Hypertriglyceridemia

Background

• Hypertriglyceridemia is a condition characterized by abnormal elevation of serum triglycerides.
• Normal triglyceride levels are < 150 mg/dL (< 1.7 mmol/L).
• Guidelines vary on definitions for the severity of hypertriglyceridemia:
  • The National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III defines hypertriglyceridemia as:
    • borderline high triglyceride 150-199 mg/dL (1.7-2.3 mmol/L)
    • high triglyceride 200-499 mg/dL (2.3-5.6 mmol/L)
    • very high triglyceride ≥ 500 mg/dL (> 5.6 mmol/L)
  • The Endocrine Society defines hypertriglyceridemia as:
    • mild hypertriglyceridemia 150-199 mg/dL (1.7-2.3 mmol/L)
    • moderate hypertriglyceridemia 200-999 mg/dL (2.3-11.2 mmol/L)
    • severe hypertriglyceridemia 1,000-1,999 mg/dL (11.2-22.4 mmol/L)
    • very severe hypertriglyceridemia ≥ 2,000 mg/dL (≥ 22.4 mmol/L)
• According to the 1999-2004 National Health and Nutrition Examination Survey the prevalence of hypertriglyceridemia at levels
  • > 150 mg/dL (1.7 mmol/L) is 33.1%, and
  • ≥ 500 mg/dL (6.65 mmol/L) is 1.7%
• Causes of elevated triglyceride levels include one or more of the following: genetic; excessive alcohol and/or carbohydrate intake; metabolic syndrome and other medical conditions; and specific drugs.
• Hypertriglyceridemia is associated with
  • increased all-cause mortality and an increased risk of cardiovascular disease or cardiovascular events.
  • pancreatitis and other complications, especially if levels > 1,000 mg/dL (11.3 mmol/L).

Evaluation

• Obtain overnight fasting triglyceride level, often as part of a lipid profile to detect hypertriglyceridemia.
• For patients diagnosed with hypertriglyceridemia, additional testing should include assessment of:
  • possible secondary causes of hyperlipidemia (Strong recommendation)
  • cardiovascular risk for patients with primary hypertriglyceridemia (Strong recommendation)

Management

• For patients with mild-to-moderate hypertriglyceridemia (200-1,000 mg/dL [2.3-11.2 mmol/L]):
  • Use lifestyle modifications including diet low in simple and complex carbohydrates, weight reduction, and increased physical activity (Strong recommendation).
  • Consider addition of fibrates, omega-3 fatty acids, or niacin for patients as needed in addition to lifestyle modifications (Weak recommendation).
• For patients with severe hypertriglyceridemia ≥ 1,000 mg/dL (> 11.2 mmol/L):
  • Use fibrates as first-line agents to lower risk of developing pancreatitis (Strong recommendation).
  • Consider adding niacin or omega-3 fatty acids for persistent hypertriglyceridemia.
• Consider adding statins for patients with mixed dyslipidemias.