High Triglycerides Treatment

Triglycerides are one of several types of fats found in the body.  Triglycerides can be sued by the body for cellular energy.  Your body needs some triglycerides in the system in order to have normal health; however, high triglycerides can increase the rate of heart disease in susceptible patients and may indicate that the diabetic patient has metabolic syndrome, which includes high blood sugars, high blood pressure, high triglycerides, high cholesterol, obesity, and an increased risk of metabolic syndrome.

When you have a lipid profile drawn, both the cholesterol and triglyceride levels are assessed.  The test is usually done fasting and gives results such as this:

• Normal triglycerides include those less than 150 mg/dL
• Borderline high triglycerides include numbers between 150 and 199 mg/dL
• High triglycerides include numbers between 200 and 499 mg/dL
• Very high triglycerides include numbers that are higher than 500 mg/dL

Causes of High Triglycerides

While some people can have elevated triglycerides from a hereditary disease, high triglycerides are usually the result of some other medical condition, including poorly controlled diabetes, kidney disease, low thyroid conditions, obesity, increased alcohol consumption, and eating too much. Sometimes medications can cause elevated triglyceride levels, including beta blockers, steroids, tamoxifen, birth control pills, estrogen, and diuretic medications.

Treating High Triglycerides

Sometimes high triglycerides are treated with medications; however, this tends to be limited to patients with very high triglyceride levels.  For all other people lifestyle and dietary changes can bring the triglyceride level into the normal range.  Some changes you might make include the following:

• Drinking less alcohol
• Quitting smoking
• Increasing activity
• Decreasing the intake of sugars and fats
• Losing weight or maintaining a normal weight.

Usually, lifestyle changes are started before resorting to medications.  If these do not treat the high triglyceride count, medications are recommended.  The medications are directed at lowering both the triglyceride and cholesterol levels as both can contribute to heart disease.

Drug therapy for high triglycerides is used if the patient has a high risk of heart disease or has an elevation of their LDL cholesterol levels.  Patients with LDL cholesterol levels that are less than 90 mg/dL are considered low risk for the development of heart disease and may not need aggressive treatment for their high triglyceride condition; however, LDL cholesterol levels that are greater than 190 mg/dL are considered high risk for heart disease and should be treated with triglyceride and cholesterol-lowering medications.

While high triglycerides alone are not considered as dangerous as having both high cholesterol and high triglycerides, many doctors will treat high triglyceride levels alone if the triglyceride level is above 500 mg/dL.  Those with triglyceride levels higher than 100 mg/dL should receive both medications and dietary management of their condition in order to prevent pancreatitis, which is the most severe complication of having high triglyceride levels.

If the patient has an underlying metabolic disease that is causing elevated triglycerides and high cholesterol, this should be treated independently from treating the high triglycerides.  For example, if diabetes is the cause of high triglycerides, it should be treated so that the blood sugar and hemoglobin A1c levels are normal.  If low thyroid conditions are the cause of high triglycerides, the patient should receive thyroid medications until their thyroid stimulating hormone (TSH) is within the normal range.

Statins are a type of medication used for the treatment of both high triglycerides and high cholesterol conditions. Statins have been found to decrease the death rate among patients with heart disease or another cardiovascular disease conditions.  The high potency statin drugs, such as atorvastatin and rosuvastatin, are highly recommended as they seem to reduce the risk of heart disease at a greater rate than the other statin drugs.

When taking statin drugs, it is important to watch out for liver disease as well as muscle weakness.  These are common complications of statin drugs.  Statins alone should not be used if the patient has extremely high triglyceride levels. There are other medications that can be added to the statin medications to further reduce the triglyceride level.

Considerations for Treating Hypertriglyceridemia

In treating high triglycerides, the doctor should check a baseline triglyceride level before prescribing medications known to increase triglyceride levels.  The patient needs to be carefully monitored while on medications that increase triglyceride levels but they can be used with caution.

If the patient has familial hyperlipidemia with high triglyceride levels, treatments include plasmapheresis and ileal bypass surgery.  If the patient has extremely high triglyceride levels (above 500 mg/dL) they should be monitored for the development of acute pancreatitis.  Some symptoms of acute pancreatitis include abdominal pain radiating to the back, nausea, and vomiting.   If pancreatitis does occur, it should be aggressively treated by giving the patient insulin and keeping them from eating orally, which worsens pancreatitis.

Common Medications for Elevated Triglycerides

Some people with high triglycerides are given a strong statin drug, such as atorvastatin, simvastatin, and rosuvastatin.  This can decrease the triglyceride level by up to 50 percent.  They also lower LDL cholesterol (the “bad” cholesterol), and increase HDL cholesterol (the “good” cholesterol).  Besides statin drugs, other drugs used to treat elevated triglyceride levels include the following:

• Nicotinic Acid.Nicotinic acid is sometimes given along with a statin drug because it helps lower both the triglyceride levels and cholesterol levels. Fibric acid medications will effectively lower the triglyceride level but are not as good at lowering the LDL cholesterol level so it shouldn’t be given alone in patients who have both high triglycerides and high cholesterol levels.
• There are four different fibrate medications used to decrease triglyceride levels, only two of which are available in the US. These include Lopid (gemfibrozil) and fenofibrate.  There are other fibrate medications that can be used in Europe but not in the US.The medication, Trilipix (fenofibric acid) has been recently approved by the US Food and Drug Administration for the use of high triglyceride levels when taken along with a statin drug.  When gemfibrozil is combined with a statin drug, it is not considered as safe as taking fenofibrate with a statin drug.  For this reason, gemfibrozil alone should be used to treat high triglyceride levels in the absence of high cholesterol but fenofibrate can safely be used with a statin drug when triglycerides and cholesterol occur at the same time.  Some side effects that must be considered when using fibrates include an increase in blood creatinine levels.  This is a reversible side effect that does not permanently damage the kidneys.
• High dose niacin (vitamin B3) has been used to lower triglyceride levels by as much as 40 percent and can increase HDL cholesterol levels as well.  It has also been found to decrease LDL cholesterol levels, which is something not seen in other triglyceride-lowering drugs.  The use of niacin to decrease cholesterol levels has been found to decrease the incidence of heart disease in those who take it.  There are many side effects of taking niacin, including flushing, itching, rash, and chemical hepatitis.   The sustained release form of niacin has been found to have fewer side effects when compared to immediate release niacin, but has a greater chance of causing liver damage.  If niacin is used to treat high triglyceride levels in type 2 diabetics, the blood sugar levels should be carefully monitored as it can cause worsening of insulin resistance.  Niacin has been shown to be the best treatment for increasing HDL cholesterol levels, so it should be used whenever high triglycerides are also associated with low HDL cholesterol levels.
• Omega 3 Fatty Acids. Omega 3 fatty acids can be used to treat high triglyceride levels because there are few side effects and don’t interact much with other types of medications. Doses of omega 3 fatty acids should be at least 4 grams per day if triglyceride lowering is the goal.  Getting this amount of omega 3 fatty acids may mean taking several capsules of fish oil capsules.  It all depends on the dose of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in the capsule.
• Statin Drugs. These are also known as HMG-CoA reductase inhibitors. They are especially good at treating patients with both high triglycerides and high cholesterol levels but are better at treating high cholesterol than they are at treating high triglyceride levels.  For this reason, if the individual has both high triglyceride and high cholesterol levels, the statin should be given with another triglyceride-lowering drug for the best effectiveness at lowering triglyceride levels.  Statin drugs should be taken in the evening.  One downside of taking statin drugs and fibrates together is that the HDL cholesterol level may decrease rather than increase; this should be monitored when both drugs are used together.

References

• High triglycerides. http://www.webmd.com/cholesterol-management/tc/high-triglycerides-overview
• Hypertriglyceridemia Treatment and Management. http://emedicine.medscape.com/article/126568-treatment#d8