How to reduce triglycerides in the body?

How to Reduce Triglycerides in the Body

The most effective approach to reducing triglycerides combines aggressive lifestyle modifications—targeting 5-10% weight loss, eliminating added sugars and alcohol, and restricting saturated fats—with pharmacologic therapy guided by triglyceride severity: fibrates for levels ≥500 mg/dL to prevent pancreatitis, statins for moderate elevation (150-499 mg/dL) with cardiovascular risk ≥7.5%, and icosapent ethyl as add-on therapy for patients with established cardiovascular disease or diabetes on statin therapy. 1, 2, 3

Classification and Risk Assessment

Before initiating treatment, triglyceride levels must be classified to determine urgency and approach 1, 2:

• Normal: <150 mg/dL
• Mild: 150-199 mg/dL
• Moderate: 200-499 mg/dL
• Severe: 500-999 mg/dL (14% risk of pancreatitis)
• Very severe: ≥1,000 mg/dL (immediate pancreatitis risk)

Evaluate for secondary causes before starting treatment, including uncontrolled diabetes, hypothyroidism, excessive alcohol intake, kidney disease, liver disease, and medications (thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, antipsychotics). 1, 2 Poor glycemic control is often the primary driver of severe hypertriglyceridemia and optimizing glucose control can dramatically reduce triglycerides independent of lipid medications. 1

Lifestyle Modifications (First-Line for All Patients)

Weight Loss and Physical Activity

Target 5-10% body weight reduction, which produces approximately 20% triglyceride decrease—the single most effective lifestyle intervention. 1, 2, 3 In some patients, aggressive weight loss can reduce triglyceride levels by 50-70%. 1, 4

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

Dietary Interventions

Sugar and Carbohydrate Restriction:

• For mild-moderate hypertriglyceridemia (150-499 mg/dL): Restrict added sugars to <6% of total daily calories, as sugar intake directly increases hepatic triglyceride production. 1, 2
• For severe hypertriglyceridemia (500-999 mg/dL): Eliminate all added sugars completely. 1, 2
• For very severe hypertriglyceridemia (≥1,000 mg/dL): Eliminate all added sugars and restrict total fat to 10-15% of daily calories. 1, 2

Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets, with very-low-carbohydrate diets producing 30-40% reductions with significant weight loss. 1, 2, 5

Fat Modification:

• Restrict saturated fats to <7% of total energy intake, replacing with monounsaturated or polyunsaturated fats. 1, 2
• Eliminate trans fatty acids completely. 1
• For mild-moderate hypertriglyceridemia: Limit total fat to 30-35% of total daily calories. 1, 2
• For severe hypertriglyceridemia (500-999 mg/dL): Restrict dietary fat to 20-25% of total calories. 1, 2
• For very severe hypertriglyceridemia (≥1,000 mg/dL): Implement extreme dietary fat restriction (<5% of total calories) until triglycerides fall below 1,000 mg/dL. 1

Omega-3 Fatty Acids:

Consume at least 2 servings per week (8+ ounces) of fatty fish rich in EPA and DHA (salmon, trout, sardines, anchovies). 1, 6 Marine-derived omega-3 fatty acids reduce triglycerides by 20-50% at doses of 2-4g/day. 1

Fiber:

Increase soluble fiber to >10g/day from sources like oats, beans, and vegetables. 1, 2 Adding plant stanols/sterols 2g/day can also help lower triglycerides. 2

Alcohol Restriction

Complete abstinence from alcohol is mandatory for patients with severe hypertriglyceridemia (≥500 mg/dL) to prevent hypertriglyceridemic pancreatitis. 1, 2 Even 1 ounce of alcohol daily increases triglycerides by 5-10%, and alcohol synergistically worsens hypertriglyceridemia when coupled with meals high in saturated fat. 1

For patients with mild-moderate hypertriglyceridemia, limit or completely avoid alcohol consumption. 1, 2

Pharmacologic Therapy (Severity-Based Algorithm)

Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)

Initiate fenofibrate 54-160 mg daily immediately as first-line therapy to prevent acute pancreatitis, regardless of LDL-C levels or cardiovascular risk factors. 1, 3, 7 Fenofibrate reduces triglycerides by 30-50% and has a better safety profile than gemfibrozil when combined with statins. 1, 3

• Start at 54 mg daily in patients with mild-moderate renal impairment and adjust based on renal function. 7
• Maximum dose is 160 mg once daily. 7
• Take with meals to optimize bioavailability. 7

Once triglycerides fall below 500 mg/dL, reassess LDL-C and consider adding statin therapy if LDL-C is elevated or cardiovascular risk is high. 1, 3

Moderate Hypertriglyceridemia (200-499 mg/dL)

For patients with 10-year ASCVD risk ≥7.5%, initiate moderate-to-high intensity statin therapy (atorvastatin 10-40 mg or rosuvastatin 5-20 mg daily) as first-line pharmacologic therapy. 1, 2, 3 Statins provide 10-30% dose-dependent triglyceride reduction and proven cardiovascular risk reduction. 1, 3

If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4g daily) for patients with established cardiovascular disease or diabetes with ≥2 additional risk factors. 1, 3 Icosapent ethyl provides a 25% reduction in major adverse cardiovascular events (number needed to treat = 21 over 5 years). 1, 3, 5

Alternatively, consider fenofibrate 54-160 mg daily if icosapent ethyl criteria are not met. 1

Mild Hypertriglyceridemia (150-199 mg/dL)

For patients with 10-year ASCVD risk ≥7.5%, consider moderate-intensity statin therapy, as persistently elevated nonfasting triglycerides ≥175 mg/dL constitute a cardiovascular risk-enhancing factor. 1, 3

For patients with ASCVD risk 5% to <7.5%, engage in patient-clinician discussion regarding statin initiation. 1

Combination Therapy Safety Considerations

When combining fenofibrate with statins, use lower statin doses (atorvastatin 10-20 mg maximum) to minimize myopathy risk, particularly in patients >65 years or with renal disease. 1, 3 Monitor creatine kinase levels and muscle symptoms at baseline and 3 months after initiation. 1, 3

Use fenofibrate rather than gemfibrozil when combining with statins, as fenofibrate has a significantly better safety profile with lower myopathy risk. 1, 3, 8 Gemfibrozil inhibits statin glucuronidation, increasing rhabdomyolysis risk. 1

Monitoring Strategy

• Reassess fasting lipid panel 4-8 weeks after implementing lifestyle modifications or initiating/adjusting therapy. 1, 3
• For moderate hypertriglyceridemia (200-499 mg/dL), calculate non-HDL cholesterol (total cholesterol minus HDL cholesterol) with a target goal of <130 mg/dL. 1
• Once therapeutic goals are achieved, continue monitoring every 6-12 months. 1, 2

Critical Pitfalls to Avoid

• Do not delay fibrate therapy while attempting lifestyle modifications alone in patients with triglycerides ≥500 mg/dL—pharmacologic therapy is mandatory to prevent pancreatitis. 1
• 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
• Do not use niacin routinely—it showed no cardiovascular benefit when added to statin therapy and increases risk of new-onset diabetes. 1, 9
• Do not overlook secondary causes, particularly uncontrolled diabetes and hypothyroidism, as treating these conditions can be more effective than additional lipid medications. 1, 2