What is the treatment for elevated triglycerides (hypertriglyceridemia)?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with lifestyle modifications for all patients, followed by pharmacologic therapy based on triglyceride levels, with fibrates being first-line for severe hypertriglyceridemia (≥500 mg/dL) and statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 1, 2

Classification of Hypertriglyceridemia

• 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
• Mild to moderate hypertriglyceridemia is associated with increased cardiovascular risk, while severe and very severe levels increase the risk of pancreatitis 2

Initial Assessment

• Evaluate for secondary causes including excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and certain medications (thiazides, beta-blockers, estrogen, corticosteroids) 1, 2
• 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

• Target a 5-10% weight loss, which can reduce triglycerides by up to 20% 1, 2, 3
• In some patients, weight loss can reduce triglyceride levels by up to 70% 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 1, 2
• For severe hypertriglyceridemia (500-999 mg/dL), further restrict added sugars and total fat to 20-25% of total daily calories 2, 4
• For very severe hypertriglyceridemia (≥1,000 mg/dL), eliminate added sugars completely 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 in patients with severe hypertriglyceridemia 1, 2, 4
• Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 1, 4

Pharmacologic Therapy Based on Triglyceride Levels

For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are the first-line drug therapy to reduce the risk of pancreatitis 1, 2, 5
• Immediate pharmacologic intervention is required to reduce the risk of acute pancreatitis 1
• Prescription omega-3 fatty acids (2-4g/day) can be used as adjunctive therapy 1, 2

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
• If triglycerides remain elevated after statin therapy, consider adding prescription omega-3 fatty acids (2-4g/day) 1
• Target non-HDL-C of <130 mg/dL 1
• Fibrates may be considered if triglycerides remain significantly elevated despite lifestyle modifications and statin therapy 1

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 2, 4
• 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 2
• Avoid fibrate-statin combinations when possible due to increased risk of myositis 4

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1, 2
• Continue to monitor for secondary causes of hypertriglyceridemia 1

Treatment Efficacy

• Fenofibrate therapy can lower triglycerides by 28.9-54.5% in clinical trials 5
• Combination of dietary intervention and regular aerobic physical activity can result in 20-50% reductions in triglyceride levels 4
• Regular endurance exercise training can reduce triglyceride levels by up to 30% 4