What are the implications of hypertriglyceridemia (elevated triglycerides)?

From the Guidelines

A triglyceride level of 429 mg/dL is significantly elevated and requires immediate treatment to reduce cardiovascular risk, starting with lifestyle modifications and considering medication therapy if necessary, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment approach for elevated triglycerides should prioritize lifestyle modifications, including:

• A low-carbohydrate diet, especially limiting simple sugars and refined carbohydrates
• Weight loss if overweight
• Regular exercise, at least 30 minutes daily
• Complete alcohol avoidance
• Increase consumption of omega-3 fatty acids through fatty fish like salmon or supplements (2-4 grams daily)

Medication Therapy

If lifestyle modifications do not reduce triglyceride levels below 200 mg/dL after 3 months, medication therapy should be considered.

• Fibrates (such as fenofibrate 145 mg daily) are typically first-line, as they have been shown to be effective in reducing triglyceride levels 1
• Prescription-strength omega-3 fatty acids (Vascepa or Lovaza, 4 grams daily) are also effective and may be considered, especially in patients with ASCVD or other cardiovascular risk factors 1
• Statins may be added if LDL cholesterol is also elevated, as they have been shown to reduce cardiovascular risk in patients with hypertriglyceridemia 1

Monitoring and Follow-up

Regular monitoring every 3-6 months is necessary to assess treatment effectiveness and adjust the treatment plan as needed.

• High triglycerides increase the risk of pancreatitis (when >500 mg/dL) and contribute to cardiovascular disease, so prompt treatment is essential to reduce these risks 1

From the FDA Drug Label

Fenofibrate therapy also lowered triglycerides and raised HDL-C (see Table 4)

Table 4: Mean Percent Change in Lipid Parameters at End of Treatment† ... TG ... All FEN (n=361) ... -28.9%*

The effects of fenofibrate on serum triglycerides were studied in two randomized, double-blind, placebo-controlled clinical trials of 147 hypertriglyceridemic patients ... In patients with hypertriglyceridemia and normal cholesterolemia with or without hyperchylomicronemia, treatment with fenofibrate at dosages equivalent to fenofibrate 160 mg per day decreased primarily very low density lipoprotein (VLDL) triglycerides and VLDL cholesterol.

Table 5: Effects of Fenofibrate in Patients with Severe Hypertriglyceridemia ... Triglycerides ... Study 1 ... Fenofibrate ... 223 -46.2*

Study 2 ... Fenofibrate ... 308 -54.5*

Fenofibrate can be used to treat elevated triglycerides.

• The medication has been shown to lower triglycerides by an average of 28.9% in clinical trials.
• In patients with severe hypertriglyceridemia, fenofibrate decreased triglycerides by 46.2% and 54.5% in two separate studies.
• The dosage used in these studies was equivalent to 160 mg per day of fenofibrate.
• It is essential to note that treatment with fenofibrate may also result in an increase in LDL-C in some patients. 2

From the Research

Elevated Triglycerides

Elevated triglycerides, with a level of 429, is a condition that requires attention due to its association with increased risk of cardiovascular disease and pancreatitis 3, 4, 5, 6, 7.

Risk Factors and Associations

• Hypertriglyceridemia affects approximately 15-20% of the adult population and is associated with overweight, metabolic syndrome, and diabetes mellitus 3.
• Risk factors for hypertriglyceridemia include genetics, lifestyle and diet, renal disease, endocrine disorders, and certain medications 5.
• Elevated triglyceride levels are independently associated with cardiovascular disease (CVD) risk, and severe hypertriglyceridemia is a risk factor for acute pancreatitis 6.

Management and Treatment

• Lifestyle modifications, such as cessation of alcohol consumption, reduced intake of rapidly metabolized carbohydrates, weight loss, and blood sugar control, are the most effective ways to lower triglyceride levels 3.
• Dietary changes, including lowering carbohydrate intake and increasing fat and protein intake, can help lower triglyceride levels 4.
• Omega-3 fatty acids, fibrates, and niacin are therapeutic options for the treatment of hypertriglyceridemia, with omega-3 fatty acids being a well-tolerated and effective alternative 6, 7.
• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 4.

Specific Treatment Options

• For patients with severely elevated triglyceride levels (≥500 mg/dL), fibrates, omega-3 fatty acids, or niacin should be considered to reduce the risk of pancreatitis 4.
• High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients at high risk who continue to have high triglyceride levels despite statin use 4.
• Insulin infusion and plasmapheresis should be considered for patients with acute pancreatitis associated with hypertriglyceridemia if triglyceride levels remain high despite conservative management 4.