What is the recommended management for a patient with low triglycerides, potentially taking medications such as fibrates or omega-3 fatty acids, and with a possible history of cardiovascular disease?

Low Triglycerides: Clinical Significance and Management

Low triglyceride levels (typically <50 mg/dL) are generally not a clinical concern and do not require treatment—in fact, lower triglyceride levels within the normal range are associated with reduced cardiovascular risk. Unlike elevated triglycerides, which increase cardiovascular disease risk and pancreatitis risk at severe levels, low triglycerides are not associated with adverse health outcomes and should not prompt discontinuation of lipid-lowering therapies if they are otherwise indicated 1, 2.

Understanding Low Triglycerides in Clinical Context

Low triglyceride levels do not represent a treatment target or therapeutic problem. The clinical focus in lipid management is on:

• Elevated triglycerides ≥150 mg/dL, which serve as a cardiovascular risk-enhancing factor 2
• Moderate hypertriglyceridemia (200-499 mg/dL), which increases cardiovascular risk and warrants intervention 1, 2
• Severe hypertriglyceridemia (≥500 mg/dL), which dramatically increases acute pancreatitis risk 1, 2

When Low Triglycerides Occur on Medication

If a patient develops low triglycerides while taking fibrates or omega-3 fatty acids:

• Do NOT discontinue these medications if they were prescribed for other indications, such as mixed dyslipidemia with elevated LDL-C or established cardiovascular disease 1
• Reassess the original indication for therapy—if the medication was initiated solely for hypertriglyceridemia that has now normalized, consider whether continued therapy provides cardiovascular benefit 1, 2
• For patients on icosapent ethyl with established cardiovascular disease or diabetes with ≥2 additional risk factors, continue therapy even if triglycerides fall below 150 mg/dL, as the REDUCE-IT trial demonstrated cardiovascular benefit independent of the degree of triglyceride lowering 2, 3

Management Algorithm for Patients with Low Triglycerides

If triglycerides are <50 mg/dL and the patient is NOT on lipid-lowering medications:

• No intervention is required—this represents a favorable lipid profile 1, 2
• Focus lipid management on LDL-C targets based on cardiovascular risk stratification 1
• Ensure the patient is not experiencing malnutrition, malabsorption, or hyperthyroidism, which can cause secondary hypolipidemia 4

If triglycerides are <50 mg/dL and the patient IS on fibrates or omega-3 fatty acids:

• Review the original indication: If prescribed for severe hypertriglyceridemia (≥500 mg/dL) to prevent pancreatitis, and triglycerides are now well-controlled, consider gradual dose reduction or discontinuation while monitoring lipid levels every 4-8 weeks 2, 4
• If prescribed for cardiovascular risk reduction (icosapent ethyl in patients with established ASCVD or diabetes with risk factors), continue therapy regardless of triglyceride level 2, 3
• If prescribed for mixed dyslipidemia, reassess non-HDL-C and LDL-C targets—if these remain elevated, continue combination therapy 1

Critical Pitfalls to Avoid

• Do not discontinue statin therapy in patients with low triglycerides if statins were prescribed for LDL-C reduction or cardiovascular risk reduction—statins provide proven mortality benefit through LDL-C lowering, not triglyceride lowering 1
• Do not assume low triglycerides indicate "over-treatment"—there is no evidence that very low triglyceride levels cause harm 2
• Do not initiate triglyceride-raising interventions—low triglycerides are protective, not pathologic 1, 2

Monitoring Strategy

For patients with normalized or low triglycerides on lipid-lowering therapy:

• Reassess fasting lipid panel every 6-12 months to ensure stability 1, 2
• Monitor for secondary causes of hypolipidemia only if triglycerides are persistently <30 mg/dL or if accompanied by other clinical signs of malnutrition or malabsorption 4
• Focus monitoring on LDL-C and non-HDL-C targets based on cardiovascular risk category 1