From the Guidelines
For a patient with triglycerides of 330 mg/dL who is already on atorvastatin 40 mg, I recommend adding fenofibrate 145 mg daily or omega-3 fatty acid ethyl esters (Vascepa) 2 grams twice daily to specifically target the elevated triglycerides. Dietary changes should include:
- Reducing simple carbohydrates and sugars
- Limiting alcohol consumption
- Increasing omega-3 rich foods like fatty fish (salmon, mackerel)
- Avoiding trans fats
- Reducing overall caloric intake if overweight Regular physical activity of at least 150 minutes per week is also essential, as recommended by the 2022 standards of medical care in diabetes 1. These recommendations are important because while atorvastatin primarily lowers LDL cholesterol, it has limited effect on significantly elevated triglycerides, as noted in the 2013 guidelines on diagnosis and management of hypertriglyceridemia 1. Fenofibrate and omega-3 supplements work through different mechanisms to specifically reduce triglyceride production and increase clearance. The dietary modifications help by reducing substrates for triglyceride synthesis in the liver and improving metabolic health, which is in line with the recommendations for lifestyle intervention to improve lipid profiles and reduce the risk of atherosclerotic cardiovascular disease in patients with diabetes 1. Regular monitoring of liver function tests and lipid panels every 3-6 months is advised to assess treatment efficacy and safety.
From the FDA Drug Label
As an adjunct to diet for the treatment of adults with: Primary dysbetalipoproteinemia. Hypertriglyceridemia. DOSAGE AND ADMINISTRATION Take orally once daily with or without food ( 2.1). Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating atorvastatin calcium, and adjust dosage if necessary ( 2.1). The patient is already on atorvastatin 40 mg, and the triglycerides are 330.
- The recommended medication is already being taken, which is atorvastatin.
- Dietary changes are recommended as an adjunct to the treatment, but the specific changes are not mentioned in the drug label. 2 2
From the Research
Medication Recommendations
- The patient is already on atorvastatin 40 mg, which is a statin commonly used to lower cholesterol and triglyceride levels 3.
- For patients with high triglyceride levels who are already on statin therapy, high-dose icosapent (purified eicosapentaenoic acid) can be considered to reduce cardiovascular mortality 4.
- Fibrates, omega-3 fatty acids, or niacin can also be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4.
- Omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown to effectively reduce triglyceride levels 5, 6.
Dietary Changes
- Lifestyle changes, including improved diet and increased physical activity, are effective triglyceride-lowering measures 3.
- Lowering carbohydrate intake, especially refined carbohydrates, and increasing fat and protein intake can help lower triglyceride levels 4.
- Increasing omega-3 fatty acid intake, particularly EPA and DHA, can help reduce triglyceride levels 5, 6.
- Moderate- to high-intensity physical activity can also help lower triglyceride levels and improve overall cardiovascular health 4.