What is the treatment for hypertriglyceridemia?

Treatment of Severe Hypertriglyceridemia (734 mg/dL)

Initiate fenofibrate 54-160 mg daily immediately to prevent acute pancreatitis, combined with aggressive dietary fat restriction to 20-25% of total calories, complete elimination of added sugars and alcohol, and urgent evaluation for secondary causes including uncontrolled diabetes and hypothyroidism. 1, 2, 3

Immediate Risk Context

Your triglyceride level of 734 mg/dL places you in the severe hypertriglyceridemia category (500-999 mg/dL), which significantly increases your risk of acute pancreatitis. 4, 1, 2 While the highest pancreatitis risk occurs above 1,000 mg/dL, levels above 500 mg/dL warrant urgent intervention to prevent progression. 1 At this level, you face a 14% incidence of pancreatitis, and the risk escalates dramatically as triglycerides approach 1,000 mg/dL. 3

Step 1: Immediate Pharmacological Intervention

Start fenofibrate immediately—do not delay while attempting lifestyle modifications alone at this triglyceride level. 1, 3

• Fenofibrate 54-160 mg daily is the first-line medication to prevent acute pancreatitis, providing 30-50% triglyceride reduction. 1, 2, 3, 5
• The FDA-approved initial dose for severe hypertriglyceridemia ranges from 54-160 mg daily, individualized based on your response and renal function. 5
• Take fenofibrate with meals to optimize bioavailability. 5
• Critical pitfall to avoid: Do not start with statin monotherapy when triglycerides are ≥500 mg/dL—statins provide only 10-30% triglyceride reduction and are insufficient for preventing pancreatitis at this level. 1, 3

Step 2: Urgent Assessment for Secondary Causes

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

• Check HbA1c immediately if you have diabetes or are at risk—uncontrolled diabetes is often the primary driver of severe hypertriglyceridemia, and optimizing glycemic control can dramatically reduce triglycerides independent of lipid medications. 1, 3
• Check TSH to rule out hypothyroidism, which significantly contributes to elevated triglycerides. 3, 5
• Mandate complete abstinence from alcohol—even 1 ounce daily increases triglycerides by 5-10%, and alcohol synergistically worsens hypertriglyceridemia and can precipitate hypertriglyceridemic pancreatitis at your level. 1, 3
• Review medications that raise triglycerides: thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, and antipsychotics should be discontinued or substituted if possible. 3, 5

Step 3: Aggressive Dietary Interventions (Start Immediately)

Restrict total dietary fat to 20-25% of total daily calories for triglycerides in the 500-999 mg/dL range. 1, 3

• Completely eliminate all added sugars—sugar intake directly increases hepatic triglyceride production. 1, 3
• Abstain completely from all alcohol consumption—this is non-negotiable at your triglyceride level. 1, 3
• Restrict saturated fats to <7% of total calories, replacing with polyunsaturated or monounsaturated fats. 3
• Increase soluble fiber to >10 g/day. 3
• Consume at least 2 servings per week of fatty fish (salmon, trout, sardines) rich in omega-3 fatty acids. 3

Target 5-10% body weight reduction if overweight or obese—this can reduce triglycerides by 20% and is the single most effective lifestyle intervention. 1, 2, 3

Step 4: 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, 3

Step 5: Monitoring Strategy

• Recheck fasting lipid panel in 4-8 weeks after initiating fenofibrate and lifestyle modifications. 1, 2
• Monitor liver function tests (AST/ALT) and creatine kinase at baseline and during treatment to screen for hepatotoxicity and myopathy. 1, 3
• Treatment goal: Reduce triglycerides to <500 mg/dL urgently to eliminate pancreatitis risk, with an ultimate goal of <150 mg/dL for optimal metabolic health. 1, 2

Step 6: Consider Add-On Therapy if Needed

Once triglycerides fall below 500 mg/dL with fenofibrate, reassess your LDL-C and cardiovascular risk:

• If LDL-C is elevated or cardiovascular risk is high, add or optimize statin therapy. 3
• If triglycerides remain >200 mg/dL after 3 months of fenofibrate plus optimized lifestyle, consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4 g daily) as adjunctive therapy. 1, 2, 3
• Do not use over-the-counter fish oil as a substitute for prescription omega-3 fatty acids—they are not equivalent. 1

Critical Pitfalls to Avoid

• Never delay fenofibrate initiation while attempting lifestyle modifications alone—pharmacologic therapy is mandatory at your triglyceride level. 1, 3
• Do not combine gemfibrozil with statins if you later need statin therapy—use fenofibrate instead, which has a significantly better safety profile. 1, 3
• Do not ignore glycemic control if you have diabetes—poor glucose control may be more important than additional lipid medications. 1, 3
• Therapy should be withdrawn if you do not have an adequate response after two months of treatment with the maximum recommended dose of 160 mg once daily. 5