What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with lifestyle modifications, followed by pharmacologic therapy based on triglyceride severity, with fibrates as first-line drug therapy for severe hypertriglyceridemia and statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 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
• Mild to moderate hypertriglyceridemia is associated with increased cardiovascular risk, while severe and very severe levels increase the risk of pancreatitis 2
• Before initiating treatment, 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

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, 2
• 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
• For severe hypertriglyceridemia (500-999 mg/dL), further restrict added sugars and limit total fat to 20-25% of total daily calories 1
• For very severe hypertriglyceridemia (≥1000 mg/dL), eliminate added sugars completely 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
• Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 1

Pharmacologic Therapy

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 3 months of optimized lifestyle modifications, consider adding prescription omega-3 fatty acids (2-4g/day) 1
• Target non-HDL-C <130 mg/dL for patients with triglycerides 200-499 mg/dL 1

Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are the first-line drug therapy to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia 2, 3
• The initial dose of fenofibrate is 54 mg to 160 mg per day, with dosage individualized according to patient response 3
• Prescription omega-3 fatty acids (2-4g/day) can be used as adjunctive therapy 1, 2
• Immediate pharmacologic intervention is required to reduce the risk of acute pancreatitis for triglycerides ≥500 mg/dL 1

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 2
• For patients with triglycerides ≥500 mg/dL, prioritize aggressive triglyceride lowering to reduce the risk of pancreatitis before focusing on LDL-C goals 1
• Monitor for potential drug interactions, particularly when combining lipid-lowering medications such as fibrates with statins (increased risk of myositis) 1
• Fenofibrate should be taken with meals to optimize bioavailability 3
• In patients with renal impairment, start fenofibrate at 54 mg per day and increase only after evaluating effects on renal function 3
• Fenofibrate is contraindicated in patients with severe renal impairment, active liver disease, preexisting gallbladder disease, and nursing mothers 3

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications or starting pharmacologic therapy 1, 2
• Consider withdrawing therapy in patients who do not have an adequate response after two months of treatment with the maximum recommended dose 3
• Monitor for side effects of medications, including myopathy with statin-fibrate combinations 1
• For fenofibrate, the maximum dose is 160 mg once daily 3

Common Pitfalls to Avoid

• Do not overlook secondary causes of hypertriglyceridemia, as addressing these may obviate the need for specific drug therapy 3
• Do not delay aggressive dietary intervention while waiting for medications to take effect in patients with severe hypertriglyceridemia 1
• Avoid bile acid sequestrants if triglycerides are >200 mg/dL as they can worsen hypertriglyceridemia 1
• Do not combine fibrates with statins without careful monitoring for myopathy 1
• Do not overlook the importance of glycemic control in patients with diabetes 1, 2