Overview of management of hypertriglyceridemia

ABI: ankle-brachial index; ASCVD: atherosclerotic cardiovascular disease; HDL-C: high-density lipoprotein cholesterol; hs-CRP: high-sensitivity C-reactive protein; IPE: icosapent ethyl; LDL-C: low-density lipoprotein cholesterol; TG: fasting serum (or plasma) triglyceride level.

* Addressing modifiable causes includes avoiding medications that cause hypertriglyceridemia and achieving excellent glycemic control for patients with diabetes mellitus. Refer to UpToDate content on causes of hypertriglyceridemia.

¶ Nonpharmacologic measures include regular aerobic exercise, management of ASCVD risk factors including hypertension, and weight loss as indicated. Specific diet and alcohol recommendations vary depending upon the severity of hypertriglyceridemia. For moderate hypertriglyceridemia, targets include <6% calories of added sugar, ≤30 to 35% calories of total dietary fat, and ≤2 drinks per day for males and ≤1 drink per day for females. For moderate to severe hypertriglyceridemia, targets include <5% calories of added sugar, ≤20 to 25% calories of total dietary fat, and alcohol abstinence. Refer to § for targets for severe hypertriglyceridemia.

Δ Refer to UpToDate content on the approach to ASCVD risk assessment and on LDL-C management for primary and secondary prevention of ASCVD.

◊ "High ASCVD risk" is defined here according to the criteria in the REDUCE-IT trial: established ASCVD or diabetes mellitus plus two of the following ASCVD risk factors: age ≥50 years, cigarette smoking, hypertension, HDL-C ≤40 mg/dL for males or ≤50 mg/dL for females, hs-CRP >3 mg/L (0.3 mg/dL), creatinine clearance <60 mL/min, retinopathy, micro- or macroalbuminuria, and ABI <0.9.

§ In the setting of severe hypertriglycedemia, it is crucial to eliminate added sugars, restrict fat to ≤10 to 15% (preferably <5%) of total calories, and abstain from alcohol.

¥ For outpatients with severe hypertriglyceridemia, drug therapy for TG lowering (beyond therapy for LDL-C) is generally deferred. Given the rapid rate of TG lowering achievable with stringent dietary fat restriction, with close monitoring it may be possible to initiate drug therapy for hypertriglyceridemia within days. However, for inpatients with severe hypertriglyceridemia and pancreatitis, immediate treatment with a fibrate is a component of therapy.

‡ The choice of marine omega-3 fatty acid varies depending upon the level of ASCVD risk (as defined above). For patients with high ASCVD risk, we prefer prescription-strength IPE. In patients without high ASCVD risk, any prescription high-dose marine omega-3 fatty acid can be used. Choices include omega-3 fatty acid ethyl esters (EPA+DHA) in generic or brand form or IPE (ethyl ester of EPA). Refer to UpToDate content on administration and side effects.

† When choosing fibrate therapy, we generally prefer fenofibrate to gemfibrozil since it has fewer drug interactions, is generally better tolerated, and patient compliance is better due to its once-daily dosage. Refer to UpToDate content on administration and side effects.