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BONUS DIGITAL CONTENT Management of Hypertriglyceridemia: Common Questions and Answers Robert C. Oh, MD, MPH, Madigan Army Medical Center, Tacoma, Washington Evan T. Trivette, MD, U.S. Army Medical Center of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas Katie L. Westerfield, DO, Martin Army Community Hospital, Fort Benning, Georgia Hypertriglyceridemia, defined as fasting serum triglyceride levels of 150 mg per dL or higher, is asso- ciated with increased risk of cardiovascular disease. Severely elevated triglyceride levels (500 mg per dL or higher) increase the risk of pancreatitis. Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus. Less common risk factors include excessive alcohol use, physical inactivity, being overweight, use of certain medications, and genetic disorders. Management of high triglyceride levels (150 to 499 mg per dL) starts with dietary changes and physical activity to lower cardiovascular risk. Lowering carbohydrate intake (especially refined carbohydrates) and increasing fat (especially omega-3 fatty acids) and protein intake can lower triglyceride levels. Moderate- to high-intensity physical activity can lower triglyceride levels, as well as improve body composition and exercise capacity. Calculating a patient’s 10-year risk of atherosclerotic cardiovas- cular disease is pertinent to determine the role of medications. Statins can be considered for patients with high triglyceride levels who have borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk. For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icos- apent (purified eicosapentaenoic acid) can reduce cardiovascular mortality (number needed to treat = 111 to prevent one cardiovascular death over five years). Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis, although this has not been studied in clinical trials. For patients with acute pancreatitis associated with hypertriglyceridemia, insulin infusion and plasmapheresis should be considered if triglyceride levels remain at 1,000 mg per dL or higher despite conservative management of acute pancreatitis. (Am Fam Physician. 2020;102:online. Copyright © 2020 American Academy of Family Physicians.) Published online June 3, 2020 excessive alcohol use (more than two standard drinks daily Hypertriglyceridemia is defined as fasting serum tri- in men and more than one standard drink daily in women), glyceride levels of 150 mg per dL (1.69 mmol per L) or physical inactivity, being overweight, use of certain medi- higher. Elevated triglyceride levels (150 to 499 mg per dL cations (e.g., atypical antipsychotics, antiretroviral protease [1.69 to 5.64 mmol per L]) are associated with increased risk inhibitors, beta blockers, bile acid–binding resins, corticoste- of cardiovascular disease (CVD), and severely elevated lev- roids, estrogens, immunosuppressants, isotretinoin, thiazide els (500 mg per dL [5.65 mmol per L] or higher) are asso- diuretics), and genetic disorders.2,3 Risk factors for hypertri- ciated with increased risk of pancreatitis. (Table 1).1 This glyceridemia are summarized in Table 2.1,2,4 article answers commonly asked questions related to the management of hypertriglyceridemia. EVIDENCE SUMMARY Hypertriglyceridemia is associated with increasing age, What Are the Risk Factors higher body mass index, elevated blood glucose levels, ele- for Hypertriglyceridemia? vated total cholesterol, and reduced high-density lipopro- Common risk factors are obesity, metabolic syndrome, and tein (HDL) cholesterol. Up to 33% of adults in the United type 2 diabetes mellitus. Less common risk factors include States have triglyceride levels of 150 mg per dL or higher.5 In studies using a cutoff of 200 mg per dL (2.26 mmol per L), CME credit for this article will be available when it is pub- 17.9% of patients had elevated triglyceride levels, and 1.7% lished in print. to 2.1% had severely elevated triglyceride levels.5,6 In one Author disclosure: No relevant financial affiliations. study, 0.4% of patients had triglyceride levels of 1,000 mg per dL (11.30 mmol per L) or higher.6 Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2020 American Academy of Family Physicians. For the private, non- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2020 American Academy of Family Physicians. For the private, non- ◆ ◆ 1 commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. DateJunecommercial 3,xx, 2020 xxxx use Online of Volume one individual xx, Number user of xxthe website. All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or Family permission Physician requests. HYPERTRIGLYCERIDEMIA After hypertriglyceridemia is identified, the TABLE 1 patient should be assessed for common and secondary causes. Common risk factors for American College of Cardiology/American Heart Asso­ hypertriglyceridemia include obesity, metabolic ciation Classification of Fasting Triglyceride Levels syndrome, and type 2 diabetes.2,3 The National Classification Triglyceride level Health and Nutrition Examination Survey Normal Less than 150 mg per dL (1.69 mmol per L) showed that 80% of the U.S. population have one 7 High 150 to 499 mg per dL (1.69 to 5.64 mmol per L) or more criteria for metabolic syndrome. Other Severe 500 mg per dL (5.65 mmol per L) or greater risk factors include excessive alcohol consump- tion (more than two standard drinks daily for Information from reference 1. men and more than one standard drink daily for women), physical inactivity, being overweight, medication use, endocrine disorders, and autoimmune disorders.1-3 Other TABLE 2 genetic syndromes cause hypertri- glyceridemia but are beyond the scope Risk Factors for Hypertriglyceridemia of this article. Risk factors Causes What Is the Clinical Signif­ Common risk factors icance of Hyper tri gly ceri­ Metabolic syndrome (increased waist Insulin resistance, visceral adiposity, and demia? circumference; reduced high-density increased fatty acid production lipoprotein cholesterol levels; and The American College of Cardiology/ elevated triglyceride levels, glucose American Heart Association cholesterol levels, and blood pressure) guidelines list hypertriglyceridemia as Type 2 diabetes mellitus Insulin resistance and decreased activity of a risk-enhancing factor for CVD.1,8 It lipoprotein lipase is also a component of metabolic syn- Secondary hypertriglyceridemia drome and is a feature of atherogenic Excess alcohol intake* Increased liver production of fatty acids dyslipidemia (hypertriglyceridemia and low HDL cholesterol levels). Despite Medication use Atypical antipsychotics, antiretroviral the association between hypertriglycer- protease inhibitors, beta blockers, bile acid– binding resins, corticosteroids, estrogens, idemia and CVD, studies have not immunosuppressants, isotretinoin, thiazide demonstrated a reduction in cardiovas- diuretics cular events or deaths with the treat- Endocrine disease Hypothyroidism-related dyslipidemia ment of isolated hypertriglyceridemia. Hypertriglyceridemia is also a risk fac- Renal disease Decreased clearance of triglyceride-rich tor for acute pancreatitis.1,9 lipoproteins Liver disease Nonalcoholic fatty liver disease EVIDENCE SUMMARY The American College of Cardiology/ Pregnancy Estrogen mediated American Heart Association guide- Autoimmune disorders Antibodies directed against lipoprotein lipase lines list elevated triglyceride levels as a risk-enhancing factor for CVD.1,8 Primary hypertriglyceridemia Risk-enhancing factors may confer Genetic disorders Familial combined hyperlipidemia, familial hypertriglyceridemia, famil- additional cardiovascular risk beyond ial dysbetalipoproteinemia, familial traditional major risk factors (e.g., cig- hypoalphalipoproteinemia, familial hyper- arette smoking, diabetes, hyperten- chylomicronemia, and related disorders sion, low-density lipoprotein [LDL] *—More than one standard drink daily in women and more than two standard drinks daily cholesterol levels). Hypertriglyceri- in men. demia is a component of metabolic syn- Information from references 1, 2, and 4. drome, which is also associated with an increased risk of CVD.10 Patients 2 American Family Physician www.aafp.org/afp Volume xx, NumberOnline xx ◆ Date◆ June xx, 3, xxxx2020 HYPERTRIGLYCERIDEMIA with hypertriglyceridemia and an increased waist circum- ference (40 inches for white males and 35 inches for white WHAT’S NEW ON THIS TOPIC females) appear to be at higher risk of CVD.3 Associations between CVD risk and a sedentary lifestyle, Hypertriglyceridemia weight gain, central obesity, triglyceride levels, HDL choles- Systematic reviews consistently do not support use of terol levels, and type 2 diabetes make the role of hypertri- omega-3 fatty acids for the primary prevention of cardiovas- glyceridemia in increased CVD risk complex.3 For example, cular disease. a meta-analysis of 68 studies including more than 300,000 For patients with established cardiovascular disease and ele- people showed an association between higher triglycer- vated triglyceride levels who are already on statins, icosapent ide levels and CVD that was attenuated after adjusting for (Vascepa) reduces cardiovascular
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