What is the treatment for high triglycerides?

Treatment of High Triglycerides

The treatment of high triglycerides should begin with lifestyle modifications followed by appropriate pharmacologic therapy based on triglyceride levels, with fibrates being the first-line drug therapy for severe hypertriglyceridemia (≥500 mg/dL) to prevent pancreatitis. 1

Classification of Hypertriglyceridemia

• Normal: <150 mg/dL 1
• Mild: 150-199 mg/dL 1
• Moderate: 200-499 mg/dL 1
• Severe: 500-999 mg/dL 1
• Very severe: ≥1000 mg/dL 1

Initial Assessment

• Evaluate for secondary causes before initiating treatment 1:

  • Excessive alcohol intake
  • Uncontrolled diabetes
  • Hypothyroidism
  • Renal disease
  • Liver disease
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 2

• Assess cardiovascular risk factors 1:

  • Family history
  • Central obesity
  • Hypertension
  • Abnormal glucose metabolism

Treatment Approach Based on Triglyceride Levels

For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL)

1. Lifestyle Interventions 1:

   • Target 5-10% weight loss to reduce triglycerides by 20%
   • Restrict added sugars to <6% of total daily calories
   • Limit total fat to 30-35% of total daily calories
   • Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity
   • Limit or avoid alcohol consumption

2. Pharmacologic Therapy 1, 3:

   • Statins are first-line therapy if there is elevated LDL-C or increased cardiovascular risk (can provide 10-30% reduction in triglycerides)
   • For patients with clinical ASCVD and persistent hypertriglyceridemia, high-intensity statin therapy is recommended as it provides greater triglyceride reduction than moderate- or low-intensity statins 3
   • Consider adding prescription omega-3 fatty acids (2-4g/day) if triglycerides remain elevated after 3 months of optimized lifestyle modifications 1

For Severe Hypertriglyceridemia (500-999 mg/dL)

1. Immediate Dietary Modifications 4:

   • Restrict dietary fat to 20-25% of total calories
   • Eliminate added sugars completely
   • Completely restrict alcohol consumption

2. Pharmacologic Therapy 1, 2:

   • Fibrates (fenofibrate) are first-line drug therapy to reduce the risk of pancreatitis
   • Initial dose of fenofibrate is 54 mg to 160 mg per day, individualized according to patient response 2
   • Dosage should be adjusted following repeat lipid determinations at 4 to 8 week intervals 2
   • Maximum dose is 160 mg once daily 2
   • Prescription omega-3 fatty acids can be used as adjunctive therapy 4

For Very Severe Hypertriglyceridemia (≥1000 mg/dL)

1. Extreme Dietary Modifications 4:

   • Implement very low-fat diet (10-15% of total calories)
   • In some cases, consider extreme dietary fat restriction (<5% of total calories) until triglyceride levels are ≤1000 mg/dL
   • Completely eliminate added sugars and alcohol consumption

2. Pharmacologic Therapy 4, 2:

   • Fibrates are first-line therapy
   • Consider insulin therapy for acute management, especially in patients with poor glycemic control
   • Prescription omega-3 fatty acids as adjunctive therapy

Special Considerations

• Diabetes Management: Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1

• Renal Impairment: For patients with mild to moderate renal impairment, initiate fenofibrate at 54 mg per day and increase only after evaluating effects on renal function and lipid levels 2

• Geriatric Patients: Dose selection should be based on renal function 2

• Monitoring: Lipid levels should be monitored periodically, and therapy should be withdrawn if there is no adequate response after two months of treatment with the maximum recommended dose 2

• Contraindications for Fibrates 2:

  • Severe renal impairment
  • Active liver disease
  • Preexisting gallbladder disease
  • Nursing mothers
  • Known hypersensitivity to fenofibrate or fenofibric acid

Treatment Algorithm

1. Identify severity of hypertriglyceridemia and assess risk:

   • If TG ≥500 mg/dL: Focus on preventing pancreatitis 1
   • If TG <500 mg/dL: Focus on cardiovascular risk reduction 3

2. Address secondary causes 1

3. Implement appropriate lifestyle modifications based on TG level 1, 4

4. Initiate pharmacologic therapy based on TG level:

   • TG 150-499 mg/dL with elevated LDL-C or cardiovascular risk: Start with statin 3, 1
   • TG ≥500 mg/dL: Start with fibrate 1, 2

5. Consider adjunctive therapy if goals not met:

   • Add omega-3 fatty acids 1, 4
   • For patients with clinical ASCVD and LDL-C ≥70 mg/dL on maximally tolerated statin therapy, consider adding ezetimibe 3

6. Monitor response and adjust therapy accordingly 2

By following this structured approach, clinicians can effectively manage hypertriglyceridemia while reducing the risk of pancreatitis and cardiovascular disease.