What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

For hypertriglyceridemia, the first-line approach is lifestyle modifications, followed by pharmacologic therapy with fibrates for severe hypertriglyceridemia (≥500 mg/dL) or statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 1, 2

Classification of Hypertriglyceridemia

• Normal: <150 mg/dL 1
• Mild: 150-199 mg/dL 1
• Moderate: 200-499 mg/dL 2
• Severe: 500-999 mg/dL 1, 2
• Very severe: ≥1,000 mg/dL 1, 2

Initial Assessment

• Evaluate for secondary causes: excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and medications (thiazides, beta-blockers, estrogen, corticosteroids) 1, 2
• Assess cardiovascular risk factors and risk of pancreatitis (particularly with triglycerides ≥500 mg/dL) 2

Lifestyle Interventions

• Target 5-10% weight loss, which can reduce triglycerides by up to 20% 1, 2
• Dietary modifications based on triglyceride levels:
  • Mild to moderate (150-499 mg/dL): Restrict added sugars to <6% of total daily calories and limit total fat to 30-35% 1, 2
  • Severe (500-999 mg/dL): Further restrict added sugars to <5% and total fat to 20-25% of total daily calories 1
  • Very severe (≥1,000 mg/dL): Eliminate added sugars 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 with severe hypertriglyceridemia 1, 2

Pharmacologic Therapy

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

• Fibrates are first-line drug therapy to reduce the risk of pancreatitis 1, 2, 3
• Initial dose of fenofibrate is 54-160 mg per day, with maximum dose of 160 mg once daily 3
• Dosage should be individualized according to patient response and adjusted following repeat lipid determinations at 4-8 week intervals 3
• Optimize glycemic control in patients with diabetes, as this can significantly improve triglyceride levels 1, 2

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Consider statins if there is elevated LDL-C or increased cardiovascular risk (10-30% reduction in triglycerides) 1, 2
• Prescription omega-3 fatty acids (2-4g/day) can be considered for patients with persistent hypertriglyceridemia despite lifestyle modifications 1, 2

For Combined Hyperlipidemia

• First choice: Improved glycemic control plus high-dose statin 4
• Second choice: Improved glycemic control plus statin plus fibric acid derivative 4
• Third choice: Improved glycemic control plus statin plus nicotinic acid 4

Special Considerations

• 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 1
• The combination of statins with nicotinic acid, fenofibrate, and especially gemfibrozil may carry an increased risk of myositis 4, 2
• Fenofibrate should be initiated at a lower dose (54 mg/day) in patients with mild to moderately impaired renal function 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 or starting pharmacotherapy 1, 2
• Therapy should be withdrawn in patients who do not have an adequate response after two months of treatment with the maximum recommended dose 3