What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with lifestyle modifications as first-line therapy, followed by pharmacologic interventions based on triglyceride severity, with fibrates being the first-line drug therapy for severe hypertriglyceridemia (≥500 mg/dL) to reduce pancreatitis risk. 1, 2

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, 2

Initial Assessment

• Evaluate for secondary causes before initiating treatment: 1, 2
  • Excessive alcohol intake
  • Uncontrolled diabetes
  • Hypothyroidism
  • Renal disease
  • Liver disease
  • Medications (thiazides, beta-blockers, estrogen, corticosteroids)

Treatment Algorithm

1. Lifestyle Interventions (First-line for all patients)

• Weight loss: Target 5-10% reduction in body weight, which can decrease triglycerides by 20% 3, 1
• Dietary modifications: 1, 2
  • For mild-moderate hypertriglyceridemia: Restrict added sugars to <6% of daily calories and limit total fat to 30-35% of daily calories
  • For severe hypertriglyceridemia (500-999 mg/dL): Further restrict added sugars to <5% and total fat to 20-25% of daily calories
  • For very severe hypertriglyceridemia (≥1000 mg/dL): Eliminate added sugars and restrict total fat to 10-15% of daily calories
• Physical activity: At least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Alcohol: Limit or completely avoid alcohol consumption, especially with severe hypertriglyceridemia 1, 2

2. Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line drug therapy to reduce pancreatitis risk 1, 4
  • Initial dose: 54-160 mg per day, maximum 160 mg daily 4
  • Dosage should be individualized based on patient response 4
  • Monitor lipid levels at 4-8 week intervals and adjust dosage as needed 4
• Prescription omega-3 fatty acids (2-4g/day) can be used as adjunctive therapy 1, 2
  • Icosapent ethyl (ethyl ester of EPA) is FDA-approved for reducing cardiovascular risk in patients with triglycerides ≥150 mg/dL with established cardiovascular disease or diabetes with ≥2 additional risk factors 3
  • Monitor for increased risk of atrial fibrillation with omega-3 fatty acids 3, 1

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

• Statins if there is elevated LDL-C or increased cardiovascular risk (can reduce triglycerides by 10-30%) 1, 2
• If triglycerides remain elevated after 3 months of optimized lifestyle modifications and statin therapy, consider adding: 1
  • Prescription omega-3 fatty acids (2-4g/day)
  • Fenofibrate as add-on therapy if cardiovascular risk is high

Special Considerations

• Optimize glycemic control in patients with diabetes, as it significantly improves triglyceride levels 1, 2
• For patients with renal impairment, initiate fenofibrate at 54 mg daily and avoid in severe renal impairment 4
• Fibrates are contraindicated in patients with active liver disease, preexisting gallbladder disease, or severe renal impairment 4
• When combining statins with fibrates, monitor for increased risk of myopathy 1
• Avoid bile acid sequestrants when triglycerides are >200 mg/dL 1

Monitoring

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications or starting pharmacotherapy 1, 2
• Consider withdrawing therapy if there is inadequate response after two months of treatment with maximum recommended doses 4
• For severe hypertriglyceridemia, the primary goal is to reduce triglycerides to <500 mg/dL to prevent pancreatitis 1
• For moderate hypertriglyceridemia, target non-HDL-C <130 mg/dL 1

Clinical Pitfalls to Avoid

• Don't focus solely on LDL-C in patients with hypertriglyceridemia; address the elevated triglycerides to reduce pancreatitis risk in severe cases 1, 2
• Don't overlook secondary causes of hypertriglyceridemia before initiating pharmacologic therapy 1, 2
• Be cautious when combining fibrates with statins due to increased risk of myopathy 1
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 3, 1