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
Medical therapy
In addition to lifestyle modification, medications are recommended to reduce atherogenic potential in patients with moderate or severe HTG and an ASCVD risk > 7.5% (Table 34,13,18,23 and Table 42,9). Before initiating medical therapy, we recommend that you engage in shared decision-making with patients to (1) delineate treatment goals and (2) describe the risks and benefits of medications for HTG.2
Statins. These agents are recommended first-line therapy for reducing ASCVD risk.2 If the TG level remains elevated (> 500 mg/dL) after statin therapy is maximized, an additional agent can be added—ie, a fibrate or fish oil (see below).
Fibrates. If a fibrate is used as an add-on to a statin, fenofibrate is preferred over gemfibrozil because it presents less risk of the severe myopathy that can develop when taken with a statin.13 Despite the effectiveness of fibrates in reducing the TG level, these drugs have not been shown to reduce overall mortality.24 The evidence on improved cardiovascular outcomes is subgroup-specific (ie, prevention of a second myocardial infarction in the setting of optimal statin use and elevated non-HDL lipoproteins).12 A study demonstrated that gemfibrozil reduced the incidence of transient ischemic attack and stroke in a subgroup of male US veterans who had coronary artery disease and a low HDL level.25
Fish oil. The omega-3 ethyl esters eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), available as EPA alone or in combination with DHA, do not interact with statins and are tolerated well. They reduce hypertriglyceridemia by 20% to 50%.13
Eicosapentaenoic acid, EPA plus DHA, and icosapent ethyl, an ethyl ester product containing EPA without DHA, are approved by the US Food and Drug Administration for HTG > 500 mg/dL, at a dosage of 2000 mg twice daily. In the REDUCE-IT trial, adding icosapent ethyl, 2 g twice daily, to a statin in patients with HTG was associated with fewer ischemic events, compared to placebo.23,26
Continue to: Fish oil formulations...
