From the Guidelines
To treat high triglycerides, start with lifestyle modifications including a low-carbohydrate diet, regular exercise (30 minutes daily), weight loss if overweight, limiting alcohol, and avoiding added sugars and refined carbohydrates. For triglyceride levels above 500 mg/dL, medication is typically recommended alongside lifestyle changes. First-line medications include omega-3 fatty acids (prescription forms like Vascepa or Lovaza at 2-4 grams daily) or fibrates such as fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily) 1. Statins like atorvastatin (10-80 mg daily) may be added, especially if LDL cholesterol is also elevated, as they reduce VLDL similarly to fibrates 2. For very high levels (>1000 mg/dL), combinations of these medications may be necessary to reduce the risk of pancreatitis and modify cardiovascular risk. Triglycerides should be monitored every 3-6 months initially, then annually once stabilized. These treatments work by reducing triglyceride production in the liver and increasing their clearance from the bloodstream. Lowering triglycerides is important because elevated levels increase risk of pancreatitis and contribute to cardiovascular disease. Key considerations in management include identifying and treating underlying causes of elevated triglycerides, such as lifestyle factors, secondary disorders, and triglyceride-raising drugs 2. Given the most recent guidelines, lifestyle interventions are the first line of therapy for the management of all patients with persistent hypertriglyceridemia 1.
From the FDA Drug Label
Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated ... Triglycerides ... 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 High Triglycerides: Fenofibrate is indicated as adjunctive therapy to diet for the treatment of adult 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 3.
- Key Considerations: + Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets. + Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. + Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus, should be looked for and adequately treated 4.
From the Research
Treatment Options for High Triglycerides
- Lifestyle changes, such as improved diet and increased physical activity, are effective measures for lowering triglyceride levels 5
- Pharmacological treatment usually starts with statins, although associated triglyceride reductions are typically modest 5
- Fibrates are currently the drugs of choice for hypertriglyceridemia, frequently in combination with statins 5
- Niacin and omega-3 fatty acids can improve control of triglyceride levels when other measures are inadequately effective 5, 6
- Prescription omega-3 fatty acids have been approved by the United States Food and Drug Administration as an adjunct to diet for the treatment of very high triglyceride levels 6
Omega-3 Fatty Acids for Hypertriglyceridemia
- A daily dose of 2-4 g omega-3 fatty acids can lower triglyceride levels 6, 7
- The active ingredients of omega-3 fatty acids are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are responsible for the triglyceride lowering effect 6
- Prescription omega-3 fatty acids are well tolerated, with a low rate of adverse events and treatment-associated discontinuations 6
Management of Hypertriglyceridemia
- Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications 8
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk 8
- For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality 8
- Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 8
American Heart Association Recommendations
- The American Heart Association recommends the use of omega-3 fatty acids (EPA and DHA) at a dose of 2-4 g/d for reducing triglycerides in patients with elevated triglycerides 9
- Prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides 9
- The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in the REDUCE-IT trial 9