What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The first-line treatment for hypertriglyceridemia includes lifestyle modifications such as weight loss, dietary changes, exercise, and alcohol restriction, followed by pharmacologic therapy with fibrates for severe hypertriglyceridemia (≥500 mg/dL) or statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 1, 2

Classification and Risk 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 (≥1,000 mg/dL) 1, 2
• Moderate hypertriglyceridemia increases cardiovascular risk, while levels ≥500 mg/dL significantly increase the risk of acute pancreatitis 1, 3
• Before initiating treatment, evaluate for secondary causes including alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and 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
• In some patients, weight loss can reduce triglyceride levels by up to 50-70% 1, 4
• Dietary recommendations based on triglyceride levels:
  • For mild to moderate hypertriglyceridemia: Restrict added sugars to <6% of total daily calories and limit total fat to 30-35% of total daily calories 1, 2
  • 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 (≥1,000 mg/dL): Eliminate added sugars and restrict total fat to 10-15% of daily calories 1, 3
• 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 in patients with severe hypertriglyceridemia 1, 2

Pharmacologic Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates are first-line drug therapy to reduce the risk of pancreatitis 1, 2, 5
• Initial dose of fenofibrate is 54-160 mg per day, with dosage individualized according to patient response 5
• Prescription omega-3 fatty acids (2-4g/day) can be used as adjunctive therapy 1, 4
• Prioritize aggressive triglyceride lowering to reduce pancreatitis risk before focusing on LDL-C goals 1, 2

For Moderate Hypertriglyceridemia (200-499 mg/dL)

• Statins are recommended if there is elevated LDL-C or increased cardiovascular risk, providing a 10-30% reduction in triglycerides 1, 2
• If triglycerides remain elevated after statin therapy, consider adding prescription omega-3 fatty acids (2-4g/day) 1
• Icosapent ethyl (prescription EPA) is indicated as an adjunct to maximally tolerated statin therapy to reduce cardiovascular risk in patients with triglycerides ≥150 mg/dL and established cardiovascular disease or diabetes with ≥2 additional risk factors 4

Special Considerations

• Optimize glycemic control in patients with diabetes, as it can significantly improve triglyceride levels 1, 5
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids 4, 1
• Use caution when combining fibrates with statins due to increased risk of myositis 1, 2
• For patients with very severe hypertriglyceridemia (≥1,000 mg/dL), consider extreme dietary fat restriction (<5% of total calories) until triglyceride levels are ≤1,000 mg/dL 1

Monitoring and Follow-up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications or starting pharmacotherapy 1, 2
• Consider withdrawing therapy if there is no adequate response after two months of treatment with the maximum recommended dose 5
• Monitor for potential drug interactions, particularly when combining lipid-lowering medications 1, 2

Treatment Algorithm

1. First step: Implement appropriate lifestyle modifications for all patients 1, 2
2. For triglycerides ≥500 mg/dL: Initiate fibrate therapy immediately to reduce pancreatitis risk 1, 2, 5
3. For triglycerides 200-499 mg/dL: Assess cardiovascular risk and consider statin therapy if risk is elevated 1, 2
4. If inadequate response: Add prescription omega-3 fatty acids or consider combination therapy 1, 4
5. For patients with diabetes: Optimize glycemic control as a priority 1, 5