Hypertriglyceridemia: Drug Treatment
As mentioned in my previous article, non pharmacological treatment for high triglyceride (TG) levels can be quite effective with diet and exercise alone contributing to an almost 33% reduction. However, for some this may not be enough, and for others the effect may be too difficult to maintain over the long run. Medication to lower TG levels can be quite safe and effective, but they are always added on top of a background of a healthy diet, weight loss, and regular exercise.
The indication to take medicine to reduce TG levels depends on your overall risk for a heart disease. If other significant risk factors exist such as history of a heart attack, high blood pressure, diabetes, strong family history, or artery disease in an extremity, then using medicine to achieve a target TG level of <150mg/dl may be warranted. High TG levels can also exist with other bad levels of cholesterol such as high LDLs and low HDLs. Since high LDL is a much stronger risk factor to heart disease, lowering LDL is a primary goal while lowering TGs a secondary one.
There are a variety of medications that can lower TGs. Statins such as lipitor, zocor, pravachol, crestor, and mevacor are some of the most popular cholesterol lowering medicines. However, their main action is to lower LDL and not TGs. Also, TGs are lowered only in 10-30% range. The 3 main medicines that specifically target high TGs are fish oil, nicotinic acid and fibric acid derivatives.
Non-prescription fish oil in the form of omega-3-fatty acid can lower TG levels substantially. Taking more than 3gms/day may lower levels by almost 50%. Side effects include abdominal discomfort, a fishy after taste, and low levels of vitamin E which can easily be corrected by taking vitamin E supplements.
Nicotinic acid is one of the forms of the common vitamin niacin. The other form called nicotinamide has no lipid lowering properties. Nicotinic acid can come in a variety of preparations ranging from non-prescription over-the-counter short acting niacin to sustained release preparations such as niaspan/niacor. These medicines can reduce TGs by 25-30% and in addition can also mildly reduced LDL and significantly raise HDL. Standard doses of nicotinic acid are 1-2 grams per day. Unfortunately, nicotinic acid is not so easily tolerated. Flushing is quite common especially with the over-the-counter short acting preparation. A dose of aspirin at least 30 minutes before can help minimize flushing and this side effect usually improves in the next 1-2 weeks. One word of caution: some over-the-counter niacin is marketed as no flushing, but you must be sure it has nicotinic acid in it and not just nicotinamide. Otherwise, you won't get any flushing nor will you get any lowering of your TGs. Itching, nausea, and tingling sensations can also occur in 1 out 5 people. More serious complications include liver damage, precipitation of gout, and the promotion of diabetes. Short acting niacin and niaspan seem to have lower incidences of these side effects.
There are currently three fibric acid derivatives available in the US to lower TGs - gemfibrozil, fenofibrate, and clofibrate. Clofibrate is rarely used since it is associated with the development of certain gastrointestinal cancers. Both gemfibrozil and fenofibrate can lower TG levels by 33-50% while also raising HDL 15-33% and lowering LDL 10-20%. Both are associated with muscle inflammation, but when used in combination with a statin, gemfibrozil seems to confer a greater risk of injury. Therefore, fenofibrate is preferred when used in combination with a statin.
In summary, a variety of medication can be useful in controlling TG levels in those people who are at risk for heart disease who cannot achieve a level < 150mg/dl through diet and exercise. Fish oil seems to be a reasonable first step since it is non-prescription and relatively safe. Nicotinic acid and fibric acids can be quite effective as add on therapy and generally are well tolerated.