Drug therapy for moderately elevated triglycerides

For patients with moderately elevated triglycerides (above 4 mmol/L), in addition to dietary measures, consider using fish oil to reduce triglyceride concentrations. High-dose purified formulations of omega-3 fatty acid (eicosapentaenoic acid) have improved cardiovascular outcomes in patients with hypertriglyceridaemia despite statin useBhatt, 2019. In addition to a statin, use:

fish oil (equivalent to 4 g of omega-3 fatty acids) orally, daily12. fish oil fish oil fish oil

If triglycerides remain elevated despite statin and fish oil therapy, consider adding fenofibrate for triglyceride lowering. Although fibrates do not improve cardiovascular outcomes, they may prevent progression to severely elevated triglycerides and the associated risks (eg pancreatitis)Das Pradhan, 2022. Add:

fenofibrate fenofibrate fenofibrate fenofibrate

eGFR more than 60 mL/min: 145 mg orally, daily

eGFR 20 to 60 mL/min: 48 mg orally, daily initially; increase to 96 mg orally, daily if no adverse effect on renal function is observed3.

Consider checking serum creatine kinase (CK) concentration regularly when using fenofibrate in combination with a statin. Although product information warns against combination use, studies suggest that combining fenofibrate with a statin does not increase the risk of myopathy beyond the level seen with statin monotherapyDavidson, 2007Elam, 2011. Conversely, the fibrate gemfibrozil significantly increases the risk of myositis when given in combination with a statin—do not add gemfibrozil to statin therapy.

1 The content of omega-3 fatty acids varies between fish oil products; check the product information. Standard fish oil formulations contain 300 mg of omega-3 fatty acids per 1000 mg of fish oil.Return
2 Omega-3 fatty acid supplementation has been associated with a dose-dependent increased risk of atrial fibrillationGencer, 2021.Return
3 Product information for fenofibrate contraindicates its use in patients with an eGFR less than 30 mL/min, but in practice fenofibrate is used in patients with an eGFR down to 20 mL/min and there are some data to support thisLevin, 2000.Return