Questions will come up about HOW TO MANAGE HIGH TRIGLYCERIDES , due to recent guidance from the American College of Cardiology. We know that a fasting triglyceride level of 150 mg/dL or higher is a marker for cardiovascular (CV) disease. But using medications specifically to lower triglycerides isn’t proven to reduce CV events or to prevent pancreatitis, even in patients with triglycerides of 500 mg/dL or above.
Continue to reinforce exercise and other lifestyle changes. Educate that 5% to 10% weight loss can drop triglycerides by about 20%. Optimize treatment for diabetes, if needed. Save triglyceride-lowering medications for high-CV-risk patients or those with very high triglycerides of 500 mg/dL or above.
- Note...!
Nutrition resources for patients are available from the National Lipid Association: https://www.lipid.org/sites/default/files/when_your_tgs_are_over_1000_mgdl.pdf and Low-Fat Cookbook https://www.learnyourlipids.com/heart-healthy-resources/fcs-cookbook.
Stick with a statin first for most patients especially if one is also needed to lower LDL and CV risk. Statins can drop triglycerides by 10% to 30%, depending on the dose. Next, guidance suggests adding omega-3, Vascepa (form of EPA [eicosapentaenoic acid] icosapent ethyl), if high-CV-risk patients still have triglycerides above 150 mg/dL despite adherence to an optimized statin.
Weigh pros and cons. Adding Vascepa 2 g BID may prevent a CV event in about 1 in 21 of these patients over 5 years versus placebo. But results could be inflated by the study’s mineral oil placebo, which may increase CV risk, possibly by reducing statin absorption. Plus its cost is high, even for generics. And taking over 1 g/day of omega-3s is linked to atrial fibrillation.
Keep in mind, fibrates (Lipanthyl) aren’t shown to improve CV outcomes when added to a statin. And niacin is no longer recommended due to side effects (flushing, hepatotoxicity, etc). Reserve these medications for low-CV-risk patients with very high triglycerides to possibly limit the risk of pancreatitis. Educate that FISH OIL supplements don’t seem to have CV benefits either and require lots of capsules to reach the recommended doses. Consider deprescribing when appropriate. For example, think twice about whether fenofibrate is still needed for most patients on a statin.
REFERENCES
-
Virani SS, Morris PB, Agarwala A, Ballantyne CM, Birtcher KK, Kris-Etherton PM, Ladden-Stirling AB, Miller M, Orringer CE, Stone NJ. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021 Aug 31;78(9):960-993. Available at: https://pubmed.ncbi.nlm.nih.gov/34332805
Oh RC, Trivette ET, Westerfield KL. Management of Hypertriglyceridemia: Common Questions and Answers. Am Fam Physician. 2020 Sep 15;102(6):347-354. Available at: https://www.aafp.org/afp/2020/0915/p347.html
Kapoor K, Alfaddagh A, Stone NJ, Blumenthal RS. Update on the omega-3 fatty acid trial landscape: A narrative review with implications for primary prevention. J Clin Lipidol. 2021 Jun 15:S1933-2874(21)00111-2. Available at: https://www.lipidjournal.com/article/S1933-2874(21)00111-2/fulltext