What are the treatments for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The first-line approach for hypertriglyceridemia is lifestyle modification, with pharmacologic therapy reserved for severe cases (≥500 mg/dL) or when lifestyle changes are insufficient to reduce cardiovascular risk in moderate hypertriglyceridemia. 1, 2

Classification and Diagnosis

• Hypertriglyceridemia is classified by severity: 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
• Moderate hypertriglyceridemia is associated with increased cardiovascular risk, while levels ≥500 mg/dL significantly increase the risk of acute pancreatitis 2
• Before initiating treatment, evaluate for secondary causes including excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and medications (thiazides, beta-blockers, estrogen, corticosteroids) 1, 2

Lifestyle Interventions

• Weight loss is the most effective lifestyle intervention, with a 5-10% reduction in body weight associated with a 20% decrease in triglycerides 1
• Restrict added sugars to <6% of total daily calories and limit total fat to 30-35% of total daily calories for mild to moderate hypertriglyceridemia 2
• For severe hypertriglyceridemia (500-999 mg/dL), further restrict dietary fat to 20-25% of total calories 1
• For very severe hypertriglyceridemia (≥1000 mg/dL), eliminate added sugars and restrict total fat to 10-15% of daily calories 2
• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Limit or completely avoid alcohol consumption, especially in patients with severe hypertriglyceridemia 1, 2

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 54-160 mg daily, with dosage individualized according to patient response 3
• Reassess lipid levels at 4-8 week intervals to adjust dosing as needed 3
• Fenofibrate should be given with meals to optimize bioavailability 3

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins are first-line if there is elevated LDL-C or increased cardiovascular risk, providing 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
• Fibrates can be considered if triglycerides remain significantly elevated despite other interventions 1

For Mixed Dyslipidemia

• Focus primarily on lowering LDL-C levels, with secondary goals of lowering non-HDL-C levels 4
• Non-HDL-C target should be <130 mg/dL for patients with triglycerides 200-499 mg/dL 1

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1
• For patients with triglycerides ≥500 mg/dL, prioritize aggressive triglyceride lowering to reduce pancreatitis risk before focusing on LDL-C goals 1, 2
• Use caution when combining fibrates with statins due to increased risk of myopathy 1
• Avoid fenofibrate in patients with severe renal impairment, active liver disease, preexisting gallbladder disease, or during nursing 3
• Start fenofibrate at 54 mg daily in patients with mild to moderate renal impairment 3

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1
• Monitor for drug interactions, particularly when combining lipid-lowering medications 2
• Consider discontinuing therapy if there is no adequate response after two months of treatment with maximum recommended dose 3

Treatment Algorithm

1. For all patients: Implement lifestyle modifications (weight loss, dietary changes, exercise, alcohol restriction) 1, 2
2. For triglycerides 200-499 mg/dL:
   • Assess cardiovascular risk and LDL-C levels 1
   • If elevated LDL-C or high cardiovascular risk, start statin therapy 1
   • If triglycerides remain elevated after 3 months, consider adding omega-3 fatty acids or fibrates 1
3. For triglycerides ≥500 mg/dL:
   • Start fibrate therapy immediately to reduce pancreatitis risk 1, 2
   • Consider prescription omega-3 fatty acids as adjunctive therapy 1
   • Implement more aggressive dietary restrictions 2