From the Guidelines
Hypertriglyceridemia in patients with uncontrolled thyroid disease, particularly hypothyroidism, should be managed by addressing both conditions simultaneously, with a focus on treating the underlying thyroid disorder and implementing lifestyle modifications to reduce triglyceride levels. According to the most recent guidelines 1, for individuals with fasting triglyceride levels ≥500 mg/dL, evaluating for secondary causes of hypertriglyceridemia and considering medical therapy to reduce the risk of pancreatitis is crucial.
Treatment Approach
- First, treat the underlying thyroid disorder with appropriate thyroid hormone replacement, typically levothyroxine, with dose adjustments based on TSH levels until euthyroidism is achieved.
- Implement lifestyle modifications including a low-fat diet, regular exercise, weight loss if overweight, and avoiding alcohol and refined carbohydrates.
- If triglyceride levels remain elevated, consider adding pharmacotherapy such as fibrates, omega-3 fatty acids, or statins if LDL is also elevated, as recommended by the guidelines 1.
Rationale
The connection between hypertriglyceridemia and uncontrolled thyroid disease stems from thyroid hormones' role in lipid metabolism—hypothyroidism decreases LDL receptor activity and reduces lipoprotein lipase activity, leading to elevated triglycerides. Treating the thyroid condition often significantly improves lipid profiles, sometimes normalizing triglyceride levels without additional lipid-lowering medications, as supported by the guidelines 1.
Key Considerations
- Hypertriglyceridemia should be addressed with nutritional and lifestyle changes, including weight loss and abstinence from alcohol.
- Severe hypertriglyceridemia may warrant pharmacologic therapy and reduction in dietary fat to reduce the risk of acute pancreatitis, as indicated in the guidelines 1.
- Moderate- or high-intensity statin therapy should also be used as indicated to reduce the risk of cardiovascular events.
From the Research
Hypertriglyceridemia and Uncontrolled Thyroid
- Hypertriglyceridemia is defined as fasting serum triglyceride levels of 150 mg per dL or higher, and is associated with increased risk of cardiovascular disease 2
- Severely elevated triglyceride levels (500 mg per dL or higher) increase the risk of pancreatitis 2, 3
- Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus, while less common risk factors include excessive alcohol use, physical inactivity, and genetic disorders 2
- Uncontrolled thyroid issues can also contribute to hypertriglyceridemia, although the exact relationship between the two is not fully understood
Management of Hypertriglyceridemia
- Management of high triglyceride levels starts with dietary changes and physical activity to lower cardiovascular risk 2
- Lowering carbohydrate intake and increasing fat and protein intake can lower triglyceride levels, while moderate- to high-intensity physical activity can also lower triglyceride levels and improve body composition and exercise capacity 2
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 2, 3
- For patients with severely elevated triglyceride levels, fibrates, omega-3 fatty acids, or niacin may be considered to reduce the risk of pancreatitis 2, 3
Treatment Options
- Icosapent ethyl is a US Food and Drug Administration approved medication for CV risk reduction in patients with hypertriglyceridemia 4
- Other treatment options, such as PPARα modulators, apoC-III mRNA antisense inhibitors, and angiopoietin-like 3 (ANGPTL3) antibodies, are currently being researched and may provide alternative options for patients in the future 4
- Fibrates, niacin, and other approved agents may also be used to treat hypertriglyceridemia, although the treatment paradigm is changing based on data from recent clinical trials 5