Management of Persistent Severe Hypertriglyceridemia Despite Current Therapy

Current Status Assessment

The American College of Cardiology recommends that patients with severe hypertriglyceridemia (TG 600-700 mg/dL) despite multiple interventions should be assessed for current therapy, which may include low-dose statin, gemfibrozil, and omega-3 fatty acids 1, 2
Patients with severe hypertriglyceridemia are at significant risk of pancreatitis with TG >500 mg/dL, according to the American Heart Association, as published in Circulation 2, 3
The American College of Cardiology suggests that patients with severe hypertriglyceridemia should achieve significant weight loss (8-10%) and follow a strict diet, with a normal BMI of 24 1

The American College of Cardiology recommends increasing statin dose if currently on very low dose and no contraindications, which can provide 10-30% dose-dependent reduction in triglycerides 1, 3
The American Diabetes Association suggests adding icosapent ethyl (prescription EPA) at a dose of 4g/day, which can reduce triglycerides by ≥30% and has shown superior cardiovascular outcomes compared to placebo in high-risk patients 3

The American Heart Association recommends monitoring for myopathy risk if combining statin with fibrate, with fenofibrate having lower risk of myopathy with statins compared to gemfibrozil 4
The American College of Cardiology suggests maintaining a very low-fat diet (<15% of calories from fat) and reducing or eliminating refined carbohydrates and alcohol, while continuing physical activity program 1, 2
The American Heart Association recommends monitoring for symptoms of pancreatitis (abdominal pain, nausea, vomiting) and reassessing secondary causes periodically 1, 2, 5