How to manage high triglycerides?

Management of Hypertriglyceridemia

The most effective approach to managing hypertriglyceridemia is to implement aggressive lifestyle modifications as first-line therapy, followed by appropriate pharmacologic interventions based on triglyceride severity levels, with fibrates being the first-line medication for severe hypertriglyceridemia (≥500 mg/dL) to prevent acute pancreatitis. 1, 2

Classification and Risk 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 (≥1000 mg/dL) 3
• Moderate hypertriglyceridemia (150-499 mg/dL) increases cardiovascular disease risk 2
• Severe hypertriglyceridemia (500-999 mg/dL) significantly increases risk for both cardiovascular disease and acute pancreatitis 2
• Very severe hypertriglyceridemia (≥1000 mg/dL) poses a high risk for acute pancreatitis 2, 4

First-Line Management: Lifestyle Interventions

For All Patients with Hypertriglyceridemia:

• Weight loss is the most effective lifestyle intervention, with a 5-10% reduction in body weight associated with a 20% decrease in triglycerides 1
• In some patients, weight loss can reduce triglyceride levels by up to 70% 1
• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 3
• Limit or completely avoid alcohol consumption, as it significantly raises triglyceride levels 1, 3

Diet Recommendations Based on Triglyceride Levels:

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

  • Limit total fat to 30-35% of total daily calories 3
  • Restrict added sugars to <6% of total daily calories 3
  • Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 1

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

  • Restrict dietary fat to 20-25% of total calories 1
  • Eliminate added sugars completely 1

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

  • Implement a very low-fat diet (10-15% of total calories) 1, 2
  • In some cases, consider extreme dietary fat restriction (<5% of total calories) until triglyceride levels are ≤1000 mg/dL 1
  • Complete abstinence from alcohol 4

Addressing Secondary Causes

• Always evaluate for secondary causes of hypertriglyceridemia 3, 4:
  • Uncontrolled diabetes mellitus (optimize glycemic control first) 1
  • Hypothyroidism 3
  • Chronic kidney disease or nephrotic syndrome 4
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 5
  • Excessive alcohol intake 3

Pharmacologic Therapy

Based on Triglyceride Severity:

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

  • Consider statins if there is elevated LDL-C or increased cardiovascular risk 3
  • If triglycerides remain elevated after 3 months of lifestyle modifications, consider adding prescription omega-3 fatty acids (2-4g/day) 3

• For severe hypertriglyceridemia (≥500 mg/dL):

  • Fibrates are first-line drug therapy to reduce the risk of pancreatitis 2, 4, 5
  • Initial dose of fenofibrate is 54-160 mg per day, with maximum dose of 160 mg once daily 5
  • Prescription omega-3 fatty acids (icosapent ethyl or omega-3 acid ethyl esters) can be used as adjunctive therapy 1, 2

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

  • Immediate implementation of intensive lifestyle modifications plus fibrate therapy 4
  • Consider insulin therapy for acute management, especially in patients with poor glycemic control 2

Monitoring and Follow-up

• Monitor lipid levels periodically and adjust dosage if triglyceride levels fall significantly below target range 5
• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 3
• Consider withdrawing therapy if no adequate response after two months of treatment with maximum recommended dose 5

Important Cautions

• Statin plus fibrate combination therapy has not been shown to improve cardiovascular disease outcomes and generally is not recommended due to increased risk of myositis 4
• Use fenofibrate with caution in patients with renal impairment; start at 54 mg per day in patients with mild to moderate renal impairment 5
• Avoid fenofibrate in patients with severe renal impairment, active liver disease, preexisting gallbladder disease, or known hypersensitivity 5