From the Guidelines
Treatment for elevated triglycerides should prioritize lifestyle modifications, including dietary changes and regular physical activity, with medication considered for triglyceride levels above 500 mg/dL to reduce the risk of pancreatitis, as recommended by the 2021 ACC expert consensus decision pathway 1. The goal of treatment is to reduce triglyceride levels to below 150 mg/dL for optimal cardiovascular health. Lifestyle interventions, such as weight loss, are the most effective way to lower triglyceride levels, with a 5% to 10% reduction in body weight associated with a 20% decrease in triglycerides 1. Key components of lifestyle modifications include:
- Reducing intake of refined carbohydrates, sugars, and alcohol
- Increasing consumption of omega-3 fatty acids from fatty fish
- Regular physical activity of at least 150 minutes per week
- Weight loss if overweight For patients with triglyceride levels above 500 mg/dL, first-line medication options include:
- Fibrates (fenofibrate 145 mg daily or gemfibrozil 600 mg twice daily)
- Prescription omega-3 fatty acids (icosapent ethyl 2 grams twice daily or omega-3 acid ethyl esters 2-4 grams daily)
- Statins for those with concurrent elevated LDL cholesterol Niacin (500-2000 mg daily) may be considered but has more side effects. Regular monitoring of triglyceride levels every 3-6 months is important to assess treatment effectiveness, as recommended by the 2013 Endocrine Society guidelines 1.
From the FDA Drug Label
Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.
Treatment for Elevated Triglycerides:
- Fenofibrate is used as an adjunct to diet to reduce triglycerides in patients with severe hypertriglyceridemia.
- The initial dose for severe hypertriglyceridemia is 54 mg per day to 160 mg per day, with a maximum dose of 160 mg once daily.
- Dosage should be individualized according to patient response and adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals.
- Key Considerations:
- Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate and continue this diet during treatment.
- Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy.
- Physical exercise can be an important ancillary measure.
- Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus, should be looked for and adequately treated. 2 2 2
From the Research
Treatment Options for Elevated Triglycerides
- 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 also help lower triglyceride levels 4.
- Physical activity, such as moderate- to high-intensity exercise, can lower triglyceride levels and improve body composition and exercise capacity 4.
Medications for Elevated Triglycerides
- Fibrates can lower triglyceride concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3.
- Omega-3 fatty acids, at a dose of 2-4 g per day, can lower triglyceride levels 3, 5.
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 4.
- High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients with high triglyceride levels who are at high risk 4.
Special Considerations
- Patients with severely elevated triglyceride levels (≥500 mg/dL) are at increased risk of pancreatitis and may require immediate treatment with triglyceride-lowering agents 4, 6.
- Patients with acute pancreatitis associated with hypertriglyceridemia may require insulin infusion and plasmapheresis if triglyceride levels remain high despite conservative management 4.
- Patients with purely genetic types of hypertriglyceridemia, such as familial chylomicronemia syndrome, should be treated in specialized outpatient clinics 3.