Management of Hypertriglyceridemia: Common Questions and Answers

 

Hypertriglyceridemia, defined as fasting serum triglyceride levels of 150 mg per dL or higher, is associated with increased risk of cardiovascular disease. Severely elevated triglyceride levels (500 mg per dL or higher) increase the risk of pancreatitis. Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus. Less common risk factors include excessive alcohol use, physical inactivity, being overweight, use of certain medications, and genetic disorders. Management of high triglyceride levels (150 to 499 mg per dL) starts with dietary changes and physical activity to lower cardiovascular risk. Lowering carbohydrate intake (especially refined carbohydrates) and increasing fat (especially omega-3 fatty acids) and protein intake can lower triglyceride levels. Moderate- to high-intensity physical activity can lower triglyceride levels, as well as improve body composition and exercise capacity. Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications. Statins can be considered for patients with high triglyceride levels who have borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk. For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality (number needed to treat = 111 to prevent one cardiovascular death over five years). Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis, although this has not been studied in clinical trials. For patients with acute pancreatitis associated with hypertriglyceridemia, insulin infusion and plasmapheresis should be considered if triglyceride levels remain at 1,000 mg per dL or higher despite conservative management of acute pancreatitis.

Hypertriglyceridemia is defined as fasting serum triglyceride levels of 150 mg per dL (1.69 mmol per L) or higher. Elevated triglyceride levels (150 to 499 mg per dL [1.69 to 5.64 mmol per L]) are associated with increased risk of cardiovascular disease (CVD), and severely elevated levels (500 mg per dL [5.65 mmol per L] or higher) are associated with increased risk of pancreatitis. (Table 1).1 This article answers commonly asked questions related to the management of hypertriglyceridemia.

WHAT'S NEW ON THIS TOPIC

Systematic reviews consistently do not support use of omega-3 fatty acids for the primary prevention of cardiovascular disease.

For patients with established cardiovascular disease and elevated triglyceride levels who are already on statins, icosapent (Vascepa) reduces cardiovascular mortality (number needed to treat = 111 to prevent one cardiovascular death over five years) but may not be cost-effective. Currently, treatment of 111 patients to prevent one cardiovascular death would cost approximately $1.8 million.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Encourage weight loss of 5% or more to lower triglyceride levels and improve risk factors for CVD.2,3

C

Weight loss and reduction of visceral adiposity through nutrition and an exercise program; consensus and disease-oriented evidence

Advise a lower-carbohydrate and higher-fat or higher-protein diet for those with triglyceride levels lower than 500 mg per dL (5.65 mmol per L).2,3,19,20

C

Simple carbohydrates, including fructose, can increase fatty acid production in the liver; consensus and disease-oriented evidence

Prescribe fibrates and omega-3 fatty acids for patients with triglyceride levels of 500 mg per dL or higher to reduce the risk of pancreatitis.14

C

Risk increases with triglyceride levels of 1,000 mg per dL (11.30 mmol per L) or higher; consensus, standard practice, and expert opinion

Consider statins in patients with triglyceride levels between 150 and 499 mg per dL (1.69 to 5.64 mmol per L) and borderline or intermediate cardiovascular risk.1,2,10

C

Hypertriglyceridemia is a risk-enhancing factor for CVD; consensus and expert opinion

Consider icosapent (Vascepa) for patients with elevated triglyceride levels (150 to 499 mg per dL) and established CVD who are taking statins.4,39

B

Patients randomized to icosapent, 4 g daily, had lower cardiovascular mortality (number needed to treat = 111 to prevent one cardiovascular death over five years); one large randomized controlled trial


CVD = cardiovascular disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Encourage

The Authors

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ROBERT C. OH, MD, MPH, CAQSM, FAAFP, is chief of the Department of Family Medicine and program director of the Faculty Development Fellowship at Madigan Army Medical Center, Tacoma, Wash. He is also an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., and a clinical associate professor in the Department of Family Medicine at the University of Washington, Seattle....

EVAN T. TRIVETTE, MD, MMAS, is medical officer of the Captains Career Course at the U.S. Army Medical Center of Excellence at Joint Base San Antonio-Fort Sam Houston, Tex. He is also an outpatient family physician at the Brooke Army Medical Center, San Antonio.

KATIE L. WESTERFIELD, DO, FAAFP, IBCLC, is a field surgeon in the 1st Security Forces Assistance Brigade and a faculty member at Martin Army Community Hospital Family Medicine Residency Program, Fort Benning, Ga. She is also an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Published online June 3, 2020

Address correspondence to Robert C. Oh, MD, MPH, CAQSM, FAAFP, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98422 (email: roboh98@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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