First-Line Therapies for Lowering Triglyceride Levels

Am Fam Physician. 2008 Feb 15;77(4):416.

TO THE EDITOR:

The article, Management of Hypertriglyceridemia, in the May 1, 2007, issue ofAmerican Family Physician addresses an important topic. However, many of the therapy suggestions discussed do not reflect current standards of care and may be misleading.
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First, the authors have given statins the preeminent position by listing them first in their choice of pharmacologic agents for treating patients with high triglycerides. Statins are not the first-line agents. In patients with triglyceride levels higher than 500 mg per dL (5.65 mmol per L), the first priority should be lowering their triglycerides, not their low-density lipoprotein cholesterol. Initial therapy should always begin with fibrates, extended-release niacin (which has fewer side effects and a better safety profile compared with immediate-release and sustained-release niacin), and fish oil (at least 3,000 mg of eicosapentaenoic acid/docosahexaenoic acid daily). When used alone or in combination, all three of these agents are more efficacious in lowering triglyceride levels than statins.
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The authors' algorithm (Figure 1 ) is f lawed and can be misleading if followed in practice. Although they have referenced a publication of the National Cholesterol Education Program (NCEP), their recommendation is not consistent with NCEP guidelines. The figure implies that dietary therapy and aggressive body weight reduction alone might effect a 50 percent or more lowering of triglyceride levels in patients with serum triglyceride levels higher than 1,000 mg dL (11.30 mmol per L). Many such persons have a genetic hyperlipidemia, such as Type V hyperlipoproteinemia, and drug therapy must be undertaken immediately (along with lifestyle measures) to expeditiously reduce serum triglyceride levels to lower than 500 mg per dL. In patients with diabetes and insulin resistance, insulin therapy with a basal insulin and multiple doses of short-acting insulin injections at mealtime will substantially impact postprandial lipemia, as patients with diabetes and high fasting triglyceride levels risk further elevation in serum triglyceride levels after a mixed meal. Bile acid sequestrants are contraindicated in those with high triglyceride levels, as these agents cause further elevation in serum triglyceride levels. Oral agents that impact prandial glucose regulation may be less effective in this situation.
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In my clinic, a common and recurrent theme is the practice of prescribing high-dose statins to treat high triglyceride levels, and then adding on a fibrate as a second-line agent. This combination often results in complications and eventual withdrawal of all drug therapy, and could be avoided if therapy was initiated with fibrates and niacin rather than statins. Rosuvastatin (Crestor), as opposed to other statins, may have a slight advantage in lowering of triglyceride levels on a weight-for-weight basis; in general, however, statin use should be limited to recalcitrant cases after initial use of fibrates, niacin, and fish oil, and after ensuring patient adherence.
VASUDEVAN A. RAGHAVAN, MBBS, MD, MRCP Columbus, Ohio E-mail: raghavan.24@osu.edu Author disclosure: Nothing to disclose.

REFERENCES 1. Oh RC, Lanier JB. Management of hypertriglyceridemia. Am Fam Physician. 2007;75(9):13651371. 2. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. NIH publication no.: 025215. Bethesda, Md.: National Heart, Lung, and Blood Institute, 2002. 3. Tan KC, Tso AW, Ma OC, Pang RW, Tam S, Lam KS. Determinants of postprandial triglyceride and remnantlike lipoproteins in type 2 diabetes. Diabetes Metab Res Rev. 2005;21(2):209214. 4. Buse JB, Tan MH, Prince MJ, Erickson PP. The effects of oral antihyperglycaemic medications on serum lipid profiles in patients with type 2 diabetes. Diabetes Obes Metab. 2004;6(2):133156. Send letters to Kenneth W. Lin, MD, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.