What is the treatment for elevated cholesterol and triglycerides?

Treatment of Elevated Cholesterol and Triglycerides

Begin with therapeutic lifestyle changes as the foundation, then add statin therapy for elevated LDL cholesterol, and consider fibrates or omega-3 fatty acids for persistent hypertriglyceridemia based on severity and cardiovascular risk.

Initial Assessment and Risk Stratification

Before initiating treatment, evaluate for secondary causes that commonly drive lipid abnormalities 1:

• Uncontrolled diabetes mellitus - often the primary driver of severe hypertriglyceridemia 1
• Hypothyroidism - assess thyroid function 1
• Excessive alcohol intake - even 1 ounce daily increases triglycerides 5-10% 1
• Medications - thiazides, beta-blockers, estrogen, corticosteroids, antiretrovirals 1
• Renal or liver disease 1

Assess cardiovascular risk factors including family history, central obesity, hypertension, and abnormal glucose metabolism 1.

Therapeutic Lifestyle Changes (First-Line for All Patients)

Dietary Modifications

For elevated LDL cholesterol 2:

• Restrict saturated fat to <7% of total calories
• Limit dietary cholesterol to <200 mg/day
• Eliminate trans fats to <1% of calories
• Add plant stanols/sterols 2 g/day (reduces LDL-C by 8-29 mg/dL) 2
• Increase soluble fiber to 10-25 g/day (reduces LDL-C by ~2.2 mg/dL per gram) 2

For elevated triglycerides - severity-based approach 1:

• Mild-Moderate (150-499 mg/dL): Restrict added sugars to <6% of calories; limit total fat to 30-35% of calories 1
• Severe (500-999 mg/dL): Eliminate all added sugars; restrict fat to 20-25% of calories 1
• Very Severe (≥1000 mg/dL): Eliminate added sugars; restrict fat to 10-15% of calories 1

Weight Loss and Physical Activity

• Target 5-10% body weight reduction - produces 20% decrease in triglycerides 1
• Engage in ≥150 minutes/week moderate-intensity or 75 minutes/week vigorous aerobic activity 1
• Regular exercise reduces triglycerides by approximately 11% 1

Alcohol Restriction

• Complete abstinence for triglycerides ≥500 mg/dL to prevent hypertriglyceridemic pancreatitis 1
• Limit or avoid alcohol for moderate hypertriglyceridemia 1

Pharmacologic Treatment Algorithm

For Elevated LDL Cholesterol

Statin therapy is first-line 2:

• Initiate statin therapy if LDL-C remains above goal after 3 months of lifestyle changes 2
• For patients with CHD or CHD equivalents: target LDL-C <100 mg/dL (Class I recommendation) 2
• Further reduction to <70 mg/dL is reasonable for very high-risk patients (Class IIa) 2
• Monitor LDL-C response after 6 weeks 2

If LDL goal not achieved on statin alone 2:

• Intensify statin dose first
• Add ezetimibe 10 mg daily (provides additional 13-20% LDL-C reduction) 3
• Combination therapy with plant stanols/sterols and viscous fiber 2

For Elevated Triglycerides - Severity-Based Approach

Triglycerides ≥500 mg/dL (IMMEDIATE ACTION REQUIRED) 1:

• Initiate fenofibrate 54-200 mg daily immediately as first-line therapy to prevent acute pancreatitis 1
• Do NOT start with statin monotherapy at this level - statins provide only 10-30% triglyceride reduction, insufficient for pancreatitis prevention 1
• Fibrates reduce triglycerides by 30-50% 1
• Aggressively optimize glycemic control in diabetic patients - often more effective than additional medications 1
• Once triglycerides fall <500 mg/dL, add statin therapy if LDL-C elevated 1

Triglycerides 200-499 mg/dL (Moderate) 1:

• Continue or initiate statin therapy if LDL-C elevated or cardiovascular risk ≥7.5% 1
• Target non-HDL-C <130 mg/dL 2
• If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle and statin therapy, add prescription omega-3 fatty acids (icosapent ethyl) 2-4 g/day 1
• Alternative: Consider niacin or fibrate therapy after LDL-C lowering 2

Triglycerides 150-199 mg/dL (Mild) 1:

• Considered a cardiovascular risk-enhancing factor 1
• Initiate statin if 10-year ASCVD risk ≥7.5% 1
• Focus on lifestyle modifications 1

For Low HDL Cholesterol (<40 mg/dL)

After achieving LDL-C goal 2:

• If triglycerides 200-499 mg/dL: prioritize non-HDL-C goal <130 mg/dL 2
• If triglycerides <200 mg/dL (isolated low HDL): consider fibrates or niacin 2
• Nicotinic acid and fibric acid derivatives can be useful therapeutic options (Class IIa) 2

Combination Therapy Considerations

When combining fibrates with statins 1:

• Use fenofibrate rather than gemfibrozil - better safety profile with lower myopathy risk 1
• Keep statin doses relatively low to minimize myopathy risk 2
• Monitor creatine kinase levels and muscle symptoms, especially in patients >65 years or with renal disease 1

Ezetimibe combinations 3:

• Can be combined with statins for additional LDL-C lowering 3
• Can be combined with fenofibrate for mixed hyperlipidemia 3
• Administer ≥2 hours before or ≥4 hours after bile acid sequestrants 3

Special Populations

Diabetic patients 2:

• Optimizing glycemic control is the highest priority - can dramatically reduce triglycerides independent of lipid medications 1
• Target HbA1c <7% 1
• Many manifest dyslipidemia with increased triglycerides, reduced HDL, and small dense LDL despite improved glycemic control 2

Patients with metabolic syndrome 2:

• Improved glycemic control, modest weight loss, dietary saturated fat restriction, increased physical activity, and incorporation of monounsaturated fats may be beneficial 2

Critical Pitfalls to Avoid

• Do not delay fibrate therapy in patients with triglycerides ≥500 mg/dL while attempting lifestyle modifications alone - pharmacologic therapy is mandatory 1
• Do not use bile acid sequestrants when triglycerides >200 mg/dL - relatively contraindicated 2
• Do not combine gemfibrozil with statins - use fenofibrate instead for lower myopathy risk 1
• Do not substitute over-the-counter fish oil for prescription omega-3 fatty acids - not equivalent formulations 1
• Do not overlook secondary causes - treating underlying conditions (especially diabetes) may be more effective than adding medications 1

Monitoring Strategy

• Reassess fasting lipid panel 4-8 weeks after initiating or adjusting therapy 1
• Monitor liver enzymes as clinically indicated; consider withdrawal if ALT/AST ≥3x ULN persist 3
• Monitor for myopathy symptoms, especially with combination therapy 1
• Once goals achieved, follow-up every 6-12 months 1