Hypertriglyceridemia Treatment & Management
- Author: Elena Citkowitz, MD, PhD, FACP; Chief Editor: George T Griffing, MD more...
Medical Care
The latest Adult Treatment Panel guidelines (ATP III) have reclassified serum triglycerides as follows:
Table 2. Classification of Triglycerides (TG) (Open Table in a new window)
| Classification | TG level, mg/dL |
| Normal TG level | < 150 |
| Borderline-high TG level | 150-199 |
| High TG level | 200-499 |
| Very high TG level | >500 |
If triglycerides are 500 or above, their treatment takes priority over LDL treatment to prevent pancreatitis, unless the patient has a high risk for an acute CAD event, in which case simultaneous treatment for both conditions should be considered.
If the secondary conditions that raise triglyceride levels cannot be managed successfully and if triglycerides are 200-499 mg/dL, the non–HDL-c (total cholesterol - HDLc) can be used as the initial target of using LDL-lowering medication. The non–HDL-c is the sum of the cholesterol carried by the atherogenic lipoproteins, LDL, VLDL, and IDL. The goals for non–HDL-c levels, similar to those for LDL-c levels, are dependent on risk and are 30 mg/dL higher than the corresponding LDL-c goals. The classification of LDL-c and non–HDL-c is as follows:
Table 3. Classification of LDL Cholesterol and Non-HDL Cholesterol (Open Table in a new window)
| Classification | LDL Goal, mg/dL | Non-HDL Goal, mg/dL | |
| CHD* and CHD risk equivalent, diabetes mellitus, and the following: | 10-year risk for CHD >20% | < 100 | < 130 |
| Two or more risk factors and the following: | 10-year risk < 20% | < 130 | < 160 |
| 0-1 risk factor | < 160 | < 190 | |
| *Coronary heart disease | |||
When hypertriglyceridemia is diagnosed, secondary causes should be sought out and controlled. If the triglyceride level is below 500 mg/dL, triglyceride-lowering medication may be withheld while secondary causes are managed. For example, lowering a substantially elevated HbA1c may normalize the triglycerides; or at least facilitate their treatment.
The importance of obesity, a sedentary lifestyle, very high fat diet, and intake of large concentrations of refined carbohydrates should not be underestimated as causes of severe hypertriglyceridemia. Instituting a program of progressive aerobic and toning exercise, weight loss, and dietary management can significantly lower triglyceride levels and, in some cases, normalize them.
During pregnancy, severe hypertriglyceridemia is an unusual complication and may cause pancreatitis.
- Many case reports have been published describing interventions to manage this condition.
- Most commonly, a very low-fat diet was sufficient to control triglycerides and prevent pancreatitis.
- Intermittent and, in persistent cases, continuous total parenteral nutrition has been used—usually in the third trimester.
- Reports also have been published describing plasma exchange or apheresis, as well as early third trimester termination of pregnancy by cesarean section.
Consultations
If the primary care provider cannot control a patient's triglycerides, referral should be made to a lipidologist or endocrinologist with expertise in treating severe and difficult-to-manage lipid disorders.[10]
Diet
- Total fat intake should be restricted if this intervention assists in weight loss. If triglyceride levels are greater than 1000 mg/dL, allowing no more than 10% of total calories from fat will usually lower triglycerides promptly and dramatically.
- Fat restriction is a 2-edged sword. Reducing fat intake causes needed weight loss, and triglycerides usually improve. When triglycerides are severely elevated (>1000 mg/dL), suggesting impaired or absent LPL activity, a low-fat diet decreases chylomicron and VLDL production and improves the metabolism of these triglyceride-rich lipoproteins.
- On the other hand, in the setting of stable weight and moderately elevated triglycerides, a very low-fat diet increases triglycerides and may, in addition, decrease HDL-c levels. Patients who are extremely compliant and motivated may choose to follow such a diet in the hope of improving their cholesterol levels. If they have a mixed hyperlipidemia, their LDL-c certainly will decrease. However, such a diet will, if anything, cause further deterioration in the HDL-c and triglycerides. If the patient has an isolated triglyceride elevation and does not lose weight on the diet, the triglycerides may increase. In such cases, addition of a healthy fat (monounsaturated or polyunsaturated fat) lowers triglycerides, increases HDL-c, and sometimes decreases LDL-c.
- In cases in which dietary intake of sugar and white flour products is substantial, restricting simple carbohydrates and increasing dietary fiber are important adjuncts that can lower triglycerides substantially.
- Large quantities or fruit juice or non-diet soda can increase triglycerides dramatically.
- Alcohol should be eliminated or restricted to no more than 1 standard alcoholic beverage per day.
- Omega-3 (N-3) fatty acids
- The class of polyunsaturated fats known as omega-3 fatty acids, which are derived mainly from fatty fish and some plant products (flax seed), has a unique impact on triglycerides.
- In large amounts (10 or more g/d), N-3 fatty acids lower triglycerides 40% or more.
- To achieve this dose, purified capsules are usually necessary, but some patients may prefer to eat large quantities of fatty fish. The fish highest in N-3 fatty acids are sardines, herring, and mackerel; daily servings of 1 pound or more may be necessary.
- If weight gain ensues, triglyceride lowering will be compromised.
Activity
- Exercise, particularly sustained aerobic activity, can have a dramatic impact on triglyceride levels and may increase HDL-c slightly.
- The American Heart Association recommends 30-60 minutes of aerobic exercise most days of the week and toning for 20-30 minutes twice a week. This prescription has substantial benefits beyond lipid effects as follows:
- Reduced weight
- Decreased insulin resistance
- Decreased blood pressure
- Improved cardiovascular conditioning
- Overall reduction in acute cardiovascular events is also a likely benefit of regular exercise.
- Toning of large muscles groups (abdomen, back, legs, arms) also improves metabolism of triglyceride-rich lipoproteins and lowers triglycerides.
Fredrickson DS, Lees RS. A system for phenotyping hyperlipidaemia. Circulation. Mar 1965;31:321-7. [Medline].
National Cholesterol Education Program. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. May 16 2001;285(19):2486-97. [Medline].
Brunzell JD, Bierman EL. Chylomicronemia syndrome. Interaction of genetic and acquired hypertriglyceridemia. Med Clin North Am. Mar 1982;66:455-68. [Medline].
Chait A, Brunzell JD. Chylomicronemia syndrome. Adv Intern Med. 1992;37:249-73. [Medline].
Assmann G, Schulte H. Relation of high-density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (the PROCAM experience). Prospective Cardiovascular Munster study. Am J Cardiol. Sep 15 1992;70(7):733-7. [Medline].
Fortson MR, Freedman SN, Webster PD 3rd. Clinical assessment of hyperlipidemic pancreatitis. Am J Gastroenterol. Dec 1995;90(12):2134-9. [Medline].
Leaf DA. Chylomicronemia and the chylomicronemia syndrome: a practical approach to management. Am J Med. Jan 2008;121(1):10-2. [Medline].
Kolovou GD, Anagnostopoulou KK, Kostakou PM, et al. Primary and secondary hypertriglyceridaemia. Curr Drug Targets. Apr 2009;10(4):336-43. [Medline].
Haffner SM. Secondary prevention of coronary heart disease: the role of fibric acids [editorial; comment]. Circulation. Jul 4 2000;102(1):2-4. [Medline].
Schaap-Fogler M, Schurr D, Schaap T, et al. Long-term plasma exchange for severe refractory hypertriglyceridemia: a decade of experience demonstrates safety and efficacy. J Clin Apher. 2009;24(6):254-8. [Medline].
Mohiuddin SM, Pepine CJ, Kelly MT, et al. Efficacy and safety of ABT-335 (fenofibric acid) in combination with simvastatin in patients with mixed dyslipidemia: a phase 3, randomized, controlled study. Am Heart J. Jan 2009;157(1):195-203. [Medline].
Wu J, Song Y, Li H, et al. Rhabdomyolysis associated with fibrate therapy: review of 76 published cases and a new case report. Eur J Clin Pharmacol. Sep 16 2009;[Medline].
Abourbih S, Filion KB, Joseph L, Schiffrin EL, Rinfret S, Poirier P. Effect of fibrates on lipid profiles and cardiovascular outcomes: a systematic review. Am J Med. Oct 2009;122(10):962.e1-8. [Medline].
Sica DA. Fibrate therapy and renal function. Curr Atheroscler Rep. Sep 2009;11(5):338-42. [Medline].
Harper CR, Jacobson TA. Managing dyslipidemia in chronic kidney disease. J Am Coll Cardiol. Jun 24 2008;51(25):2375-84. [Medline].
McKenney JM, McCormick LS, Weiss S. A randomized trial of the effects of atorvastatin and niacin in patients with combined hyperlipidemia or isolated hypertriglyceridemia. Collaborative Atorvastatin Study Group. Am J Med. Feb 1998;104(2):137-43. [Medline].
Roth EM, Bays HE, Forker AD, et al. Prescription omega-3 fatty acid as an adjunct to fenofibrate therapy in hypertriglyceridemic subjects. J Cardiovasc Pharmacol. Jul 10 2009;[Medline].
[Best Evidence] Goldberg RB, Jacobson TA. Effects of niacin on glucose control in patients with dyslipidemia. Mayo Clin Proc. Apr 2008;83(4):470-8. [Medline].
Kuklina EV, Yoon PW, Keenan NL. Trends in high levels of low-density lipoprotein cholesterol in the United States, 1999-2006. JAMA. Nov 18 2009;302(19):2104-10. [Medline].
Athyros VG, Giouleme OI, Nikolaidis NL. Long-term follow-up of patients with acute hypertriglyceridemia-induced pancreatitis. J Clin Gastroenterol. Apr 2002;34(4):472-5. [Medline].
Hsia SH, Connelly PW, Hegele RA. Successful outcome in severe pregnancy-associated hyperlipemia: a case report and literature review. Am J Med Sci. Apr 1995;309(4):213-8. [Medline].
Ahmed SM, Clasen ME, Donnelly JE. Management of dyslipidemia in adults. Am Fam Physician. May 1 1998;57(9):2192-2204, 2207-8. [Medline].
Austin MA. Plasma triglyceride as a risk factor for coronary heart disease. The epidemiologic evidence and beyond. Am J Epidemiol. Feb 1989;129(2):249-59. [Medline].
Bainton D, Miller NE, Bolton CH. Plasma triglyceride and high density lipoprotein cholesterol as predictors of ischaemic heart disease in British men. The Caerphilly and Speedwell Collaborative Heart Disease Studies. Br Heart J. Jul 1992;68(1):60-6. [Medline].
Bamba V, Rader DJ. Obesity and atherogenic dyslipidemia. Gastroenterology. May 2007;132(6):2181-90. [Medline]. [Full Text].
Bierman EL, Brunzell JD. Diet low in saturated fat and cholesterol for diabetes. Diabetes Care. Feb 1989;12(2):162-3. [Medline].
Brunzell JD. Clinical practice. Hypertriglyceridemia. N Engl J Med. Sep 6 2007;357(10):1009-17. [Medline].
Davignon J, Roederer G, Montigny M. Comparative efficacy and safety of pravastatin, nicotinic acid and the two combined in patients with hypercholesterolemia. Am J Cardiol. Feb 15 1994;73(5):339-45. [Medline].
Diabetes Atherosclerosis Intervention Study. Effect of fenofibrate on progression of coronary-artery disease in type 2 diabetes: the Diabetes Atherosclerosis Intervention Study, a randomised study. Lancet. Mar 24 2001;357(9260):905-10. [Medline].
Dunbar RL, Rader DJ. Demystifying triglycerides: a practical approach for the clinician. Cleve Clin J Med. Aug 2005;72(8):661-6, 670-2, 674-5 passim. [Medline].
Fruchart JC, Brewer HB Jr, Leitersdorf E. Consensus for the use of fibrates in the treatment of dyslipoproteinemia and coronary heart disease. Fibrate Consensus Group. Am J Cardiol. Apr 1 1998;81(7):912-7. [Medline].
Glueck CJ, Oakes N, Speirs J. Gemfibrozil-lovastatin therapy for primary hyperlipoproteinemias. Am J Cardiol. Jul 1 1992;70(1):1-9. [Medline].
Haim M, Benderly M, Brunner D. Elevated serum triglyceride levels and long-term mortality in patients with coronary heart disease: the Bezafibrate Infarction Prevention (BIP) Registry. Circulation. Aug 3 1999;100(5):475-82. [Medline].
Havel RJ and Guyton JP. Introduction: Structure and Metabolism of Plasma Lipoproteins. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. Metabolic and Molecular Bases of Inherited Disease. 3. 8th ed. New York, NY: McGraw-Hill; 2001:114. [Full Text].
Jacobson TA, Miller M, Schaefer EJ. Hypertriglyceridemia and cardiovascular risk reduction. Clin Ther. May 2007;29(5):763-77. [Medline].
Jacobson TA, Miller M, Schaefer EJ. Hypertriglyceridemia and cardiovascular risk reduction. Clin Ther. May 2007;29(5):763-77. [Medline].
Manninen V, Tenkanen L, Koskinen P. Joint effects of serum triglyceride and LDL cholesterol and HDL cholesterol concentrations on coronary heart disease risk in the Helsinki Heart Study. Implications for treatment. Circulation. Jan 1992;85(1):37-45. [Medline].
Margolis S, Dobs AS. Nutritional management of plasma lipid disorders. J Am Coll Nutr. 1989;8:Suppl: 33S-45S. [Medline].
McKenney JM, Proctor JD, Harris S. A comparison of the efficacy and toxic effects of sustained- vs immediate-release niacin in hypercholesterolemic patients. JAMA. Mar 2 1994;271(9):672-7. [Medline].
Pejic RN, Lee DT. Hypertriglyceridemia. J Am Board Fam Med. May-Jun 2006;19(3):310-6. [Medline].
Rader DJ, Rosas S. Management of selected lipid abnormalities. Hypertriglyceridemia, low HDL cholesterol, lipoprotein(a), in thyroid and renal diseases, and post-transplantation. Med Clin North Am. Jan 2000;84(1):43-61. [Medline].
Rubins HB, Robins SJ, Collins D. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med. Aug 5 1999;341(6):410-8. [Medline].
Sanderson SL, Iverius PH, Wilson DE. Successful hyperlipemic pregnancy. JAMA. Apr 10 1991;265(14):1858-60. [Medline].
Shepherd J. Fibrates and statins in the treatment of hyperlipidaemia: an appraisal of their efficacy and safety. Eur Heart J. Jan 1995;16(1):5-13. [Medline].
Wagner AM, Jorba O, Bonet R. Efficacy of atorvastatin and gemfibrozil, alone and in low dose combination, in the treatment of diabetic dyslipidemia. J Clin Endocrinol Metab. Jul 2003;88(7):3212-7. [Medline].
Wiklund O, Angelin B, Bergman M. Pravastatin and gemfibrozil alone and in combination for the treatment of hypercholesterolemia. Am J Med. Jan 1993;94(1):13-20. [Medline].
Yuan G, Al-Shali KZ, Hegele RA. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ. Apr 10 2007;176(8):1113-20. [Medline].
| Type | Serum elevation | Lipoprotein elevation |
| I | Cholesterol and triglycerides | Chylomicrons |
| IIa | Cholesterol | LDL* |
| IIb | Cholesterol and triglycerides | LDL, VLDL** |
| III | Cholesterol and triglycerides | IDL*** |
| IV | Triglycerides | VLDL |
| V | Cholesterol and triglycerides | VLDL, chylomicrons |
| *LDL (low-density lipoprotein) **VLDL (very low-density lipoprotein) ***IDL (intermediate-density lipoprotein) | ||
| Classification | TG level, mg/dL |
| Normal TG level | < 150 |
| Borderline-high TG level | 150-199 |
| High TG level | 200-499 |
| Very high TG level | >500 |
| Classification | LDL Goal, mg/dL | Non-HDL Goal, mg/dL | |
| CHD* and CHD risk equivalent, diabetes mellitus, and the following: | 10-year risk for CHD >20% | < 100 | < 130 |
| Two or more risk factors and the following: | 10-year risk < 20% | < 130 | < 160 |
| 0-1 risk factor | < 160 | < 190 | |
| *Coronary heart disease | |||

