Tuesday, June 4, 2013
A synopsis of AFP's "Management of Hypertriglyceridemia"
A synopsis of: Management of Hypertriglyceridemia
ROBERT C. OH, MPH, MAJ, MC, USA, Tripler Army Medical Center, Honolulu, Hawaii, J. BRIAN LANIER, CPT, MC, USA, Martin Army Community Hospital, Fort Benning, Georgia
Am Fam Physician. 2007 May 1;75(9):1365-1371.
http://www.aafp.org/afp/2007/0501/p1365.pdf
I was listening to a podcast on hypertriglyceridemia on the way to work today, so I thought it would be a good idea to review it. The article I am writing about is from 2007 and I believe much has changed on this topic, such as the usage of fish oils. Regardless, we will truck ahead.
Triglycerides are the red-headed stepchild of cholesterol. Physicians do not focus on the level unless it is really high. Levels above 500-1000 mg/dL are associated with pancreatitis and metabolic syndrome. Although high triglyceride levels are an independent risk factor of cardiovascular risk, it is unclear whether reduction will modify such risk.
Statins are a first line agent in patients with elevated LDL's. It can also lower triglyceride levels by 20-40%. Fibrates can lower triglycerides 40-60% and can raise HDL's. Unfortunately, fibrate therapy has not shown to decrease all-cause mortality. Combination therapy with statins may increase the risk of rhabdomyolysis by inhibiting statin metabolism.
Niacin can lower triglyceride levels by 30-50% as well as raising HDL and lowering LDL. Studies are mixed on the effects of all-cause mortality and glycemic control. Vasomotor side effects and liver enzyme elevation has limited its use as well.
"According to this article", fish oil (omega 3 fatty acids) has shown a modest decrease in all cause mortality when used in conjunction with ACEIs, BBLs, antiplatelet meds, and other lipid medications. Fish oil and statin combos have showed a decrease in triglycerides as well. New studies question the benefits of fish oil supplements on cholesterol control and heir pro inflammatory effects may cause more harm than good.
The initial management of high triglyceride level is initiating therapeutic lifestyle changes, glucose control, and screening for metabolic syndrome and secondary causes, such as hypothyroidism, CKD, nephrotic syndrome and diabetis. After that, the focus becomes centered on LDL control, with statins. A cardiac risk profile should be determined and stratified. Patients with triglycerides above 1000 mg/dL need aggressive control of diet and weight reduction. Fibrates or niacin may be an appropriate first line choice in this case.
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