How to Lower Triglycerides
Start with aggressive lifestyle modifications that can reduce triglycerides by 20-70%, and add pharmacotherapy based on triglyceride severity: fibrates for levels ≥500 mg/dL to prevent pancreatitis, statins for moderate elevation (150-499 mg/dL) with cardiovascular risk, and prescription omega-3 fatty acids as adjunctive therapy when triglycerides remain elevated despite initial treatment. 1, 2
Classification and Risk Assessment
Triglyceride levels guide treatment intensity 1:
- Normal: <150 mg/dL
- Mild: 150-199 mg/dL
- Moderate: 200-499 mg/dL (cardiovascular risk)
- Severe: 500-999 mg/dL (pancreatitis risk)
- Very severe: ≥1000 mg/dL (immediate pancreatitis risk)
Before initiating treatment, evaluate for secondary causes including uncontrolled diabetes, hypothyroidism, renal disease, liver disease, excessive alcohol intake, and medications (thiazide diuretics, beta-blockers, estrogen, corticosteroids, antiretrovirals, antipsychotics) 1, 2, 3.
Lifestyle Interventions (First-Line for All Patients)
Weight Loss and Physical Activity
Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides 4, 1, 5. Some patients achieve reductions up to 50-70% with weight loss alone 1, 5.
Engage in at least 150 minutes/week of moderate-intensity aerobic activity (or 75 minutes/week vigorous activity), which reduces triglycerides by approximately 11% 4, 1, 5.
Dietary Modifications by Triglyceride Level
For triglycerides 150-499 mg/dL 4, 1, 5:
- Restrict added sugars to <6% of total daily calories
- Limit total fat to 30-35% of total calories
- Eliminate sugar-sweetened beverages, pastries, desserts completely
- Increase soluble fiber to 10-25 g/day
- Add plant stanols/sterols 2 g/day
For triglycerides 500-999 mg/dL 1, 2:
- Restrict dietary fat to 20-25% of total calories
- Eliminate all added sugars completely
- Complete alcohol abstinence (mandatory to prevent pancreatitis)
For triglycerides ≥1000 mg/dL 1, 2:
- Implement very low-fat diet (10-15% of total calories)
- In some cases, restrict fat to <5% until levels fall below 1000 mg/dL
- Complete elimination of added sugars and alcohol
Fat Type Substitution
Low-carbohydrate diets are more effective than low-fat diets for triglyceride reduction 4, 5. When including dietary fat 4, 5, 6:
- Replace saturated fats with polyunsaturated fatty acids (lowers triglycerides by 0.4 mg/dL per 1% energy substitution)
- Substitute monounsaturated fats for saturated fats (lowers triglycerides by 1.7 mg/dL per 1% energy substitution)
- Limit saturated fat to <7% of total energy intake
- Eliminate trans fatty acids completely
Marine Omega-3 Fatty Acids from Food
Consume ≥2 servings (8+ ounces) per week of fatty fish (salmon, trout, sardines, anchovies, herring) for moderate hypertriglyceridemia 4, 5. Non-marine omega-3 sources (flaxseed, walnuts, chia) have not demonstrated consistent triglyceride reductions and should not be relied upon 4.
Pharmacologic Therapy Algorithm
For Triglycerides ≥500 mg/dL (Severe to Very Severe)
Initiate fenofibrate 54-200 mg daily immediately as first-line therapy to prevent acute pancreatitis, before addressing LDL cholesterol 1, 2, 3. Fibrates reduce triglycerides by 30-50% 4, 7.
Once triglycerides fall below 500 mg/dL, reassess LDL-C and add statin therapy if LDL-C is elevated or cardiovascular risk is high 1, 2.
For Triglycerides 150-499 mg/dL (Moderate)
Calculate 10-year ASCVD risk to guide statin therapy 1, 2, 3:
- ASCVD risk ≥7.5%: Initiate moderate- to high-intensity statin therapy (provides 10-30% triglyceride reduction plus proven cardiovascular benefit)
- ASCVD risk 5-7.4%: Consider statin therapy with patient-clinician discussion
- Persistently elevated nonfasting triglycerides ≥175 mg/dL: This is a risk-enhancing factor favoring statin initiation
Adjunctive Therapy with Prescription Omega-3 Fatty Acids
If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, add prescription omega-3 fatty acids (icosapent ethyl 2-4 g/day) 1, 2, 8.
Icosapent ethyl is specifically indicated for patients with 1, 8:
- Triglycerides ≥150 mg/dL on maximally tolerated statin therapy, AND
- Established cardiovascular disease OR diabetes with ≥2 additional risk factors
The REDUCE-IT trial demonstrated a 25% reduction in major adverse cardiovascular events (number needed to treat = 21) 1, 8. Monitor for increased risk of atrial fibrillation 1.
Over-the-counter fish oil supplements are not equivalent to prescription formulations and should not be substituted 1.
Special Considerations
Diabetes and Glycemic Control
Aggressively optimize glycemic control in diabetic patients, as poor glucose control is often the primary driver of severe hypertriglyceridemia 1, 2. This intervention can be more effective than additional lipid medications in some cases 1.
Combination Therapy Safety
When combining fenofibrate with statins, use lower statin doses (atorvastatin 10-20 mg maximum) to minimize myopathy risk, particularly in patients >65 years, with renal disease, or diabetes 1, 2. Fenofibrate has a better safety profile than gemfibrozil when combined with statins 1. Monitor creatine kinase levels and muscle symptoms 1, 2.
Niacin
Niacin should generally not be used, as it showed no cardiovascular benefit when added to statin therapy in the AIM-HIGH trial, with increased risk of new-onset diabetes and gastrointestinal disturbances 1, 9. Immediate-release niacin can reduce triglycerides by 20-50%, but extended-release formulations provide only 10-30% reduction 4.
Monitoring Strategy
Reassess fasting lipid panel 4-8 weeks after implementing lifestyle modifications or medication changes 1, 2, 5. Once therapeutic goals are achieved, continue monitoring every 6-12 months 1, 2.
Target non-HDL-C <130 mg/dL for patients with triglycerides 200-499 mg/dL 4, 1.
Critical Pitfalls to Avoid
Do not delay pharmacologic intervention when triglycerides ≥500 mg/dL by attempting lifestyle modifications alone—fibrate therapy is mandatory to prevent pancreatitis 1, 2, 5.
Do not start with statin monotherapy when triglycerides ≥500 mg/dL, as statins provide only 10-30% triglyceride reduction and are insufficient for preventing pancreatitis at this level 1.
Do not overlook secondary causes such as uncontrolled diabetes, hypothyroidism, and certain medications, as addressing these can dramatically reduce triglycerides independent of lipid medications 1, 2, 5.
Do not use bile acid sequestrants when triglycerides >200 mg/dL, as they are relatively contraindicated and may raise triglyceride levels 4, 1.