Do you increase the dose of HMG-CoA reductase inhibitors (statins) if hypertriglyceridemia persists?

From the Guidelines

Statins should not be increased solely to address high triglycerides, as they have only a modest effect on triglyceride levels, and other medications such as fibrates, omega-3 fatty acids, or niacin are generally preferred for triglyceride reduction. The most recent and highest quality study, 1, recommends addressing hypertriglyceridemia with lifestyle changes, including weight loss and abstinence from alcohol, and considering medical therapy to reduce the risk of pancreatitis in individuals with fasting triglyceride levels ≥500 mg/dL. For individuals with ASCVD or other cardiovascular risk factors on a statin with managed LDL cholesterol but elevated triglycerides (150–499 mg/dL), the addition of icosapent ethyl can be considered to reduce cardiovascular risk, as shown in the REDUCE-IT trial 1.

Key Considerations

• Lifestyle modifications, such as reducing alcohol and sugar intake, losing weight if needed, increasing physical activity, and limiting refined carbohydrates, are crucial in managing hypertriglyceridemia.
• Secondary causes of high triglycerides, such as uncontrolled diabetes, hypothyroidism, kidney disease, or certain medications, should be ruled out before adding medications.
• The decision to treat high triglycerides depends on the severity, with levels above 500 mg/dL requiring immediate treatment to prevent pancreatitis, and levels between 150-499 mg/dL may be addressed to reduce cardiovascular risk.
• Other medications, such as fibrates (e.g., fenofibrate or gemfibrozil) or omega-3 fatty acids (e.g., Vascepa or Lovaza), may be more effective options for triglyceride reduction than increasing statin dosage.

Management Approach

• Evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis in individuals with fasting triglyceride levels ≥500 mg/dL.
• Address and treat lifestyle factors, secondary factors, and medications that raise triglycerides in adults with hypertriglyceridemia.
• Consider the addition of icosapent ethyl to reduce cardiovascular risk in individuals with ASCVD or other cardiovascular risk factors on a statin with managed LDL cholesterol but elevated triglycerides (150–499 mg/dL).

From the Research

Increasing Statin Dosage for High Triglycerides

• The decision to increase statin dosage in patients with high triglycerides is not straightforward and depends on various factors, including the patient's overall cardiovascular risk profile and response to initial statin therapy 2, 3.
• Studies have shown that statins are effective in lowering LDL cholesterol, but their effect on triglycerides is typically modest 2, 4.
• In patients with residual hypertriglyceridemia despite statin treatment, adding other medications such as omega-3 fatty acids, fibrates, or niacin may be considered to further reduce triglyceride levels 4, 5, 6.
• The use of combination therapy, such as fenofibrate and statin, has been shown to be effective in reducing triglyceride levels in patients with inadequately controlled triglyceride levels despite previous statin monotherapy 6.
• However, the optimal approach to managing hypertriglyceridemia is still a topic of debate, and more research is needed to determine the best treatment strategies for reducing cardiovascular risk in patients with high triglycerides 2, 5.

Treatment Options for High Triglycerides

• Lifestyle changes, such as improved diet and increased physical activity, are effective in lowering triglyceride levels and should be recommended to all patients with hypertriglyceridemia 2.
• Pharmacological treatment options for hypertriglyceridemia include statins, fibrates, omega-3 fatty acids, and niacin, which can be used alone or in combination to achieve optimal triglyceride control 2, 4, 5, 6.
• The choice of treatment should be individualized based on the patient's specific needs and medical history, and should take into account the potential benefits and risks of each treatment option 2, 5.

Clinical Trials and Evidence

• Several clinical trials have investigated the efficacy and safety of different treatment strategies for hypertriglyceridemia, including the use of omega-3 fatty acids, fibrates, and combination therapy with statins 4, 6.
• The results of these trials have provided valuable insights into the management of hypertriglyceridemia and have helped to inform clinical practice guidelines 2, 5.
• However, more research is needed to fully understand the optimal treatment strategies for reducing cardiovascular risk in patients with high triglycerides 2, 5.