From the Guidelines
Treatment for elevated triglycerides should prioritize lifestyle modifications, including dietary changes, regular exercise, weight loss, and smoking cessation, alongside consideration of medications such as statins, fibrates, and prescription omega-3 fatty acids, as indicated by the most recent guidelines 1.
Lifestyle Modifications
- Dietary changes: Reduce intake of refined carbohydrates, sugars, and alcohol, and increase consumption of omega-3 fatty acids from fatty fish.
- Regular exercise: At least 150 minutes of moderate activity weekly.
- Weight loss: If overweight, to reduce triglyceride levels and cardiovascular risk.
- Smoking cessation: Essential for overall cardiovascular health.
Medication Therapy
- Statins: Such as atorvastatin (10-80 mg daily) or rosuvastatin (5-40 mg daily), often first-line therapy, especially with concurrent high LDL cholesterol.
- Fibrates: Like fenofibrate (48-145 mg daily) or gemfibrozil (600 mg twice daily), specifically target triglycerides.
- Prescription omega-3 fatty acids: Icosapent ethyl (2 grams twice daily) or omega-3 acid ethyl esters (2-4 grams daily) are effective for severe hypertriglyceridemia (>500 mg/dL), as recommended by recent standards of care 1.
- Niacin: Extended-release, 500-2000 mg daily, may be considered but has more side effects.
Considerations for Specific Patient Groups
- Patients with fasting triglyceride levels ≥500 mg/dL: Evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis, as advised by the latest guidelines 1.
- Adults with hypertriglyceridemia (fasting triglycerides >150 mg/dL or nonfasting triglycerides >175 mg/dL): Address and treat lifestyle factors, secondary factors, and medications that raise triglycerides, in line with current recommendations 1.
- Individuals with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with managed LDL cholesterol but elevated triglycerides: The addition of icosapent ethyl can be considered to reduce cardiovascular risk, based on recent evidence 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 can be used as an adjunct to diet to reduce elevated triglycerides in adult patients with primary hypercholesterolemia or mixed dyslipidemia.
- For severe hypertriglyceridemia, the initial dose of fenofibrate 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.
- The use of fenofibrate should be avoided in patients with severe renal impairment 2.
- Before initiating fenofibrate therapy, patients should be placed on an appropriate lipid-lowering diet and continue this diet during treatment 2.
From the Research
Elevated Triglycerides Treatment
Elevated triglycerides are a common condition that can increase the risk of cardiovascular disease and pancreatitis. The treatment of elevated triglycerides typically involves lifestyle modifications and, in some cases, medication.
Lifestyle Modifications
- Cessation of alcohol consumption 3
- Reduced intake of rapidly metabolized carbohydrates 3
- Weight loss 3
- Blood sugar control 3
- Dietary changes, such as lowering carbohydrate intake and increasing fat and protein intake 4
- Moderate- to high-intensity physical activity 4
Medication
- 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, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), can lower triglyceride levels 3, 4, 5, 6
- 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 EPA) can reduce cardiovascular mortality in patients at high risk 4
- Niacin can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 4, 5
Specialized Treatment
- Patients with very rare purely genetic types of hypertriglyceridemia (familial chylomicronemia syndrome) should be treated in specialized outpatient clinics 3
- Insulin infusion and plasmapheresis should be considered for patients with acute pancreatitis associated with hypertriglyceridemia if triglyceride levels remain high despite conservative management 4