How to manage high triglycerides?

Management of High Triglycerides

Lifestyle modifications combined with appropriate pharmacologic therapy based on triglyceride levels are the cornerstone of managing hypertriglyceridemia. 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 of hypertriglyceridemia including:
  • Uncontrolled diabetes 1, 2
  • Hypothyroidism 1
  • Renal disease 1
  • Liver disease 1
  • Medications (estrogen therapy, thiazide diuretics, beta-blockers) 3
  • Excessive alcohol consumption 1, 4
• Assess cardiovascular risk factors 1
• Determine risk of pancreatitis, particularly with triglycerides ≥500 mg/dL 1

First-Line Management: Lifestyle Modifications

Diet Recommendations

• Restrict added sugars to <6% of total daily calories for mild to moderate hypertriglyceridemia 1
• Limit total fat to 30-35% of total daily calories for mild to moderate hypertriglyceridemia 1
• For severe hypertriglyceridemia (500-999 mg/dL):
  • Restrict dietary fat to 20-25% of total calories 2
  • Restrict added sugars to <5% of total calories 5
• For very severe hypertriglyceridemia (≥1000 mg/dL):
  • Restrict total fat to 10-15% of daily calories 2
  • Eliminate added sugars completely 2

Weight Management

• Target 5-10% weight loss, which can reduce triglycerides by up to 20% 1, 6
• In some patients, weight loss can reduce triglyceride levels by up to 70% 1

Physical Activity

• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Regular endurance exercise training is most effective when baseline triglycerides are elevated (≥150 mg/dL) 5

Alcohol Consumption

• Limit or completely avoid alcohol for mild to moderate hypertriglyceridemia 1
• Complete abstinence from alcohol for severe hypertriglyceridemia 4

Pharmacologic Therapy Based on Triglyceride Levels

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

• If cardiovascular risk is elevated, consider statins as first-line therapy 1
• If triglycerides remain elevated after 3 months of optimized lifestyle modifications, consider adding:
  • Prescription omega-3 fatty acids (2-4g/day) 1
  • Fenofibrate as add-on therapy if cardiovascular risk is high 1

Severe Hypertriglyceridemia (500-999 mg/dL)

• Fibrates (fenofibrate) are first-line pharmacologic therapy to reduce risk of pancreatitis 1, 4
• Initial dose of fenofibrate is 54-160 mg per day 3
• Dosage should be individualized according to patient response with repeat lipid determinations at 4-8 week intervals 3
• Maximum dose is 160 mg once daily 3

Very Severe Hypertriglyceridemia (≥1000 mg/dL)

• Immediate implementation of very low-fat diet plus fibrate therapy 2, 4
• Consider insulin therapy for acute management, especially in patients with poor glycemic control 2
• Prescription omega-3 fatty acids may be used as adjunctive therapy 2

Special Considerations

Diabetes Management

• Optimize glycemic control in patients with diabetes, as it significantly improves triglyceride levels 1
• Target HbA1c <7% for patients with impaired glucose metabolism 1

Renal Impairment

• For patients with mild to moderate renal impairment, initiate fenofibrate at 54 mg per day 3
• Avoid fenofibrate in patients with severe renal impairment 3

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1
• Monitor for potential myopathy risk if combination therapy with statin and fibrate is considered 1
• Withdraw therapy if no adequate response after two months of treatment with maximum recommended dose 3

Common Pitfalls and Caveats

• Statin plus fibrate combination therapy has not been shown to improve cardiovascular outcomes and increases risk of myositis 4
• Bile acid sequestrants are contraindicated when triglycerides are >200 mg/dL 1
• Prioritize aggressive triglyceride lowering in patients with levels ≥500 mg/dL to reduce pancreatitis risk 1
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 1