What is the treatment for a patient with hypertriglyceridemia (high triglycerides), normal total cholesterol, and mildly elevated low-density lipoprotein (LDL) cholesterol, without atherosclerotic cardiovascular disease (ASCVD) risk factors?

Treatment for Triglycerides 207 mg/dL with Normal Total Cholesterol and LDL 107 mg/dL

Start with aggressive lifestyle modifications for 3 months, then reassess—if triglycerides remain elevated and your 10-year ASCVD risk is ≥7.5%, initiate moderate-intensity statin therapy, which will lower both LDL and triglycerides by 10-30%. 1

Risk Stratification and Initial Assessment

Your triglyceride level of 207 mg/dL falls into the "moderate hypertriglyceridemia" category (200-499 mg/dL), which is associated with increased cardiovascular risk rather than immediate pancreatitis risk 1. The primary concern here is long-term cardiovascular disease prevention, not acute pancreatitis, which becomes a risk only when triglycerides exceed 500 mg/dL 1, 2.

Before initiating any pharmacologic therapy, you must:

• Screen for secondary causes: Check TSH for hypothyroidism, hemoglobin A1c for diabetes, and review medications that raise triglycerides (thiazide diuretics, beta-blockers except carvedilol, oral estrogens, corticosteroids) 3, 2
• Assess alcohol intake: Even 1 ounce daily increases triglycerides by 5-10%, and complete abstinence may be necessary if consumption is excessive 3, 4
• Calculate your 10-year ASCVD risk: This determines whether statin therapy is warranted 1

Lifestyle Modifications: The Foundation of Treatment

Lifestyle changes can reduce triglycerides by 20-70% and must be implemented aggressively for at least 3 months before considering medications 4:

• Target 5-10% body weight loss: This produces a 20% decrease in triglycerides and is the single most effective intervention 3, 4
• Restrict added sugars to <6% of total daily calories: Sugar intake directly increases hepatic triglyceride production 3, 4
• Limit total dietary fat to 30-35% of calories: Prioritize polyunsaturated and monounsaturated fats over saturated fats (<7% of calories) 3, 4
• Eliminate trans fats completely 3
• Increase soluble fiber to >10 g/day from sources like oats, beans, and vegetables 3, 4
• Engage in ≥150 minutes/week of moderate-intensity aerobic activity: This reduces triglycerides by approximately 11% 3, 4
• Consume ≥2 servings per week of fatty fish (salmon, trout, sardines) rich in omega-3 fatty acids 3, 4

Pharmacologic Therapy Decision Algorithm

If Your 10-Year ASCVD Risk is ≥7.5% or You Have Diabetes (Age 40-75)

Initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) as first-line treatment 1, 3. Statins provide:

• 10-30% dose-dependent triglyceride reduction 1, 3
• Proven cardiovascular mortality benefit 1
• LDL-C reduction to target <100 mg/dL (your current LDL of 107 mg/dL needs lowering) 1

Calculate non-HDL cholesterol (total cholesterol minus HDL cholesterol) with a target goal of <130 mg/dL, as this becomes an important secondary lipid target when triglycerides are elevated 1, 3.

If Triglycerides Remain >200 mg/dL After 3 Months of Statin Plus Lifestyle Optimization

Consider adding icosapent ethyl 2g twice daily (prescription omega-3) ONLY if you meet ALL of the following criteria 1, 3, 4:

• Already on maximally tolerated statin therapy
• LDL-C is controlled
• You have established cardiovascular disease OR diabetes with ≥2 additional cardiovascular risk factors
• Triglycerides remain 135-499 mg/dL

Icosapent ethyl demonstrated a 25% reduction in major adverse cardiovascular events (number needed to treat = 21) in the REDUCE-IT trial 1, 3, 4. Monitor for increased risk of atrial fibrillation 1, 3.

If Your 10-Year ASCVD Risk is 5% to <7.5%

A clinician-patient discussion is reasonable regarding statin initiation, as persistently elevated triglycerides ≥175 mg/dL constitute a cardiovascular risk-enhancing factor 1, 3.

If Your 10-Year ASCVD Risk is <5%

Continue aggressive lifestyle modifications alone and reassess in 6-12 weeks 1, 3. Pharmacologic therapy is generally not indicated at this risk level unless triglycerides exceed 500 mg/dL 1.

Monitoring Strategy

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 3, 4
• Reassess lipids 4-8 weeks after initiating or adjusting statin therapy 3
• Once goals are achieved, monitor every 6-12 months 3

Critical Pitfalls to Avoid

• Do not use over-the-counter fish oil supplements expecting cardiovascular benefit—only prescription icosapent ethyl has proven outcomes data 1, 3
• Do not delay statins while attempting only lifestyle modifications in high-risk patients (ASCVD risk ≥7.5% or diabetes)—lifestyle optimization and pharmacotherapy should occur simultaneously 1, 3
• Do not start fibrates as first-line therapy when LDL-C is also elevated—statins provide superior cardiovascular benefit 1, 3
• Do not ignore secondary causes—uncontrolled diabetes, hypothyroidism, or excessive alcohol can be the primary driver and must be addressed first 3, 4, 2