What is the appropriate treatment for an adult patient with no significant medical history, presenting with hypertriglyceridemia, cholesterol 184 mg/dL, HDL (High-Density Lipoprotein) 47 mg/dL, and LDL (Low-Density Lipoprotein) 82 mg/dL?

Treatment for Triglycerides 277 mg/dL, Total Cholesterol 184 mg/dL, HDL 47 mg/dL, LDL 82 mg/dL

Begin with aggressive lifestyle modifications for 3 months, then reassess lipid panel; if triglycerides remain >200 mg/dL and you have established cardiovascular disease or diabetes with ≥2 additional risk factors, add prescription omega-3 fatty acids (icosapent ethyl 2-4g daily) to reduce cardiovascular events by 25%. 1

Understanding Your Lipid Profile and Risk

Your triglyceride level of 277 mg/dL falls into the moderate hypertriglyceridemia category (200-499 mg/dL), which is associated with increased cardiovascular risk but is well below the threshold (≥500 mg/dL) where acute pancreatitis becomes a concern. 1 Your LDL cholesterol of 82 mg/dL is already at goal (<100 mg/dL), which is excellent. 2 However, your HDL of 47 mg/dL is slightly below the optimal target of >50 mg/dL for women or >40 mg/dL for men. 2, 1

Calculate your non-HDL cholesterol (total cholesterol minus HDL): 184 - 47 = 137 mg/dL. The target for moderate hypertriglyceridemia is <130 mg/dL, so you are slightly above this secondary goal. 1, 2

Lifestyle Modifications: The Foundation of Treatment

Target a 5-10% body weight reduction, which produces a 20% decrease in triglycerides—this is the single most effective lifestyle intervention. 1 In some patients, weight loss can reduce triglyceride levels by up to 50-70%. 1

Dietary Changes

• Restrict added sugars to <6% of total daily calories, as sugar intake directly increases hepatic triglyceride production. 1
• Eliminate all sugar-sweetened beverages completely. 1
• Limit total dietary fat to 30-35% of total daily calories for moderate hypertriglyceridemia. 1
• Restrict saturated fats to <7% of total energy intake, replacing with monounsaturated or polyunsaturated fats. 2, 1
• Increase soluble fiber to >10 g/day from sources like oats, beans, and vegetables. 1, 2
• Consume ≥2 servings (8+ ounces) per week of fatty fish (salmon, trout, sardines, anchovies) rich in omega-3 fatty acids. 1

Alcohol and Physical Activity

• Limit or completely avoid alcohol consumption, as even 1 ounce daily increases triglycerides by 5-10%. 1, 2
• Engage in ≥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

When to Consider Pharmacologic Therapy

Statin Therapy Decision

If you are 40-75 years old with a 10-year ASCVD risk ≥7.5%, or if you have diabetes, initiate moderate-to-high intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) as first-line. 1, 3 Statins provide 10-30% dose-dependent triglyceride reduction in addition to proven cardiovascular mortality benefit through LDL-C reduction. 1, 2

However, if your LDL is already well-controlled at 82 mg/dL and you are not on a statin, you may not need statin therapy unless you have other cardiovascular risk factors. 1

Prescription Omega-3 Fatty Acids (Icosapent Ethyl)

If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications, consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4g daily) IF you meet ALL of the following criteria: 1

• Triglycerides ≥150 mg/dL (you qualify at 277 mg/dL)
• Already on maximally tolerated statin therapy with controlled LDL-C, OR
• Established cardiovascular disease, OR
• Diabetes with ≥2 additional cardiovascular risk factors

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

Fibrate Therapy

Fenofibrate 54-160 mg daily can be considered if triglycerides remain >200 mg/dL after 3 months of lifestyle modifications and you do NOT meet criteria for icosapent ethyl. 1 Fenofibrate provides 30-50% triglyceride reduction. 1 However, fibrates are typically reserved for more severe hypertriglyceridemia or when statins cannot be used. 2, 1

Monitoring and Follow-Up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications. 1
• Target goals: Triglycerides <200 mg/dL (ideally <150 mg/dL), non-HDL-C <130 mg/dL, and maintain LDL-C <100 mg/dL. 1, 2
• If adding pharmacotherapy, recheck lipids 4-8 weeks after initiating or adjusting therapy. 1

Critical Pitfalls to Avoid

• Do not use over-the-counter fish oil supplements expecting cardiovascular benefit—only prescription formulations (icosapent ethyl) have proven cardiovascular outcomes. 1
• Do not delay lifestyle modifications while waiting for medications to take effect—implement dietary changes, exercise, and weight loss immediately. 1
• Do not ignore secondary causes of hypertriglyceridemia, including uncontrolled diabetes, hypothyroidism, excessive alcohol intake, or medications (thiazide diuretics, beta-blockers, estrogen therapy). 1