3.5.0.0 Treat­ment of Other Lipopro­tein Frac­tions or Tar­gets

Rec­om­men­da­tions

10.26 For pa­tients with fast­ing triglyc­eride lev­els ≥500 mg/dL (5.7 mmol/‍L), eval­u­ate for sec­ondary caus­es of hypertriglyc­eridemia and con­sid­er med­i­cal ther­a­py to re­duce the risk of pan­cre­ati­tis. C

10.27 In adults with mod­er­ate hypertriglyc­eridemia (fast­ing or nonfast­ing triglyc­erides 175–499 mg/dL), clin­icians should ad­dress and treat lifestyle fac­tors (obe­si­ty and metabol­ic syn­drome), sec­ondary fac­tors (di­a­betes, chron­ic liver or kid­ney dis­ease and/‍or nephrot­ic syn­drome, hy­pothy­roidism), and med­i­ca­tions that raise triglyc­erides. C

Hypertriglyc­eridemia should be ad­dressed with di­etary and lifestyle changes in­clud­ing weight loss and ab­sti­nence from al­co­hol (98). Se­vere hypertriglyc­eridemia (fast­ing triglyc­erides ≥500 mg/dL and especial­ly >1,000 mg/dL) may war­rant phar­ma­co­log­ic ther­a­py (fibric acid deriva­tives and/‍or fish oil) to re­duce the risk of acute pan­cre­ati­tis. In ad­di­tion, if 10-year ASCVD risk is ≥7.5%, it is rea­son­able to ini­ti­ate mod­er­ate-‍in­ten­si­ty statin ther­a­py or in­crease statin in­ten­si­ty from mod­er­ate to high. In pa­tients with mod­er­ate hypertriglyc­eridemia, lifestyle in­ter­ven­tions, treat­ment of sec­ondary fac­tors, and avoid­ance of med­i­ca­tions that might raise triglyc­erides are rec­om­mend­ed.

Low lev­els of HDL choles­terol, often as­so­ci­at­ed with el­e­vat­ed triglyc­eride lev­els, are the most preva­lent pat­tern of dys­lipi­demia in in­di­vid­u­als with type 2 di­a­betes. How­ev­er, the ev­i­dence for the use of drugs that tar­get these lipid frac­tions is sub­stan­tially less ro­bust than that for statin ther­a­py (99). In a large trial in pa­tients with di­a­betes, fenofibrate failed to re­duce over­all car­dio­vas­cu­lar out­comes (100).