What is the treatment for hypertriglyceridemia?

Treatment for Hypertriglyceridemia

The treatment for hypertriglyceridemia should begin with aggressive lifestyle modifications, followed by pharmacologic therapy with fibrates for severe hypertriglyceridemia (≥500 mg/dL) or statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 1, 2

Classification and Initial 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) 1
• Before initiating treatment, evaluate for secondary causes such as excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and medications (estrogen therapy, thiazide diuretics, beta-blockers) 1, 3
• Assess cardiovascular risk factors, including family history, central obesity, hypertension, and abnormal glucose metabolism 1
• Determine the risk of pancreatitis, particularly with triglycerides ≥500 mg/dL 1

Lifestyle Interventions (First-Line Therapy)

• Target 5-10% weight loss, which can reduce triglycerides by approximately 20% 1, 4
• For moderate hypertriglyceridemia, restrict total fat to 20-25% of total daily calories 4
• For severe hypertriglyceridemia (≥500 mg/dL), further restrict fat to 10-15% of calories 2, 4
• For very severe hypertriglyceridemia (≥1000 mg/dL), implement a very low-fat diet (10-15% of total calories) and eliminate added sugars completely 1
• Limit added sugars to <6% of total daily calories 1, 4
• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1, 4
• Limit or completely avoid alcohol consumption 1, 4
• Low-carbohydrate diets may be more effective than low-fat diets for triglyceride reduction in some patients 1

Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line drug therapy to reduce the risk of pancreatitis 1, 2
• Initial dose of fenofibrate is 54 mg to 160 mg per day, with dosage individualized according to patient response 3
• Monitor lipid levels at 4 to 8 week intervals and adjust dosage if necessary 3
• The maximum dose of fenofibrate is 160 mg once daily 3
• Prescription omega-3 fatty acids can be added if triglycerides remain elevated 2

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins are first-line therapy if 10-year ASCVD risk ≥7.5% or if LDL-C is also elevated 2
• Statins can provide a 10-30% reduction in triglycerides 1
• If triglycerides remain elevated after statin therapy, consider adding prescription omega-3 fatty acids (2-4g/day) 1
• Consider fenofibrate as an add-on therapy if triglycerides remain significantly elevated and cardiovascular risk is high 1

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 4
• Avoid fibrate-statin combinations when possible due to increased risk of myositis 2
• For patients with renal impairment, start fenofibrate at a lower dose (54 mg/day) and avoid in severe renal impairment 3
• Monitor for potential myopathy risk, especially in patients >65 years of age, if combination therapy with a fibrate is considered 1
• Avoid bile acid sequestrants if triglycerides are >200 mg/dL 1

Treatment Goals and Monitoring

• For moderate hypertriglyceridemia, target non-HDL cholesterol level 30 mg/dL higher than LDL goal 2
• For severe hypertriglyceridemia, primary goal is to reduce triglycerides below 500 mg/dL to prevent pancreatitis 2
• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1
• Consider withdrawing therapy in patients who do not have an adequate response after two months of treatment with the maximum recommended dose 3

Clinical Pearls

• The combination of dietary intervention and regular aerobic physical activity can result in 20-50% reductions in triglyceride levels 4
• In some patients, weight loss can reduce triglyceride levels by up to 70% 1
• Improving glycemic control in diabetic patients showing fasting chylomicronemia will usually obviate the need for pharmacologic intervention 3
• Fenofibrate should be given with meals to optimize bioavailability 3