Elevated triglycerides

Elevated triglyceride concentrations contribute to atherosclerotic cardiovascular disease (ASCVD) riskTriglyceride Coronary Disease Genetics Consortium & Emerging Risk Factors Collaboration, 2010. They are often associated with a low concentration of high-density lipoprotein cholesterol (HDL-C), which also contributes to ASCVD risk. Severely elevated triglycerides (above 10 mmol/L) increase the risk of acute pancreatitis.

Identify and manage factors that contribute to elevated triglycerides. Nondrug measures (including weight loss, exercise, and restriction of alcohol, sugar, refined carbohydrates and saturated fats) should be used in all patients; they can significantly reduce triglyceride concentrations and should be promoted at the time of diagnosis and after drug therapy has started. For more information, see Nondrug modification of lipids.

Drug treatment of elevated triglycerides depends on the severity. For patients with:

  • mildly elevated triglycerides (4 mmol/L or less), use statin therapy if elevated triglycerides do not respond to nondrug measures
  • moderately elevated triglycerides (above 4 mmol/L), use combination therapy with a statin and fish oil (and, if necessary, fenofibrate) if elevated triglycerides do not respond to nondrug measures
  • severely elevated triglycerides (above 10 mmol/L), use combination therapy with fenofibrate and fish oil, starting at the same time as nondrug measures.

Comorbidities, particularly diabetes, can cause elevation of triglycerides. Identify and manage these secondary causes when elevated triglycerides are identified. Suboptimally managed diabetes is a common cause of elevated triglycerides, and improved management can rapidly normalise triglyceride concentrations without the need for specific triglyceride-lowering therapy. In patients with diabetic retinopathy, the addition of fenofibrate to statin treatment should be considered to slow the progression of retinopathy, irrespective of the patient’s lipid concentrations—see Management of diabetic retinopathyAccord Study Group, 2010.

Recheck lipid concentrations after 6 weeks to assess the response to lifestyle changes or improved control of diabetes.