Investigations for Hypertriglyceridemia
Initial Lipid Assessment
Obtain at least two fasting lipid panels, preferably 2 weeks apart, to confirm the diagnosis and guide treatment decisions 1. Fasting measurements are essential to accurately classify severity and identify patients at risk for pancreatitis 1.
- Measure fasting triglycerides, total cholesterol, HDL-C, and calculate LDL-C using the Martin-Hopkins method for more accurate LDL-C assessment in hypertriglyceridemia 1
- Calculate non-HDL cholesterol (total cholesterol minus HDL-C) with a target goal of <130 mg/dL for moderate hypertriglyceridemia 1
- Classify severity: Mild (150-199 mg/dL), Moderate (200-499 mg/dL), Severe (500-999 mg/dL), Very Severe (≥1,000 mg/dL) 1, 2
Evaluation for Secondary Causes
Screen systematically for reversible causes before initiating pharmacotherapy, as treating these conditions may eliminate the need for lipid-lowering medications 1.
Metabolic and Endocrine Testing
- Hemoglobin A1c and fasting glucose to assess for diabetes mellitus or prediabetes, as poor glycemic control is often the primary driver of severe hypertriglyceridemia 1, 2
- Thyroid-stimulating hormone (TSH) to rule out hypothyroidism 1
- Serum creatinine and estimated GFR to assess for chronic kidney disease or nephrotic syndrome 1
Hepatic Assessment
- Liver function tests (AST, ALT, alkaline phosphatase, gamma-GT) to screen for non-alcoholic fatty liver disease and assess baseline hepatic function before initiating fibrate therapy 1, 3
Additional Laboratory Tests
- Urinalysis to screen for proteinuria suggesting nephrotic syndrome 3
- Serum amylase and lipase if triglycerides ≥500 mg/dL and any abdominal symptoms are present, as the risk of acute pancreatitis is 14% at this level 2, 4
Cardiovascular Risk Assessment
Evaluate for other components of metabolic syndrome and cardiovascular risk factors to guide comprehensive management 1.
- Assess for central obesity (waist circumference), hypertension, and abnormal glucose metabolism 1
- Calculate 10-year ASCVD risk using the pooled cohort equations for patients aged 40-75 years to determine statin therapy indications 1, 2
- Obtain detailed family history of premature cardiovascular disease, dyslipidemia, and genetic lipid disorders 1
Medication and Lifestyle Review
Conduct a thorough medication review and assess lifestyle factors that contribute to hypertriglyceridemia 1.
- Review medications that elevate triglycerides: thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, bile acid sequestrants, antiretroviral protease inhibitors, immunosuppressants, and antipsychotics 1
- Quantify alcohol consumption, as even 1 ounce daily increases triglycerides by 5-10%, and complete abstinence is mandatory for severe hypertriglyceridemia (≥500 mg/dL) 1, 2
- Assess dietary intake of added sugars, saturated fats, and total fat consumption 1, 2
Special Considerations for Severe Hypertriglyceridemia
For patients with triglycerides ≥500 mg/dL, prioritize urgent evaluation to prevent acute pancreatitis 2, 4.
- Measure serum amylase and lipase immediately if any abdominal symptoms are present 4
- Consider genetic testing for familial chylomicronemia syndrome or familial combined hyperlipidemia in cases of severe primary hypertriglyceridemia, especially if family history is positive 1
- Assess for multifactorial chylomicronemia syndrome, which is 40-60 fold more prevalent than monogenic conditions and results from genetic predisposition combined with secondary factors 1
Monitoring Parameters
Establish baseline values before initiating therapy and schedule appropriate follow-up 2, 4.