What is the best treatment for hypertriglyceridemia?

Best Treatment for Hypertriglyceridemia

For hypertriglyceridemia, fibrates are the first-line pharmacologic therapy for severe cases (≥500 mg/dL), while lifestyle modifications are the foundation of treatment for all patients regardless of severity. 1, 2

Classification and Initial Assessment

• Hypertriglyceridemia is classified as: 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
• 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) 2
• Assess cardiovascular risk factors, including family history, central obesity, hypertension, and abnormal glucose metabolism 1
• Determine risk of pancreatitis, particularly with triglycerides ≥500 mg/dL 1

Treatment Algorithm Based on Severity

For All Severity Levels - Lifestyle Modifications

• Target 5-10% weight loss, which can reduce triglycerides by up to 20% 1, 2
• Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 2
• Limit or completely avoid alcohol consumption 1, 2
• Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 1

Dietary Recommendations by Severity

• Mild to moderate (150-499 mg/dL): Restrict added sugars to <6% of total daily calories and limit total fat to 30-35% of total daily calories 2
• Severe (500-999 mg/dL): Further restrict added sugars to <5% and total fat to 20-25% of total daily calories 2
• Very severe (≥1000 mg/dL): Eliminate added sugars and restrict total fat to 10-15% of daily calories 2

Pharmacologic Therapy

• For severe to very severe hypertriglyceridemia (≥500 mg/dL): Fibrates are first-line drug therapy to reduce pancreatitis risk 1, 2, 3
  • Initial dose of fenofibrate is 54-160 mg per day, with maximum dose of 160 mg daily 3
• For moderate hypertriglyceridemia with elevated LDL-C or increased cardiovascular risk: Consider statins first, which can provide 10-30% reduction in triglycerides 1
• For persistent hypertriglyceridemia despite lifestyle modifications: Consider prescription omega-3 fatty acids (2-4g/day) 1, 2
• For patients with diabetes and hypertriglyceridemia: Optimize glycemic control 1

Special Considerations

• For triglycerides ≥500 mg/dL, prioritize aggressive triglyceride lowering to reduce pancreatitis risk before focusing on LDL-C goals 1, 2
• Avoid fenofibrate in patients with severe renal impairment 3
• Monitor for potential drug interactions, particularly when combining lipid-lowering medications 2
• Take fenofibrate with meals to optimize bioavailability 3
• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1
• Consider discontinuing therapy if no adequate response after two months of treatment with maximum recommended dose 3

Treatment Pitfalls to Avoid

• Don't overlook secondary causes of hypertriglyceridemia, which may obviate the need for specific drug therapy 3
• Don't delay pharmacologic therapy for severe hypertriglyceridemia (≥500 mg/dL) due to pancreatitis risk 1
• Don't use bile acid sequestrants when triglycerides are >200 mg/dL as they may worsen hypertriglyceridemia 1
• Don't combine fibrates with statins without careful monitoring for myopathy risk, especially in patients >65 years 1
• Don't underestimate the impact of lifestyle modifications, which can reduce triglyceride levels by up to 70% in some patients 1, 4