, with fibrates as first-line therapy for severe hypertriglyceridemia (≥500 mg/dL) and statins for moderate hypertriglyceridemia with cardiovascular risk factors. 1, 2

Classification and Severity Assessment

• Hypertriglyceridemia is classified as: Normal (<150 mg/dL), Mild (150-199 mg/dL), Moderate (200-499 mg/dL), Severe (500-999 mg/dL), and Very severe (≥1,000 mg/dL) 1, 2
• Moderate hypertriglyceridemia is associated with increased cardiovascular risk, while severe and very severe levels increase the risk of acute pancreatitis 2, 3
• Before initiating treatment, evaluate for secondary causes including excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and certain medications (thiazides, beta-blockers, estrogen, corticosteroids) 1, 4

Lifestyle Interventions (First-Line for All Patients)

• Target a 5-10% weight loss, which can reduce triglycerides by up to 20% 1, 2
• Restrict added sugars to <6% of total daily calories 1, 2
• Adjust fat intake based on triglyceride levels:
  • For moderate hypertriglyceridemia: limit total fat to 30-35% of total daily calories 1, 2
  • For severe hypertriglyceridemia (500-999 mg/dL): restrict total fat to 20-25% of daily calories 2, 5
  • For very severe hypertriglyceridemia (≥1,000 mg/dL): eliminate added sugars and restrict total fat to 10-15% of daily calories 6, 2
• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1, 2
• Limit or completely avoid alcohol consumption, especially in patients with severe hypertriglyceridemia 1, 2

Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line drug therapy to reduce the risk of pancreatitis 1, 5, 7
• Initial dose of fenofibrate is 54 mg to 160 mg per day, with dosage individualized according to patient response 7
• Monitor for adequate response after 4-8 weeks and adjust dose as needed, with maximum dose of 160 mg once daily 7
• In patients with renal impairment, start with 54 mg per day and adjust based on response and renal function 7

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins are first-line therapy if LDL-C is elevated or 10-year ASCVD risk ≥7.5% 1, 5
• If triglycerides remain elevated after statin therapy, consider adding prescription omega-3 fatty acids (2-4g/day) 6, 1
• For patients with diabetes, optimizing glycemic control can significantly improve triglyceride levels 1, 2

For Persistent Hypertriglyceridemia Despite Initial Therapy

• If triglycerides remain elevated after 3 months of optimized lifestyle modifications and initial pharmacotherapy, consider:
  • Adding prescription omega-3 fatty acids (2-4g/day) if not already prescribed 1, 2
  • Adding fenofibrate if triglycerides remain significantly elevated and cardiovascular risk is high 1
• Monitor for potential drug interactions, particularly when combining lipid-lowering medications 2, 8

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications or starting pharmacotherapy 1, 2
• For moderate hypertriglyceridemia, target non-HDL cholesterol level 30 mg/dL higher than LDL goal 5, 8
• For severe hypertriglyceridemia, primary goal is to reduce triglycerides below 500 mg/dL to prevent pancreatitis 5, 3
• Monitor for potential myopathy risk when combining statins with fibrates, especially in patients >65 years of age 1

Special Considerations

• Avoid fibrate-statin combinations when possible due to increased myositis risk 5, 9
• Avoid bile acid sequestrants if triglycerides are >200 mg/dL as they may further increase triglyceride levels 1
• For patients with very severe hypertriglyceridemia (≥1,000 mg/dL), consider referral to specialized lipid clinics 1, 3