What is the treatment for hypertriglyceridemia?

From the Guidelines

Treatment for elevated triglycerides should prioritize lifestyle modifications, including dietary changes and regular exercise, alongside consideration of medications such as statins, fibrates, and prescription omega-3 fatty acids, especially in cases of severe hypertriglyceridemia (>500 mg/dL) to reduce the risk of pancreatitis and cardiovascular disease, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Dietary changes: reducing intake of simple carbohydrates, sugars, and alcohol, and increasing consumption of omega-3 fatty acids from fatty fish.
• Regular exercise: at least 150 minutes of moderate activity weekly.
• Weight loss if overweight, and smoking cessation.

Medication Considerations

• Statins like atorvastatin (10-80 mg daily) or rosuvastatin (5-40 mg daily) for first-line therapy, especially if LDL cholesterol is also elevated.
• Fibrates such as fenofibrate (48-145 mg daily) or gemfibrozil (600 mg twice daily) specifically target triglycerides.
• Prescription omega-3 fatty acids (icosapent ethyl 2 grams twice daily or omega-3 ethyl esters 2-4 grams daily) are effective for severe hypertriglyceridemia (>500 mg/dL), as supported by recent guidelines 1.

Importance of Treatment

• Elevated triglycerides increase the risk of pancreatitis (when very high) and contribute to cardiovascular disease risk.
• Regular monitoring of lipid levels is necessary to assess treatment effectiveness, with a goal of bringing triglycerides below 150 mg/dL, in line with recommendations from the American College of Cardiology and other expert consensus pathways 1.

Specific Considerations for Severe Hypertriglyceridemia

• For patients with triglycerides ≥500 mg/dL, especially ≥1,000 mg/dL, a very rigorous approach to lifestyle interventions is advised, including Medical Nutrition Therapy (MNT) with reduced intake of dietary fat, as outlined in recent expert consensus decision pathways 1.
• Pharmacologic therapy, such as fibrin acid derivatives and/or fish oil, may be warranted to reduce the risk of acute pancreatitis, alongside moderate- or high-intensity statin therapy to reduce cardiovascular risk, as recommended in the latest standards of care in diabetes-2025 1.

From the FDA Drug Label

Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

Treatment for Elevated Triglycerides:

• Fenofibrate is indicated for the treatment of adult patients with severe hypertriglyceridemia.
• The initial dose for severe hypertriglyceridemia is 54 mg per day to 160 mg per day, with a maximum dose of 160 mg once daily.
• Dosage should be individualized according to patient response and adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals.
• Fenofibrate therapy has been shown to lower triglycerides and raise HDL-C in clinical studies 2, 2.

From the Research

Elevated Triglycerides Treatment

Elevated triglycerides are a common condition that can increase the risk of cardiovascular disease and pancreatitis. The treatment of elevated triglycerides typically involves lifestyle modifications and, in some cases, medication.

Lifestyle Modifications

• Cessation of alcohol consumption 3
• Reduced intake of rapidly metabolized carbohydrates 3
• Weight loss 3
• Blood sugar control 3
• Dietary changes, such as lowering carbohydrate intake and increasing fat and protein intake 4
• Moderate- to high-intensity physical activity 4

Medications

• Fibrates can lower triglyceride concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3
• Omega-3 fatty acids can lower triglyceride levels, with a daily dose of 2-4 g being effective 3, 5, 6
• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 4
• High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients at high risk 4
• Fenofibrate therapy can decrease triglycerides, total cholesterol, and non-HDL cholesterol, and improve flow-mediated dilation and insulin sensitivity 5, 6

Special Considerations

• Patients with severely elevated triglyceride levels (500 mg/dL or higher) are at increased risk of pancreatitis and may require more aggressive treatment 4, 7
• Patients with acute pancreatitis associated with hypertriglyceridemia may require insulin infusion and plasmapheresis 4
• Patients with purely genetic types of hypertriglyceridemia (familial chylomicronemia syndrome) should be treated in specialized outpatient clinics 3