From the Guidelines
Lifestyle interventions, including weight loss, dietary changes, and regular exercise, are the first line of therapy for managing hypertriglyceridemia, as they can effectively lower triglyceride levels and reduce the risk of cardiovascular events. According to the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1, lifestyle modifications are recommended as the initial treatment for all patients with hypertriglyceridemia.
Some key lifestyle interventions for hypertriglyceridemia include:
- Weight loss of 5-10% of body weight, which can lead to a 20% decrease in triglyceride levels 1
- A low-carbohydrate diet with less than 50% of calories from carbohydrates
- Regular exercise, such as 150 minutes of moderate activity per week
- Alcohol restriction and avoidance of added sugars and refined carbohydrates
For patients with severely elevated triglyceride levels (≥500 mg/dL), immediate intervention is necessary to prevent pancreatitis. Prescription omega-3 fatty acids, such as icosapent ethyl (Vascepa) 2g twice daily, have been shown to be effective in reducing triglyceride levels and cardiovascular risk 1. Fibrates, such as fenofibrate (145mg daily) or gemfibrozil (600mg twice daily), are also effective but carry interaction risks with statins. Statins may be added for patients with concomitant LDL elevation or cardiovascular risk.
Regular monitoring every 3-6 months is essential to assess treatment efficacy and adjust the management plan as needed. The goal of treatment is to reduce triglyceride levels, prevent cardiovascular events, and improve overall quality of life. As noted in the 2020 standards of medical care in diabetes, hypertriglyceridemia should be addressed with dietary and lifestyle changes, and pharmacologic therapy may be necessary for severe cases 1.
From the FDA Drug Label
The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Estrogen therapy, thiazide diuretics and beta-blockers, are sometimes associated with massive rises in plasma triglycerides, especially in subjects with familial hypertriglyceridemia In such cases, discontinuation of the specific etiologic agent may obviate the need for specific drug therapy of hypertriglyceridemia.
The management options for hypertriglyceridemia include:
- Dietary therapy: specific for the type of lipoprotein abnormality
- Addressing excess body weight and alcoholic intake
- Physical exercise as an ancillary measure
- Treating underlying diseases such as hypothyroidism or diabetes mellitus
- Discontinuation of etiologic agents like estrogen therapy, thiazide diuretics, and beta-blockers
- Fenofibrate therapy: with initial doses ranging from 54 mg to 160 mg per day, depending on the patient's response and renal function 2 2
From the Research
Management Options for Hypertriglyceridemia
The management of hypertriglyceridemia involves a combination of lifestyle modifications and pharmacological treatments.
- Lifestyle modifications are the first line of treatment and include:
- Cessation of alcohol consumption 3, 4
- Reduced intake of rapidly metabolized carbohydrates 3, 5
- Weight loss 3, 5, 4
- Blood sugar control 3
- Increased physical activity, such as moderate- to high-intensity exercise 5, 4
- Dietary changes, including lowering carbohydrate intake and increasing fat and protein intake 5
- Pharmacological treatments may be necessary for patients with severely elevated triglyceride levels or those who do not respond to lifestyle modifications.
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of cardiovascular disease 5, 6, 7
- Fibrates can lower triglyceride concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3, 6, 7
- Omega-3 fatty acids can lower triglyceride levels, with a daily dose of 2-4 g being effective 3, 5, 7
- Niacin can improve control of triglyceride levels when other measures are inadequately effective 6, 7
- Novel therapies, such as anti-sense oligonucleotides and inhibitors of microsomal triglyceride transfer protein, have shown significant triglyceride-lowering efficacy 6
Special Considerations
- Patients with severely elevated triglyceride levels (≥ 500 mg/dL) are at increased risk of pancreatitis and may require immediate treatment with triglyceride-lowering agents 5, 7
- Patients with acute pancreatitis associated with hypertriglyceridemia may require insulin infusion and plasmapheresis if triglyceride levels remain elevated despite conservative management 5
- Patients with purely genetic types of hypertriglyceridemia, such as familial chylomicronemia syndrome, should be treated in specialized outpatient clinics 3