What is the treatment for elevated triglycerides and low-density lipoprotein (LDL) cholesterol levels?

Treatment of Triglycerides 200 mg/dL and LDL 120 mg/dL

Begin with intensive therapeutic lifestyle changes (TLC) for 12 weeks, targeting saturated fat reduction to <7% of calories, adding plant stanols/sterols, and increasing soluble fiber; if LDL remains >130 mg/dL after this period or if you have diabetes or established cardiovascular disease, initiate statin therapy immediately with a goal LDL <100 mg/dL. 1, 2

Initial Risk Stratification

Your lipid values place you in a treatment category that requires careful assessment:

• Triglycerides at 200 mg/dL exceed the optimal goal of <150 mg/dL and indicate metabolic dysfunction requiring intervention 1, 2
• LDL at 120 mg/dL is above the optimal target of <100 mg/dL but below the threshold that automatically triggers medication in all patients 1

The decision to use medication depends critically on your cardiovascular risk profile, which must be calculated using the Framingham Risk Score if you have ≥2 risk factors 1.

First-Line Treatment: Intensive Lifestyle Modifications (12-Week Trial)

Dietary Changes - The Foundation

Saturated fat restriction is the single most effective dietary intervention: limit saturated fatty acids to <7% of total daily calories and dietary cholesterol to <200 mg/day 1, 2. This intervention alone can reduce LDL by 10-15% 1.

Eliminate all trans-unsaturated fatty acids completely from your diet, as these worsen both LDL and triglycerides 1, 2.

Add specific cholesterol-lowering foods:

• Plant stanols/sterols at 2 g/day enhance LDL lowering by an additional 6-15% 1, 2
• Increase viscous (soluble) fiber to 10-25 g/day for additional LDL reduction 1, 2

For triglyceride reduction specifically:

• Reduce simple sugar intake significantly, as refined carbohydrates directly raise triglycerides 1
• Increase dietary omega-3 fatty acids from fish 1
• Eliminate or severely restrict alcohol consumption, which is a major triglyceride driver 1

Weight Loss and Physical Activity

If you are overweight, even modest weight loss (5-10% of body weight) will significantly reduce triglycerides and modestly lower LDL 1, 2. Weight reduction is particularly effective when triglycerides are elevated 1.

Regular physical activity reduces plasma triglycerides and improves insulin sensitivity independent of weight loss 1, 2.

Address Secondary Causes

Before starting any medication, evaluate and treat:

• Diabetes or prediabetes - optimize glycemic control, as this is highly effective for triglyceride reduction 1
• Hypothyroidism - check TSH 1
• Medications that worsen lipids: thiazide diuretics, beta-blockers, estrogen therapy 3

When to Initiate Statin Therapy

Immediate Statin Initiation (No 12-Week Wait)

Start a statin immediately if you have any of the following, regardless of your current LDL of 120 mg/dL:

• Diabetes mellitus (diabetes is now considered a "CHD risk equivalent") 1
• Established cardiovascular disease 1
• 10-year Framingham risk ≥20% 1

Goal: LDL <100 mg/dL 1, 2

Statin After 12-Week Lifestyle Trial

If you do NOT have diabetes or established CVD:

• Complete a full 12-week trial of intensive TLC first 1, 2
• Recheck lipids after 12 weeks 2
• If LDL remains >130 mg/dL, initiate statin therapy 1
• If LDL is 100-129 mg/dL and you have ≥2 risk factors with 10-year risk 10-20%, statin therapy is a reasonable option 1

Addressing Persistent Triglyceride Elevation

If Triglycerides Remain Elevated on Statin

The decision point for adding triglyceride-specific therapy is between 200-400 mg/dL, based on clinical judgment 1. However, specific scenarios warrant more aggressive action:

Add fibrate therapy if:

• Triglycerides remain >400 mg/dL despite optimal glycemic control and lifestyle changes, to reduce pancreatitis risk 1
• You have established ASCVD or diabetes with ≥2 risk factors and triglycerides 135-499 mg/dL on maximally tolerated statin - consider icosapent ethyl (purified EPA) specifically, as this is the only triglyceride therapy proven to reduce cardiovascular events 4, 5

Combination therapy considerations:

• Statins can be combined with fibrates, but gemfibrozil specifically should be avoided due to increased myositis risk; fenofibrate is preferred 1
• High-dose statins alone have moderate efficacy for triglycerides >300 mg/dL 1

Monitoring Strategy

Recheck lipids after 6 weeks of any new intervention to assess response 2.

Once at goal, monitor annually if values are stable 1.

If lipid levels fall significantly below target range on medication, consider dose reduction 3.

Critical Pitfalls to Avoid

Do not start fibrate monotherapy in diabetic patients with uncontrolled hyperglycemia - optimize glucose control first, as this is highly effective for triglyceride reduction 1.

Do not combine gemfibrozil with statins due to substantially increased myositis risk; use fenofibrate if combination therapy is needed 1.

Do not assume your LDL of 120 mg/dL is "acceptable" without calculating your actual cardiovascular risk - patients with diabetes or multiple risk factors require LDL <100 mg/dL regardless of baseline level 1.

Do not neglect the 12-week lifestyle trial in low-to-moderate risk patients - dietary changes can reduce LDL by 10-15% and triglycerides substantially, potentially avoiding medication entirely 1, 2.