Hypertriglyceridemia: A strategic approach
This review, and the at-a-glance tables that follow, detail indications and strategies for the treatment of adults with hypertriglyceridemia.
PRACTICE RECOMMENDATIONS
› Evaluate patients for hypertriglyceridemia when they have a comorbid condition (eg, type 2 diabetes, obesity, hypothyroidism, metabolic syndrome, alcoholism). B
› Do not require fasting status when evaluating triglycerides in a lipid panel. B
› Make therapeutic lifestyle changes first-line treatment for hypertriglyceridemia. C
› Prescribe fibrates for severe hypertriglyceridemia to reduce the risk and recurrence of pancreatitis. A
› Prescribe a statin and an omega-3 fatty acid (fish oil) to lower the triglyceride level and thus reduce resulting atherogenicity when the risk of atherosclerotic cardiovascular disease is > 7.5%. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The purpose of testing lipids in a fasting state (> 9 hours) is to minimize the effects of an elevated TG level on the calculated LDL. In severe HTG, beta-quantitation by ultracentrifugation and electrophoresis can be performed to determine the LDL level directly.
Advantage of nonfasting measurement. When LDL-C is not a concern, there is, in fact, value in measuring TGs in the nonfasting state. Why? Because a nonfasting TG level is a better indicator of a patient’s average TG status: Studies have found a higher ASCVD risk in the setting of an elevated postprandial TG level accompanied by a low HDL level.7
The Copenhagen City Heart Study identified postprandial HTG as an independent risk factor for atherogenicity, even in the setting of a normal fasting TG level.8 American Association of Clinical Endocrinologists and American College of Endocrinology guidelines endorse testing the nonfasting TG level when the fasting TG level is elevated in a lipid profile; if the nonfasting TG level is > 500 mg/dL, evaluation for secondary causes is warranted9,10 (Table 11,2).
In a practical sense, therefore, offering patients nonfasting lipid testing allows more people to obtain access to timely care.
Pancreatitis. Acute pancreatitis commonly prompts an evaluation for HTG. The risk of acute pancreatitis in the general population is 0.04%, but that risk increases to 8% to 31% for a person with HTG.11 Incidence when the TG level is > 500 mg/dL is thought to be increased because chylomicrons, acting as a TG carrier in the bloodstream, are responsible for pancreatitis.3 Treating HTG can reduce both the risk and recurrence of pancreatitis12,13; given that the postprandial TG level can change rapidly from severe to very severe (> 2000 mg/dL), multiple guidelines recommend pharmacotherapy to a TG goal of < 500-1000 mg/dL.1,9,13,14
Continue to: An ASCVD risk-HTG connection?
