Hypertriglyceridemia: A strategic approach

The Journal of Family Practice. 2020 May;69(4):180-187

May 11, 2020|Family Medicine

Zahra Raza, MD;Ashwini Kamath Mulki, MD;Linda Contillo Garufi, MD, MEd;Grant M. Greenberg, MD, MHSA, MA

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

Fish oil formulations can inhibit platelet aggregation and increase bleeding time in otherwise healthy people; however, such episodes are minor and nonfatal. Patients on anticoagulation or an antiplatelet medication should be monitored periodically for bleeding events, although recommendations on how to monitor aren’t specified in a recent advisory by the American Heart Association.²³

There is a strong association between a BMI > 30 and hypertriglyceridemia.

DHA was thought to increase the LDL-C levels and, by doing so, potentially counterbalance benefit,^23,27 but most studies have failed to reproduce this effect.²⁸ Instead, studies have shown minimal elevation of LDL-C when DHA is used to treat HTG.^23,27

Niacin. At a dosage of 500-2000 mg/dL, niacin lowers the TG level by 10% to 30%. It also increases HDL by 10% to 40% and lowers LDL by 5% to 20%.¹³

Considerations in pancreatitis. For management of recurrent pancreatitis in patients with HTG, lifestyle modification remains the mainstay of treatment. When medication is considered for persistent severe HTG, fibrates have evidence of primary and secondary prevention of pancreatitis.¹¹ When a patient is intolerant of fibrates, consider a different option to reduce the TG level—eg, fish oil supplementation.

CASE 1

Recommendation for Mr. M: Therapeutic lifestyle changes to address moderate HTG.

Continue to: Because Mr. M's...

References

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