From the Guidelines
Triglyceride treatment should prioritize lifestyle modifications, including a low-carbohydrate, low-sugar diet, increased intake of omega-3 fatty acids, regular exercise, weight loss, and avoidance of alcohol, alongside medications such as statins, fibrates, and prescription omega-3 fatty acids for significantly elevated levels. When considering treatment for triglycerides, it's essential to evaluate the patient's overall cardiovascular risk and the presence of secondary causes of hypertriglyceridemia 1.
Lifestyle Modifications
Key lifestyle changes include:
- Adopting a low-carbohydrate, low-sugar diet
- Increasing intake of omega-3 fatty acids from fish or supplements
- Regular exercise, aiming for at least 150 minutes weekly
- Weight loss if the patient is overweight
- Avoiding alcohol consumption
Medication Therapy
For medication, the choice depends on the triglyceride levels and the presence of other cardiovascular risk factors.
- Statins like atorvastatin (10-80mg daily) or rosuvastatin (5-40mg daily) are often first-line treatments, especially when both cholesterol and triglycerides are elevated.
- Fibrates such as fenofibrate (48-145mg daily) or gemfibrozil (600mg twice daily) specifically target triglycerides and are preferred for very high levels.
- Prescription omega-3 fatty acids (icosapent ethyl 2g twice daily or omega-3 ethyl esters 2-4g daily) can reduce triglyceride levels by 20-50% and are considered for patients with elevated triglycerides despite statin therapy 1.
- Niacin (500-2000mg daily) is effective but has more side effects and is less commonly used as a first-line treatment.
Severe Hypertriglyceridemia
For patients with severe hypertriglyceridemia (triglycerides ≥500 mg/dL), evaluating for secondary causes and considering medical therapy to reduce the risk of pancreatitis is crucial 1. The American College of Cardiology expert consensus decision pathway recommends therapies to reduce both chylomicrons and VLDL in severe hypertriglyceridemia, including lifestyle interventions and medical nutrition therapy (MNT) with a rigorous approach for patients with triglycerides ≥1,000 mg/dL, which may include reducing dietary fat to 10% to 15% of calories 1.
Conclusion is not needed as per the guidelines, the above information is sufficient to guide the treatment of triglycerides.
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.
Triglycerides treatment with fenofibrate involves:
- Adjunctive therapy to diet to reduce elevated triglycerides in adult patients with primary hypercholesterolemia or mixed dyslipidemia
- Adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia
- Initial dose of 54 mg per day to 160 mg per day for severe hypertriglyceridemia, with a maximum dose of 160 mg once daily 2
- Monitoring of lipid levels and adjustment of dosage as necessary 2
From the Research
Treatment Options for Hypertriglyceridemia
- Lifestyle changes, such as improved diet and increased physical activity, are effective in lowering triglyceride levels 3, 4
- Pharmacological treatment usually starts with statins, although associated triglyceride reductions are typically modest 4
- Fibrates are currently the drugs of choice for hypertriglyceridemia, frequently in combination with statins 4
- Niacin and omega-3 fatty acids can improve control of triglyceride levels when other measures are inadequately effective 4, 5
- Prescription omega-3 fatty acids can be used as an adjunct to fenofibrate therapy in hypertriglyceridemic subjects 6
- Long-chain omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin 5
Management of Severe Hypertriglyceridemia
- Immediate use of triglyceride-lowering agents is recommended for severe hypertriglyceridemia (≥500 mg/dL) 5
- Fibrates, niacin, or long-chain omega-3 fatty acids can be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist 5
- Omega-3 fatty acids have been shown to be beneficial in decreasing liver lipid and possibly ameliorating inflammation in non-alcoholic fatty liver disease (NAFLD) 7