U. Evaluation and Treatment of High Triglycerides

objective

Evaluate and treat TG levels above 200 mg/dl.

background

In the management of dyslipidemia, therapy targeted at LDL lowering is the first priority to lower CVD risk.  Some dyslipidemic disorders manifest with significantly elevated TG levels.  Although there are no clinical trials that have shown that reducing TG levels reduces CV risk, there are situations when emphasis needs to be placed on reducing the serum TG level.  Patients with very high levels of TGs are at risk for the development of acute pancreatitis, and some authorities recommend TG level ≥ 500 mg/dL as a threshold for treatment to prevent pancreatitis.  Accurate measurement of TG requires fasting for 9-12 hours prior to the test.  Thus, for TG levels >400 mg/dL the first step would be to ensure that it was done in a fasting state, and repeat the measurement, if not.

Box 7. Treatment for Hypertriglyceridemia
TG >200 – 499 mg/dL	TG >500 mg/dL	TG >1000 mg/dL
Lifestyle management Weight loss Alcohol cessation Secondary causes	Very low fat diet Low concentrated carbohydrate diet Alcohol cessation Secondary causes Consider drugs, if no response to above Consider referral	Strict MNT (avoidance of alcohol, fat, and restrict calories) Secondary causes Drug therapy, if no response to above Consider referral

recommendations

1. Patients with elevated TG (>200 mg/dL) should have a repeat fasting lipid profile, and if persistent receive intensive MNT, an appropriate exercise program, and be screened for underlying causes.  [B]
2. Drug therapy may be considered in patients with very high TG levels (≥ 500 mg/dL) that do not respond to lifestyle interventions and the treatment of underlying causes of elevated TG, for the purpose of preventing pancreatitis.  [I]
3. Effective drugs for lowering hypertriglyceridemia include: fibrates, niacin, and fish oil.  [B]

Table 9.  Drug Treatment for Hypertriglyceridemia

TG 500-1000 mg/dL
	Drug	Efficacy (Expected % Reduction in TG )
Initial	Fibrates	-20 to -50
Alternate	Niacin	-20 to -35
	n-3 PUFA Supplements, Omega-3 Fatty Acids/Fish Oils	-20 to -30

·  Fibrates are contraindicated in severe renal disease.
·  Niacin is contraindicated in hepatic disease and relatively contraindicated in DM, gout, and history of complicated/active peptic ulcer disease (PUD).

discussion

Since the goal of the management of dyslipidemia is ultimately to decrease CV risk, and the evidence is best at reducing such risk through LDL-C lowering therapies, LDL-C remains the treatment priority, and should be addressed regardless of the TG level.

Pancreatitis is typically seen with TG levels ≥1,000 mg/dl, but patients with TG levels ≥500 mg/dL may develop a rapid elevation in the TG level (e.g., after a high-fat meal) resulting in acute pancreatitis.  Therefore, some recommend lowering very high TG levels (>500 mg/dL) to prevent acute pancreatitis.

Patients with hypertriglyeridemia will often have an acquired or secondary condition responsible for the TG elevation.  Acquired causes of elevated TG include: obesity, excess alcohol intake, physical inactivity, cigarette smoking, and high carbohydrate intake.  Secondary causes of elevated TG may also include poorly controlled DM, chronic renal failure, Cushing’s syndrome, pregnancy, and various drugs (beta blockers, thiazide diuretics, oral estrogens, tamoxifen, protease inhibitors, and retinoids).

The primary treatment for elevated TG is lifestyle modification and the treatment of underlying causes.  In many instances, life style modification and treatment of secondary conditions will correct the hypertriglyceridemia.  Poorly controlled DM and alcohol abuse are common conditions responsible for very high TG value, and therefore, assessment and treatment of these conditions if present, should always be a priority in the management of very high TG levels.  Drug therapy should be considered in patients with very high levels (>500 mg/dL) that does not respond to other measures.  Drugs that are known to lower TG levels include fibrates, nicotinic acid, fish oil (omega-3 fatty acids), and statins.