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
Because Mr. M’s 10-yr ASCVD risk is < 5%, statin therapy is not indicated for risk reduction. With a fasting TG value < 500 mg/dL, he is not considered at increased risk of pancreatitis.
CASE 2
Recommendations for Ms. F:
- Therapeutic lifestyle changes to address severe HTG. Ms. F agrees to wean off alcohol; add relaxation exercises before bedtime; do aerobic exercise 30 minutes a day, 3 times a week; decrease dietary carbohydrates daily by cutting portion size in half; and increase intake of fresh vegetables and lean protein.
- Treatment with fenofibrate to reduce the risk of pancreatitis. Ms. F begins a trial. Six months into treatment, she has reduced her BMI to 24 and the TG level has fallen to < 500 mg/dL. Ms. F also reports that she is sleeping well, believes that she is able to manage her infrequent anxiety, and is now in a routine that feels sustainable.
You congratulate Ms. F on her success and support her decision to undertake a trial of discontinuing fenofibrate, after shared decision-making about the risks and potential benefits of doing so.
Summing up: Management of HTG
Keep these treatment strategy highlights in mind:
- Lifestyle modification with a low-fat, low-carbohydrate diet, avoidance of alcohol, and moderate-intensity exercise is the mainstay of HTG management.
- The latest evidence supports that (1) HTG is a risk-enhancing factor for ASCVD and (2) statin therapy is recommended for patients who have HTG and an ASCVD risk > 7.5%.
- When the TG level remains elevated despite statin therapy and lifestyle changes, an omega-3 ethyl ester can be used as an adjunct for additional atherogenic risk reduction.
- For severe HTG, a regimen of therapeutic lifestyle changes plus a fibrate is recommended to reduce the risk and recurrence of pancreatitis.1,24
* In comparison, a normal level of triglycerides is < 175 mg/dL; a moderately elevated level, measured in a fasting or nonfasting state, 175-499 mg/dL; and a very severely elevated level, ≥ 2000 mg/dL.2
CORRESPONDENCE
Ashwini Kamath Mulki, MD, Family Health Center, 1730 Chew Street, Allentown, PA 18104; Ashwini.KamathMulki@lvhn.org.
