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
Exercise. Thirty minutes a day of moderate-intensity exercise is associated with a significant drop in postprandial TG. This benefit can last as long as 3 days, suggesting a goal of at least 3 days a week of an active lifestyle. Such a program can include intermittent aerobics or mild resistance exercise.19
Healthy eating habits. The difference between a low-fat, high-carbohydrate diet and a high-fat, low-carbohydrate diet is less important than the overall benefit of weight loss from either of these diets. Complex carbohydrates are recommended over simple carbohydrates. A low-carbohydrate diet in a patient with diabetes has been demonstrated to improve the TG level, irrespective of weight change.
A Mediterranean diet can reduce the TG level by 10% to 15%, and is recommended over a low-fat diet.14 (This diet generally includes a high intake of extra virgin olive oil; leafy green vegetables, fruits, cereals, nuts, and legumes; moderate intake of fish and other meat, dairy products, and red wine; and low intake of eggs and sugars.) The American Heart Association recommends 2 servings of fatty fish a week for its omega-3 oil benefit of reducing ASCVD risk. Working with a registered dietician to assist with lipid lowering can produce better results than physician-only instruction on healthy eating.9
Alcohol consumption. Complete cessation or moderation of alcohol consumption (1 drink a day/women and 2 drinks a day/men*) is recommended to improve HTG. Among secondary factors, alcohol is commonly the cause of an unusually high elevation of the TG level.14
Smoking cessation. Smoking increases the postprandial TG level.10 Complete cessation for just 1 year can reduce a person’s ASCVD risk by approximately 50%. However, in a clinical trial,22 smoking cessation did not significantly decrease the TG level—possibly because of the counterbalancing effect of weight gain following cessation.
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