Evaluation and Treatment of Hypertriglyceridemia

Publication Date: September 1, 2012

Key Points

Key Points

Diagnosis and Definitions

Severe and very severe hypertriglyceridemia increase the risk for pancreatitis, whereas mild or moderate hypertriglyceridemia may be a risk factor for cardiovascular disease. Therefore, similar to the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III guideline committee’s recommendations, the Endocrine Society recommends screening adults for hypertriglyceridemia as part of a lipid panel at least every 5 yr. (1, L)
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Base the diagnosis of hypertriglyceridemia on fasting triglyceride levels and not on nonfasting triglyceride levels. (1, M)
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AVOID the routine measurement of lipoprotein particle heterogeneity in patients with hypertriglyceridemia. (1, L)
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Measurement of apolipoprotein B (apoB) or lipoprotein(a) [Lp(a)] levels can be of value, whereas measurement of other apolipoprotein levels has little clinical value. (2, L)
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Causes of elevated triglycerides—primary and secondary

Evaluate individuals found to have any elevation of fasting triglycerides for secondary causes of hyperlipidemia including endocrine conditions and medications. Focus treatment on such secondary causes. ( 1 , L )
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Assess patients with primary hypertriglyceridemia for other cardiovascular risk factors such as central obesity, hypertension, abnormalities of glucose metabolism, and liver dysfunction. (1, L)
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Evaluate patients with primary hypertriglyceridemia for family history of dyslipidemia and cardiovascular disease to assess genetic causes and future cardiovascular risk. (1, L)
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Table 1. Causes of Hypertriglyceridemia

Primary hypertriglyceridemia
  • Familial combined hyperlipidemia
  • Familial hypoalphalipoproteinemia
  • Familial hypertriglyceridemia
  • Familial chylomicronemia and related disorders
  • Familial dysbetalipoproteinemia
Primary genetic susceptibility
  • Metabolic syndrome
  • Treated type 2 diabetes
Secondary hypertriglyceridemia
  • Excess alcohol intake
  • Renal disease
  • Drug-induced (eg, thiazides, β-blockers, estrogens, isotretinoin, corticosteroids, bile acid-binding resins, antiretroviral protease inhibitors, immunosuppressants, antipsychotics)
  • Liver disease
  • Untreated diabetes mellitus
  • Pregnancy
  • Endocrine diseases
  • Autoimmune disorders

Table 2. Criteria Proposed for Clinical Diagnosis of Elevated Triglyceride Levels Under Fasting Conditions

NCEP ATP III (3) The Endocrine Society 2010a
Normal <150 mg/dL <1.7 mmol/liter Normal <150 mg/dL <1.7 mmol/liter
Borderline-high triglycerides 150-199 mg/dL 1.7-2.3 mmol/liter Mild HTG 150-199 mg/dL 1.7-2.3 mmol/liter
High triglycerides 200-499 mg/dL 2.3-5.6 mmol/liter Moderate HTG 200-999 mg/dL 2.3-11.2 mmol/liter
Very high triglycerides ≥500 mg/dL ≥5.6 mmol/liter Severe HTG 1000-1999 mg/dL 11.2-22.4 mmol/liter
Very severe HTG ≥2000 mg/dL ≥22.4 mmol/liter
The criteria developed for the present guidelines focus on the ability to assess risk for premature aCVD vs. risk for pancreatitis. The designations of mild and moderate hypertriglyceridemia correspond to the range of levels predominant in risk assessment for premature CVD, and this range includes the vast majority of subjects with hypertriglyceridemia. Severe hypertriglyceridemia carries a susceptibility for intermittent increases in levels above 2000 mg/dL and subsequent risk of pancreatitis; very severe hypertriglyceridemia is indicative of risk for pancreatitis. In addition, these levels suggest different etiologies. Presence of mild or moderate hypertriglyceridemia is commonly due to a dominant underlying cause in each patient, whereas severe or very severe hypertriglyceridemia is more likely due to several contributing factors.

Treatment

...Tre...

...Managemen...

...initial treatment of mild-to-moderate hypertriglyc...

...very severe hypertriglyceridemia (>1000 mg/dL...

...atment goal for patients with moderate hypertrigl...

...as a first-line agent for reduction of...

...nsider three drug classes (fibrate...

...NOT use statins as monotherapy for sev...

...Fibrates...

...Niacin Clinical tr...

...n-3 Fatty acids...

...gure 1. Management of Hypertriglyceridemia...