What is the management plan for a 46-year-old with hypertriglyceridemia (elevated triglycerides) and elevated low-density lipoprotein (LDL) cholesterol who is otherwise healthy except for anemia?

Management of Moderate Hypertriglyceridemia with Borderline LDL

For this 46-year-old with triglycerides 219 mg/dL and LDL 116 mg/dL, prioritize aggressive lifestyle modifications for 3 months, then reassess lipids and cardiovascular risk to determine if statin therapy is warranted. 1

Initial Assessment

Evaluate for secondary causes before initiating any pharmacologic therapy:

• Screen for uncontrolled diabetes by checking HbA1c and fasting glucose, as poor glycemic control is often the primary driver of hypertriglyceridemia and optimizing glucose control can dramatically reduce triglycerides independent of lipid medications 1
• Check thyroid function (TSH) to rule out hypothyroidism, which commonly elevates triglycerides 1
• Assess alcohol consumption, as even 1 ounce per day increases triglycerides by 5-10%, and alcohol synergistically worsens hypertriglyceridemia when combined with dietary saturated fat 1
• Review medications that raise triglycerides including thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, and antipsychotics 1
• Evaluate the anemia as this may represent an underlying systemic condition contributing to metabolic dysfunction 1

Calculate Cardiovascular Risk

Determine 10-year ASCVD risk using the pooled cohort equation to guide statin decision-making 1:

• If ASCVD risk ≥7.5%, initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily), which provides 10-30% triglyceride reduction and proven cardiovascular benefit 1
• If ASCVD risk 5% to <7.5%, engage in patient-clinician discussion regarding statin initiation, as persistently elevated triglycerides ≥175 mg/dL constitute a cardiovascular risk-enhancing factor 1
• If ASCVD risk <5%, focus exclusively on lifestyle modifications for 3 months before reconsidering pharmacotherapy 1

Calculate non-HDL cholesterol (total cholesterol minus HDL cholesterol) with a target goal of <130 mg/dL, as this secondary lipid target becomes important when triglycerides are 200-499 mg/dL 1

Aggressive Lifestyle Modifications (First-Line Therapy)

Weight loss is the single most effective intervention:

• Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides 1
• In some patients, weight loss can reduce triglyceride levels by up to 50-70% 1

Dietary modifications:

• Restrict added sugars to <6% of total daily calories, as sugar intake directly increases hepatic triglyceride production 1
• Eliminate all sugar-sweetened beverages completely 1
• Limit total dietary fat to 30-35% of total calories for moderate hypertriglyceridemia 1
• Restrict saturated fats to <7% of total energy intake, replacing with monounsaturated or polyunsaturated fats 1
• Eliminate trans fatty acids completely 1
• Consume ≥2 servings (8+ ounces) per week of fatty fish (salmon, trout, sardines, anchovies) rich in EPA and DHA 1
• Increase soluble fiber to >10 g/day 1
• Replace refined grains with fiber-rich whole grains 1

Alcohol management:

• Limit or completely avoid alcohol consumption, as it significantly raises triglyceride levels 1
• Complete abstinence is mandatory if triglycerides approach 500 mg/dL 1

Physical activity:

• Engage in ≥150 minutes per week of moderate-intensity aerobic activity (or 75 minutes per week vigorous activity), which reduces triglycerides by approximately 11% 1

Reassessment Strategy

Recheck fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1:

• If triglycerides fall to <150 mg/dL and LDL remains <130 mg/dL, continue lifestyle modifications and monitor annually 1
• If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy (if initiated), consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4 g daily) specifically for patients with established cardiovascular disease or diabetes with ≥2 additional risk factors 1
• If triglycerides approach or exceed 500 mg/dL, immediately initiate fenofibrate 54-160 mg daily to prevent acute pancreatitis 1, 2

Address the Anemia

Investigate and treat the anemia concurrently, as underlying conditions such as chronic kidney disease, chronic liver disease, or inflammatory states can contribute to both anemia and dyslipidemia 1

Critical Pitfalls to Avoid

• Do not start fibrate therapy at this triglyceride level (219 mg/dL) unless triglycerides exceed 500 mg/dL or remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy 1
• Do not ignore secondary causes, particularly uncontrolled diabetes and hypothyroidism, as treating these conditions may obviate the need for lipid-lowering medications 1
• Do not delay lifestyle modifications while waiting to start medications, as dietary changes and weight loss are more effective than pharmacotherapy for moderate hypertriglyceridemia 1
• Do not use over-the-counter fish oil supplements as a substitute for prescription omega-3 fatty acids if pharmacotherapy becomes necessary 1