The treatment for hypertriglyceridemia involves a combination of lifestyle modifications and pharmacotherapy, tailored to the severity of the condition and the patient's overall cardiovascular risk.
Lifestyle modifications
- Dietary and lifestyle changes: For patients with severe hypertriglyceridemia (fasting triglycerides ≥ 500 mg/dL; ≥ 5.7 mmol/L), the AAPA/ABC/ACC/ACPM/ADA/AGS/AHA/APhA/ASPC/PCNA 2019 guidelines recommend implementing a very low-fat diet, avoiding refined carbohydrates and alcohol, especially if triglycerides are persistently elevated or increasing after addressing other causes of hypertriglyceridemia
- Physical activity and weight reduction: The ES 2012 guidelines advise dietary modification, physical activity, and weight reduction programs as first-line therapy in overweight and obese patients with mild-to-moderate hypertriglyceridemia
Pharmacotherapy
- Statins: Statins are recommended by various guidelines for the management of hypertriglyceridemia. The AAPA/ABC/ACC/ACPM/ADA/AGS/AHA/APhA/ASPC/PCNA 2019 guidelines suggest initiating statin therapy in 40–75-year-old adult patients with severe hypertriglyceridemia and ASCVD risk of ≥ 7.5% . The EAS/ESC 2020 guidelines recommend initiating statins as first-line therapy to reduce cardiovascular risk in high-risk patients with hypertriglyceridemia (triglyceride levels > 2.3 mmol/L; > 200 mg/dL)
- Fibrates: The ES 2012 guidelines recommend initiating fibrates as first-line therapy to reduce triglycerides in patients at risk for triglyceride-induced pancreatitis . The EAS/ESC 2020 guidelines also suggest adding fenofibrate or bezafibrate to statins for primary prevention in patients with triglyceride levels of > 2.3 mmol/L (> 200 mg/dL) who have achieved their LDL-C goal
- Omega-3 fatty acids: The ES 2020 guidelines suggest adding eicosapentaenoic acid ethyl ester to reduce the risk of cardiovascular disease in adult patients with moderate hypertriglyceridemia (> 150 mg/dL; > 1.7 mmol/L) on statins and with either ASCVD or diabetes plus two additional risk factors . The EAS/ESC 2020 guidelines also suggest adding n-3 polyunsaturated fatty acids (icosapent ethyl 2×2 g/day) in high- or very high-risk patients with triglyceride levels of 1.5–5.6 mmol/L (135–499 mg/dL) despite statin treatment
Novel therapies
- ANGPTL3 inhibitors: Evinacumab, an ANGPTL3 inhibitor, has shown promise in reducing triglycerides in hypertriglyceridemic subjects
- Apolipoprotein C-III and ANGPTL3 targeting therapies: Antisense oligonucleotides and small interfering RNA (siRNA) targeting APOC3 and ANGPTL3 are being studied for the treatment of severe hypertriglyceridemia
In conclusion, the treatment of hypertriglyceridemia is multifaceted and should be individualized based on the patient's specific clinical context, including the severity of hypertriglyceridemia, the presence of comorbid conditions, and the patient's overall cardiovascular risk.