Management of Hypertriglyceridemia

Mechanism of Action and Approved Indications

The American College of Cardiology recommends evolocumab, a monoclonal antibody that binds to PCSK9, for reducing LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia, and for reducing risk of MI, stroke, and coronary revascularization in adults with atherosclerotic cardiovascular disease 1, 2
The FDA-approved indications for evolocumab include reducing LDL-C in adults and pediatric patients with homozygous familial hypercholesterolemia 1, 2

The American College of Cardiology and other major clinical guidelines do not recommend PCSK9 inhibitors like evolocumab for the primary treatment of hypertriglyceridemia 3, 4, 5
For patients with hypertriglyceridemia (≥500 mg/dL), the American Diabetes Association recommends evaluation for secondary causes and specific treatments aimed at reducing pancreatitis risk 5

For severe hypertriglyceridemia (≥500 mg/dL), fibrates are the first-line pharmacological treatment, reducing triglycerides by up to 50%, according to the American College of Cardiology 6
Omega-3 fatty acids can reduce triglycerides by up to 40% in patients with severe hypertriglyceridemia (≥500 mg/dL) 6
For patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL-C but elevated triglycerides (135-499 mg/dL), icosapent ethyl may be considered to reduce cardiovascular risk, as recommended by the American Diabetes Association 5

Combination therapy with a statin and a fibrate has not been shown to improve ASCVD outcomes and is generally not recommended due to increased risk of myopathy, according to the American College of Physicians 4
Lifestyle modifications, including weight reduction, decreased intake of simple carbohydrates, reduced alcohol consumption, and increased physical activity, are essential for all patients with hypertriglyceridemia, as recommended by the American College of Cardiology 6