Understanding High Triglycerides
What are triglycerides?
Triglycerides are the most common type of fat in the body. When you eat, your body converts any unused calories into triglycerides, which are then stored in fat cells. Hormones later release these triglycerides for energy between meals. High levels of triglycerides, known as hypertriglyceridemia, are associated with an increased risk of heart disease, stroke, and pancreatitis. A fasting triglyceride level of 150 mg/dL or higher is considered elevated.
When are medications necessary?
Lifestyle modifications, including diet, exercise, and weight management, are the first-line treatment for high triglycerides. However, if these changes are not enough, or if triglyceride levels are severely elevated (e.g., above 500 mg/dL), a doctor may prescribe medication. Medication selection is highly individualized, based on the patient's specific lipid profile and overall cardiovascular risk.
Types of Medications to Lower Triglycerides
Fibrates
Fibrates are often considered a primary option for patients with very high triglyceride levels ($>500 ext{ mg/dL}$), mainly to prevent acute pancreatitis. They work by activating a receptor in the body that helps to decrease the liver's production of very-low-density lipoproteins (VLDL), which transport triglycerides.
- How they work: Decrease VLDL production and increase the breakdown of triglycerides by activating lipoprotein lipase.
- Common examples: Fenofibrate (TriCor, Fenoglide) and Gemfibrozil (Lopid). Fenofibrate is often preferred for use with statins due to a lower risk of muscle-related side effects compared to gemfibrozil.
- Primary usage: Reducing the risk of pancreatitis in individuals with severely elevated triglyceride levels.
Prescription Omega-3 Fatty Acids
Derived from marine sources, prescription-grade omega-3 fatty acids are a potent treatment for significantly high triglycerides.
- How they work: Reduce triglyceride synthesis in the liver and enhance the clearance of triglycerides from the bloodstream.
- Common examples: Icosapent ethyl (Vascepa) and Omega-3-acid ethyl esters (Lovaza).
- Primary usage: Icosapent ethyl is approved to reduce cardiovascular event risk in patients with elevated triglycerides ($>150 ext{ mg/dL}$) who are already taking statins and have established cardiovascular disease or diabetes. Both medications are approved for severe hypertriglyceridemia. Prescription versions contain higher and more consistent amounts of active ingredients than over-the-counter supplements.
Statins
While primarily known for their cholesterol-lowering effects, statins can also significantly reduce triglycerides.
- How they work: Block cholesterol production in the liver, which indirectly affects triglyceride levels, causing a reduction of 20% to 40%.
- Common examples: Atorvastatin (Lipitor) and Rosuvastatin (Crestor).
- Primary usage: First-line therapy for patients who need to lower both their LDL cholesterol and triglycerides, and for overall cardiovascular risk reduction.
Niacin (Nicotinic Acid)
This B-vitamin can lower triglycerides when taken in high, prescription-strength amounts.
- How it works: Inhibits the liver's secretion of VLDL cholesterol.
- Primary usage: Historically used to lower both triglycerides and LDL, and raise HDL. However, its use has decreased due to adverse effects (like flushing and potential liver toxicity) and studies showing limited additional benefit when combined with statins. It is now primarily used for patients who cannot tolerate other medications.
Emerging Therapies
Newer treatments are being developed to target triglycerides more specifically.
- Olezarsen: This investigational antisense oligonucleotide medication effectively lowers triglycerides by inhibiting the production of a protein called apolipoprotein C-III (APOC3), which inhibits the breakdown of triglycerides. It has shown significant reductions in triglycerides and is being studied for various hypertriglyceridemia types.
Comparison of Triglyceride-Lowering Medications
| Medication Class | Primary Mechanism | Primary Use Case | TG Reduction (%) | LDL-C Effect | Key Side Effects |
|---|---|---|---|---|---|
| Fibrates | Decrease VLDL production | Severe hypertriglyceridemia to prevent pancreatitis | 40–60 | Variable (can increase) | Stomach pain, muscle pain (especially with statins) |
| Prescription Omega-3s | Reduce hepatic VLDL-TG synthesis | Very high triglycerides or residual CVD risk on statins | 20–50 | Variable (may increase LDL with Lovaza) | Fishy aftertaste, GI upset |
| Statins | Inhibit cholesterol synthesis | High cholesterol and/or triglycerides; overall CVD risk | 20–40 | 18–55 reduction | Myopathy, elevated liver enzymes |
| Niacin | Inhibit hepatic VLDL secretion | Very high triglycerides (now limited use) | 30–50 | 5–25 reduction | Flushing, worsened glycemic control, liver issues |
The Importance of Lifestyle Changes
Medication is most effective when combined with a heart-healthy lifestyle. These changes are crucial for all levels of high triglycerides, whether used alone or with pharmacotherapy.
- Exercise regularly: Aim for at least 30 minutes of moderate-intensity exercise most days of the week.
- Limit sugar and refined carbohydrates: Excess simple sugars, found in sugary drinks and sweets, are a major source of extra calories that the body converts to triglycerides.
- Reduce alcohol intake: Alcohol is high in calories and sugar and can significantly raise triglyceride levels.
- Eat healthy fats and omega-3-rich foods: Include sources like salmon, mackerel, and flaxseed in your diet.
- Manage weight: Losing just 5% to 10% of your body weight can significantly lower triglyceride levels.
Conclusion: Choosing the Best Treatment
There is no single medication that is definitively "best" for everyone to lower triglycerides. The most effective treatment plan is a personalized one, determined by a healthcare provider after a thorough evaluation of your specific health needs. For moderate elevations, statins may be sufficient, especially if LDL cholesterol is also a concern. For very high levels, fibrates or high-amount prescription omega-3 fatty acids are often the main treatment to prevent complications like pancreatitis. For certain patients on statins with residual cardiovascular risk, icosapent ethyl offers a proven benefit. The best strategy for reducing your triglyceride levels always begins with foundational lifestyle changes, followed by appropriate medication as needed, and should be regularly monitored by your doctor. The American Heart Association provides extensive resources on managing triglycerides and other lipids for overall cardiovascular health.
Frequently Asked Questions
What is the difference between prescription and over-the-counter fish oil supplements? Over-the-counter fish oil supplements are not the same as prescription versions like Lovaza and Vascepa. Prescription omega-3s are FDA-regulated and contain consistent, high amounts of EPA and DHA, whereas OTC supplements are not as strictly regulated and may have varying amounts and quality of active ingredients.
Can statins be used to lower triglycerides? Yes, statins are very effective at lowering LDL cholesterol and can also lower triglycerides by 20% to 40%. They are a common first-line treatment, especially for patients with both high cholesterol and high triglycerides.
Are fibrates used for high cholesterol too? While fibrates are highly effective for lowering triglycerides and can modestly raise HDL cholesterol, they have a variable effect on LDL cholesterol and are not typically used for isolated high LDL.
What are some of the lifestyle changes that can lower triglycerides? Effective lifestyle changes include regular exercise, managing weight, limiting alcohol, reducing sugar and refined carbohydrates, and incorporating healthy fats from sources like fish and nuts.
Can high triglycerides be a side effect of other medications? Yes, certain medications can increase triglyceride levels. Examples include some diuretics, beta-blockers, corticosteroids, and certain HIV medications. Your doctor will consider all medications you are taking when creating a treatment plan.
What is the goal of treating very high triglyceride levels ($>500 ext{ mg/dL}$)? For very high triglyceride levels, the primary goal of treatment is to reduce the risk of acute pancreatitis. Fibrates and high-amount prescription omega-3s are often the first choice in these cases.
How will my doctor decide which medication is right for me? Your doctor will consider your overall cardiovascular risk, your specific lipid profile (including LDL, HDL, and triglyceride levels), and any other health conditions you have, such as diabetes or kidney disease. They will also discuss potential side effects and costs with you.
