This document provides recommendations for the evaluation and treatment of hypertriglyceridemia. It defines normal triglyceride levels and categories of mild, moderate, severe and very severe hypertriglyceridemia. Primary causes include genetic factors while secondary causes include endocrine diseases, medications and lifestyle factors. Management involves addressing the underlying cause, lifestyle modifications like diet and exercise, and pharmacological treatment including fibrates, niacin, omega-3 fatty acids and statins depending on the severity of hypertriglyceridemia and cardiovascular risk factors. The goal is to lower triglyceride levels and cardiovascular risk through a combination of lifestyle and medical interventions.

1. Evaluation & Treatment of
Hypertriglyceridedemia
Presented By:
Dr. Md. Jahid Hasan, MBBS
Ex-Honorary Medical Officer
Department of Endocrinology and Metabolism
DMCH
jahidjpg61@gmail.com
: An Endocrine Society Clinical Practice Guideline

4. Authors
Lars Berglund,
John D.Brunzell,
Anne C.Goldberg
et al.

5. Summary of Recommendations
1. Diagnosis and definitions (III)
2. Causes of elevated Triglyceride(III)
3. Management of Hypertriglyceridemia (VI)

6. Normal level of lipid profile
• Serum triglyceride :
< 150 mg/dl
• Total cholesterol :
75-169 mg/dL for those age 20 and younger
100-199 mg/dL for those over age 21
• VLDL:
< 70 mg/dL for those with heart or blood vessel disease and for other
patients at very high risk of heart disease (those with metabolic syndrome)
<100 mg/dL for high risk patients (e.g., some patients who have multiple
heart disease risk factors)
<130 mg/dL for individuals who are at low risk for coronary artery disease
• LDL
75-169 mg/dL for those age 20 and younger
100-199 mg/dL for those over age 21
• HDL: > 40 mg/dL

7. WHAT’S NEW ???
TRAITS
(Hypertriglyceridemia)
THE ENDOCRINE SOCIETY 2010
(mg/dl)
NCEP ATP III(3)
mg/dl
Normal <150 <150
MILD (Borderline-
high)
150-199 150-199
Moderate (High) 200-999 200-499
Severe (Very High) 1000-1999 ≥500
Very Severe ≥ 2000
NCEP ATP : National Cholesterol Education Program Adult Treatment Panel

8. WHY WE ARE SO MUCH
CONCERN WITH TRYGLYCERIDE ???
 Mild-Moderate :
Risk factor for CV
Disease
 Severe-Very severe:
Risk for Pancreatitis

9. Recommendation Regarding Diagnosis and
definitions
 Diagnosis should be on the basis of Fasting TG level
(Why???
: the average fasting 187mg/dl and non-fasting 284 mg/dl have same
predictive value for nonfatal and fatal coronary heart disease.)
 Diagnosis should be prompt as it increases the risk of life
 measure Apo-lipoprotein B or lipoprotein level (a) instead
of routine measurement of lipoprotein level

10. Primary : FHTG(familial hypertriglyceridemia),FCHL(familial combined
hypertriglyceridemia), Familial Dysbetalipoproteneimia,
Familial chylomicronemia and related disorder
Secondary :
 Endocrine disease : Hypothyroidism and Untreated DM
 Others : Renal disease, liver disease, pregnancy , Autoimmune
disease
 Medications :
 Atypical anti-psychotics
 Beta blockers
 Bile acid binding resins
 Estrogen (in higher dose oral contraceptives and unopposed
 oral estrogen)
 Glucocorticoids
 Immunosuppressants
 Isotretinoin
 Protease inhibitors
 Tamoxifen
 Thiazides
Factors..
• Physical inactivity
• Alcohol intake
• Overweight
Primary Genetic
susceptibility
 Metabolic syndrome
 Treated DM

11. As treatment should be on the basis of etiology ;
so recommendations are -
Individual found to have any elevation of fasting
triglycerides should be evaluated for secondary causes
Patients with primary hypertriglyceridemia be assessed for
other cardiovascular risk factors, such as central obesity,
hypertension, abnormalities of glucose metabolism and liver
dysfunction
Clinicians should evaluate patient with primary
hypertriglyceridemia for family history of dyslipidemia and
cardiovascular disease to asses genetic causes and future
cardiovascular risk

12. Management of Hypertriglyceridemia
• Non pharmacological Approach:
Lifestyle modifications
Appropriate dietary combination
Physical activity
Weight reduction
• Pharmacological Approach:
 Fibrates
Niacin
n-3 fatty acid and/or
Statin

13. Non pharmacological approaches
Diet :
• There is a quantitative linear relation between replacement of dietary
carbohydrate with fat and reduction in serum TG
• avoid saturated fat and trans fatty acid as both increases LDL and it is
atherogenic.
• Monosaturated and n-6 polyunsaturated fatty acid reduced LDL level
• Fructose contained in sweetened beverage have strong triglyceride raising
effects than glucose.
• Proportionate portion of protein, vegetables, fruits and foods of low
glycemic index should be taken to avoid this hazards.
Exercise: A period of 30-60 min aerobic exercise or mild resistance
exercise has been shown to be effective in lowering plasma and VLDL
triglycerides.
Physical activity: So active lifestyle reduces the risk
Weight reduction: weight reduction is crucial steps to reduce TG

14. Recommendations regarding management
of Hypertriglyceridemia
Non pharmacological approach as the initial treatment of
mild-moderate Hypertriglyceridemia
For severe and very severe Hypertriglyceridemia
combining reduction of fat and simple carbohydrate intake
with drug treatment to reduce the risk of pancreatitis

15. Treatment goal for patient with moderate
hypertriglyceridemia be a Non-HDL cholesterol level in
agreement with NCEP ATP guidelines.
• Non HDL cholesterol = (total cholesterol –HDL cholesterol)
• Non HDL cholesterol reflects the amount of cholesterol in all
atherogenic lipoprotein particles. Therefore it is recommended to
measure Non HDL cholesterol in patient with hypertriglyceridemia
both for risk stratification and as a secondary target for therapy.
• Alternatively it can be assessed by measuring apoB level because
one apoB molecule is present on the surface of each
chylomicron,VLDL,LDL and IDL and indicates atherogenic
potential.

16. Pharmacological approach
Type of
drug
Effects
on TG
Effects
on LDL
Effects on
HDL
Side effects Contraindication Reducti
on of
CV risk
Fibrates Cholelithiasis
Myositis
Gastrointestinal upset
Drug interaction
Pregnancy and lactating
mother
Hepatic and renal
failure
Gall bladder disease
Niacin Cutaneous flush
Predispose
Hyperuricemia
Hepatotoxicity
Active peptic ulcer
disease
N-3 fatty
acid
Fishy taste
Burping
Statins Elevate liver enzyme
Myopathy
pregnancy
 if primary goal is to reduce TG –Fibrate and perhaps n-3 FA should first choice
 if p. goal is to modify size and density of LDL and HDL particles- Niacin is best

17. Continue…
Fibrate should be used as a first line agent for reduction of TG
in patients at risk for TG induced pancreatitis
Three classes of drug(F,N,n-3) alone or in combination with
statin could be considered as treatment options in patients
with moderate to severe TG level
Statins should not be used as monotherapy for severe and
very severe hypertriglyceridemia though it may be useful for
treatment of moderate hypertriglyceridemia when indicated
to modify the cardiovascular risk factors

19. The End