Download Management of High Triglyceride Levels

Management of High Triglyceride Levels
The primary approach to prevention of heart
disease through management of the blood
lipids is to address the problem of high
cholesterol. We especially focus on the
LDL cholesterol because it is the most
serious cause of premature heart attacks.
However, after cholesterol, the triglycerides
also represent an important risk factor for
the later development of heart disease.
Fortunately, there are very effective ways to
treat elevated levels of triglyceride.
The first step is to understand why it has
happened. There are a few forms of
inherited risk for high triglycerides. At the
present time, nothing can be done about this.
In the distant future, we might have the
possibility of changing our genetic
background but we have to be realistic and
do what is best for us today. In other
words, whether the high triglycerides are
caused by an inherited problem or are due to
your present lifestyle, the treatment
approach is going to be the same.
For more than 95% of patients, the serum
triglyceride level is high because of some
acquired problem. For 80% of the people
who live in America, a high triglyceride
level is associated with obesity, cigarette
smoking, or both. Diabetes is associated
with high triglycerides especially when it is
not well controlled. Other medical problems
that cause high triglyceride levels include
nephrotic syndrome (a kidney disease where
protein is spilled into the urine), and low
thyroid. Estrogen replacement may be
associated with fall in LDL-cholesterol and
a rise in triglyceride. Some patients who
take Tamoxifen for breast cancer can have
very high levels of triglyceride. Sometimes
medications cause the problem: the usual
beta blockers may cause the triglyceride
levels to go up whereas the new beta blocker
carvedilol (Coreg) might lower it. Cortisone
and prednisone cause high triglyceride
levels.
A major risk of high triglyceride levels is to
develop pancreatitis. Three types of patients
are most likely to have this occur:
 The most common patient to develop
pancreatitis from high triglyceride
levels is a poorly-controlled diabetic
with a history of high triglyceride
levels. In this case the administration
of insulin will rapidly lower the
serum triglycerides.
 An alcoholic patient with high
triglyceride levels.

A non-diabetic, non-alcoholic, nonobese patient with diet- or druginduced hypertriglyceridemia.
Treatment Recommendations:
The experts recommend that the treatment
for high triglyceride levels be based upon
the lab test result.


When triglycerides are borderline
high (150-199 mg/dL) the emphasis
is on weight reduction and increased
physical activity.
When triglycerides are high (200499 mg/dL) we recommend a
treatment of the high level indirectly.
That is, we calculate the non-HDL
cholesterol by subtracting it from the
total cholesterol level. First we treat
the LDL cholesterol. The non-HDL
cholesterol becomes a secondary
target of treatment after the LDL
cholesterol has been treated first.
Drug therapy can be considered in
high-risk patients, including those
who have had a heart attack, in order
to reach the non-HDL cholesterol
goal. These goals may be achieved
by intensifying the treatment with an
LDL-cholesterol lowering drug, by
adding nicotinic acid, or a fibrate,
such as Lopid. (The non-HDL
cholesterol is measured by taking the
HDL cholesterol and subtracting it
from the total cholesterol result. This
value should be 30 points higher than
the LDL-cholesterol goal.)

When triglycerides are very high
(greater than 500 mg/dL) the initial
goal is to prevent pancreatitis by
quickly lowering the triglycerides
with a combination of nonpharmacologic therapy and a
triglyceride-lowering drug such as a
fibrate or nicotinic acid. Once the
triglycerides are below 500 mg/dL,
the LDL cholesterol goals should be
addressed. Patients in this category
MUST absolutely avoid any alcohol
consumption at all. In this setting,
drinking alcohol is like throwing
gasoline on a fire.
amounts helps protect against the
development of heart trouble, and is antiinflammatory. More than 14 drinks per week
for men, or more than 7 drinks per week for
women puts a person at the threshold where
alcohol is no longer beneficial, and instead it
has serious health problems.
Fish oil therapy is beneficial for patients
with high triglyceride levels. Over-thecounter preparations are good. For patients
with triglyceride levels above 300 mg/dL,
the prescription form of Lovaza should be
covered by the health care insurance plan,
and it is a superior form of treatment.
Non-Pharmacologic Therapy:
A Related Topic – Low HDL-Cholesterol
High triglyceride levels are often caused by
or made worse by secondary, potentially
correctable problems. Therefore, a nonpharmacologic approach is the mainstay of
treatment in all patients. For people who are
overweight or obese, weight loss is critical.
Aerobic exercise is of major benefit. All
patients should avoid concentrated sugars,
such as desserts, sweets and soda pop. As a
general rule, patients should avoid all foods
that are high in calorie content and low in
nutrition value. For diabetic patients, strict
control of blood sugar is the first-line of
therapy. To prevent heart problems, high
blood pressure and smoking have to be
addressed.
HDL-cholesterol abbreviated HDL-C is the
good, protective cholesterol. It is an antiinflammatory agent and an antioxidant. It
removes cholesterol from the peripheral
blood vessels and sends the cholesterol to
the liver, where it is then excreted into the
intestinal system. Low HDL-C is
associated with metabolic syndrome, which
typically leads to the development of
diabetes, and is also associated with diabetes
itself, overweight and obesity. Another
cause of low HDL-C is elevation of the
triglyceride levels.
Alcohol abuse must be avoided because it
can cause large increases in triglyceride
levels. This is a place where common sense
is needed. Regular intake of alcohol in low
Here is one clear-cut thing for low HDL-C.
Smoking causes low levels. Therefore,
anyone who smokes and has a low HDL-C
should stop smoking completely. This is not
rocket science!
Medications have been used to try to raise
the HDL cholesterol but they may only
increase the HDL-C by 2-3 mg/dL.
Recently a research study tested an
investigational drug that caused substantial
increases in HDL-C, but unfortunately, that
drug had a prohibitive number of side
effects, and it will never make it to market.
As it turns out, the best thing we can do to
raise HDL cholesterol is to quit smoking
cigarettes, exercise and lose weight. Of
course, these are the same things we have
just recommended as the means to lower
triglyceride levels. As often happens,
elements of a healthy lifestyle have multiple
benefits in a variety of ways.
We wish you well!
An increase in HDL-C by just 1 mg/dL is
associated with a decrease in the chance of
cardiovascular death of almost 5%.
However, this is easier said than done.
There are very few things that are effective
in helping us to increase this healthy form of
cholesterol.
Felix J. Rogers, D.O.
February 17, 2009