Drug therapy for severely elevated triglycerides
Severely elevated triglycerides (above 10 mmol/L) increase the risk of acute pancreatitis. The primary goal of treatment is to reduce the concentration to less than 10 mmol/L to prevent pancreatitis. In patients with severe primary hypertriglyceridaemia, consider referral to a specialist.
Treat severely elevated triglycerides with fenofibrate in combination with fish oil. In addition to dietary measures, maximum doses of fish oil are usually necessary to reduce severely elevated 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. Use:
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 observed1
PLUS
fish oil (equivalent to 4 g of omega-3 fatty acids) orally, daily23. fish oil fish oil fish oil
Statin therapy is not effective as monotherapy for severely elevated triglycerides; however, it is often still indicated to reduce ASCVD risk and to reduce triglyceride-rich very low-density lipoprotein cholesterol (VLDL-C). Consider checking serum creatine kinase (CK) concentration regularly when using fenofibrate in combination with a statin.
Some cases of severe triglyceride elevation are extremely resistant to treatment and may require the addition of nicotinic acid or serum apheresis; seek specialist advice. Patients who develop hypertriglyceridaemia pancreatitis require inpatient specialist care and (in addition to fenofibrate and fish oil) often require treatment with insulin and glucose infusion, heparin infusion and apheresis to rapidly reduce triglyceride levels.