What is the best approach to manage elevated triglycerides (hypertriglyceridemia) in a patient with diabetes (hyperglycemia) who is already on a statin?

Management of Hypertriglyceridemia in a Diabetic Patient on Statin Therapy

For a 67-year-old patient with poorly controlled diabetes (A1c of 10%, blood glucose 221 mg/dL) and elevated triglycerides (319 mg/dL) who is already on a statin, the most effective approach is to add a fibrate (specifically fenofibrate) to the current statin therapy while simultaneously improving glycemic control. 1

Assessment of Current Status

• The patient has moderate hypertriglyceridemia (triglycerides 319 mg/dL), which falls in the 200-499 mg/dL range 1
• Poor glycemic control (A1c of 10%) is significantly contributing to the elevated triglycerides 1
• The slightly low sodium and elevated triglycerides may be related to the uncontrolled diabetes 1
• The patient is already on a statin, which typically provides only modest triglyceride reduction (10-30%) 1

Treatment Algorithm

Step 1: Optimize Glycemic Control

• Improving glycemic control should be prioritized as it can significantly reduce triglyceride levels 1
• Insulin therapy (alone or with insulin sensitizers) may be particularly effective for lowering triglycerides in poorly controlled diabetes 1

Step 2: Implement Lifestyle Modifications

• Recommend a Mediterranean or DASH eating pattern with reduced saturated fat and trans fat 1
• Limit refined carbohydrates and added sugars to <6% of total daily calories 1, 2
• Replace some dietary carbohydrates with unsaturated fats, particularly omega-3 fatty acids 2
• Eliminate alcohol consumption 1, 2
• Target 5-10% weight loss, which can reduce triglycerides by approximately 20% 3
• Encourage at least 150 minutes of moderate-intensity physical activity weekly 2

Step 3: Add Pharmacological Therapy

• Add fenofibrate to the current statin therapy 1
• Fenofibrate is indicated as adjunctive therapy for treatment of severe hypertriglyceridemia 4
• Monitor for potential side effects of combined statin-fibrate therapy, particularly myositis 1
• Consider dose adjustments based on renal function, as fenofibrate requires dose reduction in patients with mild to moderate renal impairment 4

Monitoring and Follow-up

• Reassess fasting lipid panel in 4-12 weeks after implementing medication changes 1
• Monitor for signs of myositis when combining statins with fibrates 1
• Check renal function periodically, as fenofibrate should be avoided in severe renal impairment 4
• Target non-HDL-C level 30 mg/dL higher than LDL goal for moderate hypertriglyceridemia 5

Important Considerations and Caveats

• The combination of statins with fibrates increases the risk of myositis, though the risk of clinical myositis appears to be low 1
• Fenofibrate is preferred over gemfibrozil when combining with statins due to lower risk of myositis 1
• If triglycerides remain elevated despite statin and fibrate therapy, consider adding prescription omega-3 fatty acids 1, 6
• For patients with triglycerides ≥500 mg/dL, the primary goal is to reduce triglyceride levels to lower the risk of pancreatitis 3
• Fenofibrate has not been shown to reduce coronary heart disease morbidity and mortality in patients with type 2 diabetes 4

By addressing both the glycemic control and adding appropriate lipid-lowering therapy, this comprehensive approach should effectively manage the patient's hypertriglyceridemia while minimizing cardiovascular risk.