Management of Severe Hypertriglyceridemia

Introduction to Management

The American College of Cardiology recommends initiating fenofibrate 54-160 mg daily immediately to rapidly reduce triglycerides below 500 mg/dL and prevent acute pancreatitis, which occurs in 14% of patients at this triglyceride level 1.

The American College of Cardiology suggests restricting total dietary fat to 20-25% of total daily calories for triglycerides in the 500-999 mg/dL range 1.
Completely eliminating all added sugars is recommended, as sugar intake directly increases hepatic triglyceride production 1.
Abstaining completely from all alcohol consumption is advised, as even 1 ounce daily increases triglycerides by 5-10% 1.
Targeting 5-10% body weight reduction is recommended, which produces a 20% decrease in triglycerides 1.
Engaging in at least 150 minutes per week of moderate-intensity aerobic activity is suggested, which reduces triglycerides by approximately 11% 1.

The American College of Cardiology recommends initiating moderate-to-high intensity statin therapy (atorvastatin 20-40 mg or rosuvastatin 10-20 mg daily) once triglycerides fall below 500 mg/dL with fenofibrate therapy 1.
If triglycerides remain >200 mg/dL after 3 months of fenofibrate plus optimized lifestyle and statin therapy, adding prescription omega-3 fatty acids (icosapent ethyl 2-4 g daily) is recommended 1.

The primary goal is the rapid reduction of triglycerides to <500 mg/dL to eliminate pancreatitis risk 1.
The secondary goal is further reduction to <200 mg/dL (ideally <150 mg/dL) to reduce cardiovascular risk 1.
The LDL-C goal is <100 mg/dL for patients with cardiovascular risk profiles 1.
The Non-HDL-C goal is <130 mg/dL (calculated as total cholesterol minus HDL-C) 1.

Fenofibrate alone is expected to reduce triglycerides by 30-50% 1.
Dietary modifications are expected to result in an additional 20-50% reduction in triglycerides if fully implemented 1.
Adding statin therapy is expected to result in an additional 10-30% triglyceride reduction plus 30-50% LDL-C reduction 1.