What is Hypertriglyceridemia?

Hypertriglyceridemia is elevated levels of triglycerides in the blood. Triglycerides are a type of fat (lipid) that the body uses for energy. High levels increase the risk of pancreatitis, cardiovascular disease, and are often part of metabolic syndrome.

Triglyceride Levels:

• Normal: <150 mg/dL
• Borderline High: 150-199 mg/dL
• High: 200-499 mg/dL
• Very High: ≥500 mg/dL (acute pancreatitis risk)
• Severe: ≥1000 mg/dL (high pancreatitis risk)

Causes:

Primary (Genetic):

• Familial Hypertriglyceridemia: Inherited condition; triglycerides typically 200-500 mg/dL
• Familial Chylomicronemia Syndrome (FCS): Very rare; severe hypertriglyceridemia (often >1000 mg/dL); high pancreatitis risk from childhood
• Familial Combined Hyperlipidemia: High triglycerides + high LDL
• Lipoprotein Lipase (LPL) Deficiency: Enzyme defect; very rare

Secondary (Much More Common):

• Obesity, Metabolic Syndrome
• Diabetes (Poorly Controlled): High glucose → high triglycerides
• Alcohol Abuse: Common cause; even moderate alcohol can raise triglycerides
• High-Carb Diet: Especially refined sugars
• Sedentary Lifestyle
• Hypothyroidism: Low thyroid hormone → high triglycerides
• Chronic Kidney Disease, Nephrotic Syndrome
• Pregnancy (Especially 3rd Trimester)
• Medications:
  • Beta-blockers (non-selective)
  • Thiazide diuretics
  • Estrogen (oral contraceptives, HRT)
  • Corticosteroids
  • Retinoids (isotretinoin for acne)
  • Antipsychotics (olanzapine, clozapine)
  • Protease inhibitors (HIV medications)

Symptoms:

Mild to Moderate Hypertriglyceridemia (150-500 mg/dL):

• Usually asymptomatic

Severe Hypertriglyceridemia (>500-1000 mg/dL):

• Pancreatitis: Severe abdominal pain, nausea, vomiting (can be life-threatening)
• Eruptive Xanthomas: Small, yellow-red bumps on skin (buttocks, elbows, knees)
• Lipemia Retinalis: Creamy appearance of retinal blood vessels (seen on eye exam)
• Hepatosplenomegaly: Enlarged liver and spleen (rare)

Risks:

• Acute Pancreatitis: Life-threatening; risk increases significantly at >500 mg/dL, very high at >1000 mg/dL
• Cardiovascular Disease: Modest increased risk (especially if combined with low HDL and high LDL)
• Fatty Liver Disease

Diagnosis:

Lipid Panel (Fasting):

• Triglycerides, total cholesterol, LDL, HDL
• Note: Fasting (9-12 hours) required for accurate triglyceride measurement

Identify Underlying Cause:

• Fasting Glucose, HbA1c: Rule out diabetes
• TSH: Rule out hypothyroidism
• Kidney Function (Creatinine, Urinalysis): Rule out kidney disease
• Liver Enzymes: Check for fatty liver
• Medication Review
• Alcohol History
• Family History: If triglycerides persistently very high, consider genetic testing for familial chylomicronemia syndrome

Treatment:

Goals:

• Triglycerides <150 mg/dL (ideal)
• Priority: If >500 mg/dL, urgent reduction to prevent pancreatitis

1. Lifestyle Modifications (ESSENTIAL):

Diet:

• Reduce Simple Carbs and Sugars: Biggest impact—avoid soda, candy, baked goods, white bread/rice
• Limit Refined Carbohydrates
• Increase Omega-3 Fatty Acids: Fatty fish (salmon, mackerel, sardines) 2-3x/week
• Healthy Fats: Olive oil, nuts, avocados
• Increase Fiber: Whole grains, vegetables, legumes
• AVOID or Severely Limit Alcohol: Critical—alcohol strongly raises triglycerides
• Very Low-Fat Diet (if >1000 mg/dL): <15-20% of calories from fat to prevent chylomicron formation

Weight Loss:

• Even 5-10% body weight loss significantly lowers triglycerides

Exercise:

• 150+ minutes/week aerobic activity
• Lowers triglycerides by 20-30%

Stop or Limit Alcohol

2. Treat Underlying Causes:

• Diabetes: Optimize glucose control (improves triglycerides dramatically)
• Hypothyroidism: Thyroid hormone replacement → triglycerides normalize
• Medications: Switch to alternatives if possible

3. Medications (if lifestyle + treating secondary causes insufficient):

Fibrates (First-Line):

• Fenofibrate (Tricor®, Trilipix®): Lower triglycerides 30-50%, raise HDL 10-20%
• Gemfibrozil (Lopid®): Alternative
• Side Effects: Muscle aches (especially with statins), gallstones, liver enzyme elevation
• Do NOT combine gemfibrozil with statins (high rhabdomyolysis risk); fenofibrate safer

High-Dose Omega-3 Fatty Acids (Prescription):

• Icosapent Ethyl (Vascepa®): 4 grams/day (highly purified EPA)
• Omega-3-Acid Ethyl Esters (Lovaza®): 4 grams/day (EPA + DHA)
• Lower triglycerides 20-50%
• Vascepa® also reduces cardiovascular events in high-risk patients
• Note: OTC fish oil supplements NOT as effective (lower dose, variable quality)

Statins:

• Primary benefit: Lower LDL cholesterol
• Modest triglyceride-lowering effect (10-30%)
• Used if mixed dyslipidemia (high LDL + high triglycerides)

Niacin (Nicotinic Acid):

• Lowers triglycerides 20-40%, raises HDL
• Side effects: Flushing, itching, liver toxicity, worsening glucose control
• Less commonly used now

For Severe/Refractory Hypertriglyceridemia (>1000 mg/dL):

• Combination Therapy: Fibrate + high-dose omega-3s
• Very Low-Fat Diet
• Volanesorsen (Waylivra®): Antisense oligonucleotide for familial chylomicronemia syndrome (very rare; expensive; not widely available)

Emergency Treatment (Acute Pancreatitis from Hypertriglyceridemia):

• Hospitalization
• NPO (Nothing by Mouth): Bowel rest
• IV Fluids, Pain Control
• IV Insulin Infusion: Rapidly lowers triglycerides
• Plasmapheresis: For severe, refractory cases (removes triglycerides from blood)

Monitoring:

• Lipid Panel: 4-12 weeks after lifestyle changes or starting medication, then every 3-6 months
• Liver Enzymes: If on fibrates or niacin
• Glucose, HbA1c: If diabetic
• TSH: If hypothyroid