Tailored Treatment for High Triglycerides

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Ashish Sarraju, MD:

My name is Ashish Sarraju. I am the Director of the Inherited Lipid Disorder Center here at the Cleveland Clinic in the Section of Preventive Cardiology and Rehabilitation. My expertise is in managing preventive cardiology risk factors, mainly abnormal cholesterol levels and abnormal triglyceride levels.

Hypertriglyceridemia essentially stands for a condition where the triglyceride levels are higher than normal. Triglycerides are detected on blood tests, typically as part of a routine lipid panel, a fasting lipid panel that you might obtain as part of your routine preventive screening. High triglycerides can happen for many reasons. Most commonly, they're mildly or moderately elevated. Generally speaking, they can be elevated because of diet. That is, high refined carbohydrates or high fat diets, lack of physical activity, increased alcohol intake, weight gain, can all elevate your triglyceride levels. But there are other things that can raise triglyceride levels too, commonly. Glucose control or diabetes, if it's uncontrolled, can raise triglyceride levels as well. Certain medications can raise triglyceride levels as well, so this is a common condition.

Some patients, however, have genetic predispositions to high triglycerides that can really raise their triglyceride levels to very high levels. A normal triglyceride level is generally defined as less than 150 milligrams per deciliter. Severe hypertriglyceridemia is usually defined as a triglyceride level greater than 500 or 8,000 milligrams per deciliter. Now, at those very high levels, the risks include mainly pancreatitis. Now that's essentially inflammation of the pancreas that can cause abdominal pain and nausea. So that's something we really want to avoid. There is an association, also, of high triglycerides with heart disease.

So, there are many reasons to try to control the triglyceride levels and try to restore them to normal if you have those. But the first step is to try to understand why they're elevated. In terms of treatment, when we see high triglycerides, the first question we ask is, why do we think they're elevated? Is it because the diet may need to be modified? Alcohol intake needs to be reduced? Exercise needs to be increased? Maybe weight loss is required, or maybe certain medications need to be modified, or diabetes needs to be under better control. In some cases, it may be genetic in nature. Then we try to formulate a treatment plan personalized to why we think the triglycerides are elevated.

In the majority of cases, lifestyle modification, meaning cutting down on simple carbohydrates like sugars in sugar-sweetened beverages, white rice, white pasta, and desserts, cutting those out is often part of the first step of improving the diet. Cutting out high-fat foods can also be important, and cutting down alcohol can also be important. Raising the physical activity also forms the initial step often in the management of triglyceride levels. Of course, we take a close look at the medication list to see if there are medications that need to be modified to improve the triglyceride levels.

Beyond lifestyle modification, there are certain medications that can reduce triglyceride levels. Our focus is always on trying to reduce your heart disease risk, but also your risk for pancreatitis when we treat triglyceride levels. So, we make sure that we consider medications like statins, which can modestly reduce triglyceride levels, but also reduce heart disease risk. We often consider statins for our patients with high triglyceride levels. Beyond that, there are specific medications like fibrates or certain fish oil formulations that can reduce triglyceride levels and could be used in selected patients in whom they can reduce triglyceride levels and hopefully reduce the risk of pancreatitis. In certain patients who have rare genetic conditions that raise their triglyceride levels to very high levels and predispose them to pancreatitis, there are even more advanced options that may be potentially available now and in the future to control their triglyceride levels.

Overall, a multidisciplinary, thoughtful approach is always helpful when dealing with triglyceride levels that are above normal. A team that consists of nutrition expertise, exercise expertise, cardiology and lipid expertise, maybe even endocrinology expertise, would be well positioned to take care of patients with high triglyceride levels. At the Cleveland Clinic, our section of Preventive Cardiology has all these experts and has tremendous experience in evaluating and managing patients with high triglyceride levels, coming up with a personalized plan in discussion with patients, discussing their values and their goals for treatment.

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