How can I reduce elevated triglycerides?

How to Reduce Elevated Triglycerides

For triglycerides ≥500 mg/dL, initiate fenofibrate 54-160 mg daily immediately to prevent acute pancreatitis, while simultaneously implementing extreme dietary fat restriction and eliminating all added sugars and alcohol. 1, 2

Classification and Immediate Risk Assessment

Your triglyceride level determines the urgency and type of intervention needed:

• Normal: <150 mg/dL 1
• Mild: 150-199 mg/dL - cardiovascular risk-enhancing factor 1
• Moderate: 200-499 mg/dL - increased cardiovascular risk 1, 2
• Severe: 500-999 mg/dL - 14% pancreatitis risk, requires immediate pharmacotherapy 1
• Very severe: ≥1,000 mg/dL - dramatic pancreatitis risk, medical emergency 1, 2

Lifestyle Modifications (Foundation for All Levels)

Weight Loss - Most Effective Single Intervention

Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides. 1, 2 In some patients, weight loss can reduce triglyceride levels by up to 50-70%. 1

Dietary Changes by Severity Level

For mild-moderate hypertriglyceridemia (150-499 mg/dL):

• Restrict added sugars to <6% of total daily calories 1, 2
• Limit total fat to 30-35% of total calories 1, 2
• Restrict saturated fats to <7% of total energy intake, replacing with monounsaturated or polyunsaturated fats 1, 2
• Increase soluble fiber to >10 g/day 1, 2

For severe hypertriglyceridemia (500-999 mg/dL):

• Restrict total dietary fat to 20-25% of total calories 1, 2
• Eliminate all added sugars completely 1, 2
• Complete alcohol abstinence is mandatory 1, 2

For very severe hypertriglyceridemia (≥1,000 mg/dL):

• Implement extreme dietary fat restriction to 10-15% of total calories (or <5% until levels drop below 1,000 mg/dL) 1, 2
• Eliminate all added sugars and alcohol completely 1, 2

Physical Activity

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

Alcohol Restriction

Even 1 ounce of alcohol daily increases triglycerides by 5-10%. 1 Complete abstinence is mandatory for triglycerides ≥500 mg/dL to prevent hypertriglyceridemic pancreatitis. 1, 2

Pharmacologic Therapy Algorithm

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

Initiate fenofibrate 54-160 mg daily immediately as first-line therapy to prevent acute pancreatitis, before addressing LDL cholesterol. 1, 2, 3 Fenofibrate reduces triglycerides by 30-50%. 1, 3 Do not start with statin monotherapy at this level, as statins provide only 10-30% triglyceride reduction and are insufficient for preventing pancreatitis. 1

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

For Moderate Hypertriglyceridemia (200-499 mg/dL)

If 10-year ASCVD risk is ≥7.5% or LDL-C is elevated, initiate moderate-to-high intensity statin therapy as first-line. 1, 2 Statins provide 10-30% dose-dependent triglyceride reduction plus proven cardiovascular benefit. 1

If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, add icosapent ethyl 2g twice daily if you have established cardiovascular disease OR diabetes with ≥2 additional cardiovascular risk factors. 1, 4 Icosapent ethyl demonstrated a 25% reduction in major adverse cardiovascular events (number needed to treat = 21). 1

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

For Mild Hypertriglyceridemia (150-199 mg/dL)

For patients aged 40-75 years with 10-year ASCVD risk ≥7.5%, consider initiating moderate-intensity statin therapy. 1 Persistently elevated nonfasting triglycerides ≥175 mg/dL constitute a cardiovascular risk-enhancing factor favoring statin therapy. 1

Address Secondary Causes First

Before initiating pharmacotherapy, aggressively evaluate and treat:

• Uncontrolled diabetes mellitus - often the primary driver of severe hypertriglyceridemia; optimizing glucose control can reduce triglycerides by 20-50% independent of lipid medications 1, 2
• Hypothyroidism - check TSH 1, 2
• Chronic kidney disease or nephrotic syndrome 1
• Medications that raise triglycerides: thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, antipsychotics 1
• Excessive alcohol consumption 1, 2

Treatment Goals

• Primary goal: Reduce triglycerides to <200 mg/dL (ideally <150 mg/dL) 1, 2
• For severe hypertriglyceridemia: Rapid reduction to <500 mg/dL to eliminate pancreatitis risk 1
• Secondary goal: Non-HDL-C <130 mg/dL 1
• LDL-C goal: <100 mg/dL for high-risk patients (or <70 mg/dL for very high-risk patients) 1

Critical Safety Considerations

When combining fenofibrate with statins, use lower statin doses to minimize myopathy risk, particularly in patients >65 years or with renal disease. 1 Use fenofibrate, NOT gemfibrozil, when combining with statins—fenofibrate has a significantly better safety profile because it does not inhibit statin glucuronidation. 1

Monitor creatine kinase levels and muscle symptoms when using combination therapy. 1 Monitor renal function within 3 months after fenofibrate initiation and every 6 months thereafter. 1

Monitoring Strategy

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications 1, 2
• Reassess lipids 4-8 weeks after initiating or adjusting pharmacotherapy 1
• Once goals are achieved, follow-up every 6-12 months 1

Common Pitfalls to Avoid

• Do not delay fibrate therapy while attempting lifestyle modifications alone when triglycerides are ≥500 mg/dL—pharmacologic therapy is mandatory at this level 1
• Do not use over-the-counter fish oil supplements expecting cardiovascular benefit—prescription omega-3 formulations (icosapent ethyl) are required for proven cardiovascular risk reduction 1
• Do not ignore uncontrolled diabetes as the primary driver—optimizing glycemic control may be more effective than additional lipid medications 1, 2
• Do not use gemfibrozil when combining with statins—fenofibrate has a much better safety profile 1