What are the appropriate oral medications for a 79-year-old African American (AA) female with hypertriglyceridemia (Triglycerides (TG) of 200) and mildly elevated total cholesterol (153) with normal High-Density Lipoprotein (HDL) and Low-Density Lipoprotein (LDL) levels?

From the Guidelines

For a 79-year-old African American female with triglycerides of 200 mg/dL, total cholesterol of 153 mg/dL, and normal HDL and LDL, I recommend starting with fenofibrate 145 mg once daily. This medication specifically targets elevated triglycerides while having minimal effects on her already normal HDL and LDL levels. Fenofibrate works by activating peroxisome proliferator-activated receptors (PPARs), which regulate genes involved in lipid metabolism, particularly decreasing triglyceride production and increasing their clearance from circulation 1. Before starting treatment, baseline liver function tests and renal function should be checked, with monitoring at 3 months and periodically thereafter. Lifestyle modifications should accompany medication therapy, including:

• Limiting simple carbohydrates
• Reducing alcohol intake
• Increasing physical activity as tolerated
• Consuming omega-3 rich foods If fenofibrate is not tolerated or contraindicated, omega-3 fatty acid supplements (2-4 grams daily) or gemfibrozil 600 mg twice daily could be considered as alternatives, though gemfibrozil has more drug interactions 1. Given her age, it's essential to monitor for side effects and drug interactions, especially if she takes multiple medications. The goal is to achieve a non-HDL-C level of 130 mg/dL, as recommended for patients with triglycerides between 200-499 mg/dL 1.

From the FDA Drug Label

The effects of fenofibrate at a dose equivalent to 160 mg fenofibrate tablets per day were assessed from four randomized, placebo-controlled, double-blind, parallel-group studies including patients with the following mean baseline lipid values: total-C 306.9 mg/dL; LDL-C 213.8 mg/dL; HDL-C 52. 3 mg/dL; and triglycerides 191 mg/dL.

In a subset of the subjects, measurements of apo B were conducted. Fenofibrate treatment significantly reduced apo B from baseline to endpoint as compared with placebo (-25.1% vs. 2.4%, p < 0.0001, n=213 and 143 respectively).

The effects of fenofibrate on serum triglycerides were studied in two randomized, double-blind, placebo-controlled clinical trials of 147 hypertriglyceridemic patients

For a 79-year-old African American female with a triglyceride level of 200 mg/dL and a total cholesterol level of 153 mg/dL, with normal HDL and LDL levels, fenofibrate may be considered as an oral medication to lower triglycerides.

• The patient's triglyceride level is elevated, and fenofibrate has been shown to decrease triglycerides in clinical trials.
• However, the patient's total cholesterol and LDL levels are within normal limits, and fenofibrate may increase LDL-C in some patients.
• It is essential to weigh the potential benefits and risks of fenofibrate treatment in this patient, considering her age and other health factors.
• The dosage of fenofibrate is typically 160 mg per day, and the patient should be advised to take the medication once daily with a meal and to follow an appropriate lipid-modifying diet 2.

From the Research

Oral Medications for Hypertriglyceridemia

The patient is a 79-year-old African American female with a triglyceride (TG) level of 200 mg/dL and a total cholesterol level of 153 mg/dL, with normal high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels.

• The patient's TG level is considered elevated, as it is above 150 mg/dL 3.
• According to the study by 3, management of high TG levels starts with dietary changes and physical activity to lower cardiovascular risk.
• The study by 4 suggests that statins can be considered for patients with high TG levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease.
• For patients with severely elevated TG levels, fibrates, omega-3 fatty acids, or niacin can be considered to reduce the risk of pancreatitis 3, 4.
• The study by 5 found that concomitant use of prescription omega-3 fatty acids and fenofibrate resulted in a greater reduction in TG levels compared to fenofibrate monotherapy.
• The study by 6 found that the TG/HDL-C ratio is a poor predictor of insulin resistance in African American women, but is associated with decreased β-cell function.

Treatment Options

• Statins: can be considered for patients with high TG levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 4.
• Fibrates: can be considered for patients with severely elevated TG levels to reduce the risk of pancreatitis 3, 4.
• Omega-3 fatty acids: can be considered for patients with severely elevated TG levels to reduce the risk of pancreatitis, and may be a well-tolerated and effective alternative to fibrates and niacin 4, 5.
• Niacin: can be considered for patients with severely elevated TG levels to reduce the risk of pancreatitis 3, 4.