What is the treatment for severely elevated triglycerides (hypertriglyceridemia)?

Management of Severely Elevated Triglycerides (830 mg/dL)

Initiate fenofibrate 54-160 mg daily immediately to prevent acute pancreatitis, combined with extreme dietary fat restriction (<5% of total calories until triglycerides fall below 1,000 mg/dL, then 20-25% of calories), complete elimination of added sugars and alcohol, and aggressive evaluation for secondary causes—particularly uncontrolled diabetes and hypothyroidism. 1, 2, 3

Immediate Priorities: Preventing Pancreatitis

Your triglyceride level of 830 mg/dL places you in the severe hypertriglyceridemia category (500-999 mg/dL), which carries significant risk for acute pancreatitis. 1, 2, 3 The risk escalates dramatically as levels approach 1,000 mg/dL, making aggressive intervention essential now. 2

First-Line Pharmacologic Therapy

• Start fenofibrate immediately at 54-160 mg daily (adjust based on renal function) as first-line therapy before addressing LDL cholesterol. 1, 2, 3, 4, 5
• Fenofibrate reduces triglycerides by 30-50%, which should bring your level from 830 mg/dL to approximately 415-580 mg/dL. 2, 5, 6
• Do not start with statin monotherapy at this triglyceride level—statins provide only 10-30% triglyceride reduction and are insufficient for preventing pancreatitis when triglycerides exceed 500 mg/dL. 1, 2
• Once triglycerides fall below 500 mg/dL with fenofibrate therapy, reassess LDL-C and consider adding statin therapy if LDL-C is elevated or cardiovascular risk is high. 1, 2

Critical Dietary Interventions

Immediate Fat Restriction

• Restrict total dietary fat to 20-25% of total daily calories for severe hypertriglyceridemia in the 500-999 mg/dL range. 1, 2, 3
• If triglycerides approach or exceed 1,000 mg/dL, implement extreme dietary fat restriction (<5% of total calories) until levels fall below 1,000 mg/dL, as pharmacotherapy has limited effectiveness above this threshold. 1, 2, 3
• Choose lean fish or seafood rather than fatty fish when fat intake must be severely restricted. 2

Sugar and Alcohol Elimination

• Eliminate all added sugars completely—sugar intake directly increases hepatic triglyceride production. 1, 2, 3, 4
• Abstain completely from all alcohol consumption—alcohol synergistically increases triglycerides and can precipitate hypertriglyceridemic pancreatitis at these levels. 1, 2, 3, 4, 6
• Even 1 ounce of alcohol daily increases triglycerides by 5-10%, and effects are synergistically exaggerated when coupled with high-fat meals. 2

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity (or 75 minutes per week of vigorous activity), which reduces triglycerides by approximately 11%. 1, 2

Urgent Assessment for Secondary Causes

Before attributing hypertriglyceridemia to primary causes, aggressively evaluate and treat these common secondary drivers:

Uncontrolled Diabetes

• Check HbA1c and fasting glucose immediately—poor glycemic control is often the primary driver of severe hypertriglyceridemia. 1, 2, 3, 4
• Optimizing glucose control can dramatically reduce triglycerides independent of lipid medications and may obviate the need for additional therapy. 1, 2, 5
• In patients with markedly elevated triglycerides and insulin insufficiency, treat hyperglycemia first, then re-evaluate hypertriglyceridemia. 1, 3

Other Secondary Causes to Evaluate

• Hypothyroidism: Check TSH—hypothyroidism significantly elevates triglycerides. 2, 6
• Chronic kidney disease: Assess renal function (creatinine, eGFR)—CKD elevates triglyceride levels. 2, 6
• Medications: Review for thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, and antipsychotics—discontinue or substitute if possible. 2, 6
• Chronic liver disease: Check transaminases (AST/ALT) to screen for non-alcoholic fatty liver disease. 2

Monitoring and Follow-Up Strategy

• Reassess fasting lipid panel in 4-8 weeks after initiating fenofibrate and implementing dietary changes. 1, 2
• Monitor for muscle symptoms and obtain baseline and follow-up creatine kinase (CPK) levels when using fenofibrate. 2, 4
• Adjust fenofibrate dose based on renal function to minimize myopathy risk. 4, 5

Add-On Therapy if Triglycerides Remain Elevated

If triglycerides remain >200 mg/dL after 3 months of fenofibrate therapy plus optimized lifestyle modifications:

• Consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4g daily) as adjunctive therapy. 1, 2, 3
• Icosapent ethyl is specifically indicated for patients with triglycerides ≥150 mg/dL on maximally tolerated statin with established cardiovascular disease OR diabetes with ≥2 additional risk factors. 2
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids. 2

Critical Pitfalls to Avoid

• Do not delay fenofibrate initiation while attempting lifestyle modifications alone—pharmacologic therapy is mandatory at this triglyceride level to prevent pancreatitis. 1, 2
• Do not ignore secondary causes, particularly uncontrolled diabetes and hypothyroidism—treating these may be more effective than additional lipid medications. 1, 2, 3
• Do not use over-the-counter fish oil supplements as a substitute for prescription omega-3 formulations—they are not equivalent. 2
• Do not combine high-dose statin with fibrate initially—this significantly increases myopathy risk; if combination therapy becomes necessary later, use lower statin doses (atorvastatin 10-20 mg maximum). 2, 4

Expected Outcomes

With fenofibrate therapy (30-50% reduction) plus aggressive lifestyle modifications (potentially 20-70% reduction with weight loss and dietary changes), your triglycerides should decrease from 830 mg/dL to approximately 250-580 mg/dL within 4-8 weeks. 2, 5, 6 The primary goal is to reduce triglycerides below 500 mg/dL to eliminate acute pancreatitis risk, then target <200 mg/dL (ideally <150 mg/dL) for cardiovascular risk reduction. 1, 2