Treatment of Hypertriglyceridemia

Classification and Diagnosis

The American College of Cardiology classifies hypertriglyceridemia as follows: Normal: <150 mg/dL, Mild: 150-199 mg/dL, Moderate: 200-499 mg/dL, Severe: 500-999 mg/dL, Very severe: ≥1,000 mg/dL 1, 2

Evaluate patients for secondary causes of hypertriglyceridemia, including excessive alcohol intake, uncontrolled diabetes, hypothyroidism, renal disease, liver disease, and certain medications, and assess cardiovascular risk factors and risk of pancreatitis 1, 2

Target a 5-10% weight loss to reduce triglycerides by up to 20%, and recommend dietary modifications, such as restricting added sugars and total fat, based on triglyceride levels 1, 2
Engage in at least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity, and limit or avoid alcohol consumption, especially with severe hypertriglyceridemia 1, 2

For severe to very severe hypertriglyceridemia (≥500 mg/dL), fibrates are first-line drug therapy to reduce the risk of pancreatitis, and optimize glycemic control in patients with diabetes to improve triglyceride levels 1, 2
For moderate hypertriglyceridemia (200-499 mg/dL), consider statins if there is elevated LDL-C or increased cardiovascular risk, which can reduce triglycerides by 10-30% 1, 2
Prescription omega-3 fatty acids (2-4g/day) can be considered for patients with persistent hypertriglyceridemia despite lifestyle modifications 1, 2

For patients with triglycerides ≥500 mg/dL, prioritize aggressive triglyceride lowering to reduce the risk of pancreatitis before focusing on LDL-C goals, and monitor for potential drug interactions, particularly when combining lipid-lowering medications 1, 2
The combination of statins with nicotinic acid, fenofibrate, and especially gemfibrozil may carry an increased risk of myositis 3, 2

Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications or starting pharmacotherapy 1, 2