Treatment of Hypertriglyceridemia
The treatment of hypertriglyceridemia should begin with aggressive lifestyle modifications, followed by pharmacologic therapy with fibrates as first-line medication for severe hypertriglyceridemia (≥500 mg/dL) to reduce pancreatitis risk, while statins are preferred for moderate hypertriglyceridemia with elevated cardiovascular risk. 1, 2
Classification and Initial Assessment
- Hypertriglyceridemia is classified by severity: Normal (<150 mg/dL), Mild (150-199 mg/dL), Moderate (200-999 mg/dL), Severe (1,000-1,999 mg/dL), and Very Severe (≥2,000 mg/dL) 1
- Mild to moderate hypertriglyceridemia increases cardiovascular risk, while severe and very severe levels significantly increase the risk of acute pancreatitis 1, 2
- Before initiating treatment, evaluate for secondary causes including:
Lifestyle Interventions
- Weight loss is the most effective lifestyle intervention - target 5-10% weight reduction, which can decrease triglycerides by up to 20% 1, 2
- In some patients, weight loss can reduce triglyceride levels by up to 70% 2
- Dietary modifications based on triglyceride levels:
- Mild to moderate (150-499 mg/dL): Restrict added sugars to <6% of total daily calories and limit total fat to 30-35% of total daily calories 1, 2
- Severe (500-999 mg/dL): Further restrict added sugars to <5% and total fat to 20-25% of total daily calories 1
- Very severe (≥1,000 mg/dL): Eliminate added sugars and restrict total fat to 10-15% of daily calories 1, 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 with severe hypertriglyceridemia 1, 2
- Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 2
Pharmacologic Therapy
For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)
- Fibrates are first-line drug therapy to reduce the risk of pancreatitis 1, 2, 3
- Initial dose of fenofibrate is 54 mg to 160 mg per day, with dosage individualized according to patient response 3
- Dosage should be adjusted following repeat lipid determinations at 4 to 8 week intervals, with maximum dose of 160 mg once daily 3
- For patients with renal impairment, start with 54 mg per day and avoid use in severe renal impairment 3
For Moderate Hypertriglyceridemia (200-499 mg/dL)
- Consider statins if there is elevated LDL-C or increased cardiovascular risk, which can provide a 10-30% reduction in triglycerides 1, 2
- Prescription omega-3 fatty acids (2-4g/day) can be considered for patients with persistent hypertriglyceridemia despite lifestyle modifications 1, 2
- If triglycerides remain elevated >200 mg/dL after 3 months of optimized lifestyle modifications, consider adding prescription omega-3 fatty acids or fenofibrate as add-on therapy 2
Special Considerations
- Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 2
- For patients with triglycerides ≥500 mg/dL, prioritize aggressive triglyceride lowering to reduce the risk of pancreatitis before focusing on LDL-C goals 1, 2
- Monitor for potential drug interactions, particularly when combining lipid-lowering medications 1
- Fenofibrate should be given with meals to optimize bioavailability 3
- Fenofibrate has been shown to decrease VLDL triglycerides by 44-50% in patients with severe hypertriglyceridemia 3
- Avoid bile acid sequestrants if triglycerides are >200 mg/dL 2
- Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 2
Monitoring and Follow-up
- Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1
- Consider reducing the dosage of fenofibrate if lipid levels fall significantly below the targeted range 3
- Withdraw therapy in patients who do not have an adequate response after two months of treatment with the maximum recommended dose 3
- Continue appropriate lipid-lowering diet during treatment with fenofibrate 3