How to treat high triglycerides in a 51-year-old woman?

Question

Hello doctor,

My 51-year-old sister has extremely high triglycerides at 890 mg/dL, and we are worried about the risk of pancreatitis. She has been dealing with high triglycerides for the past five years, but they have continued to worsen despite multiple medications. She has tried Fenofibrate, Gemfibrozil, and fish oil supplements, but her levels remain above 600 mg/dL.

Her HDL is low at 28 mg/dL, and her calculated LDL is 145 mg/dL. She also has type 2 diabetes with an HbA1c of 8.9, which her doctor says is making the triglycerides harder to control. She takes Metformin and Jardiance, but her blood sugars still run high.

She gained weight during menopause and has gained about 45 pounds over the past three years. She has been unable to lose weight despite trying a low-carbohydrate diet. She had one episode of abdominal pain last month that raised concern for pancreatitis, but her lipase level was normal.

There is a strong family history, as her father died of a heart attack at age 58 and her mother has diabetes.

Are there prescription medications stronger than fibrates, and should she be screened for familial hyperlipidemia?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Your sister's triglyceride level is very high. Extremely high triglyceride levels, especially above 1000 mg/dL, can indicate either a genetic predisposition, such as familial hyperlipidemia (high lipid levels), or a secondary cause.

Secondary causes include uncontrolled diabetes (consistently high blood sugar level due to inadequate management), obesity (too much body fat), a sedentary lifestyle, renal disease, nephrotic syndrome (a kidney disease in which a kidney excretes an excessive amount of protein in the urine), metabolic syndrome (a group of conditions that increase the risk of heart disease, stroke and type 2 diabetes), or hypothyroidism (abnormally low activity of the thyroid gland). Certain medications, such as beta blockers, thiazide diuretics, some antipsychotics, and steroids, can also elevate triglyceride levels.

At such high levels, a patient is susceptible to several complications, including pancreatitis (inflammation of the pancreas), coronary artery disease (CAD, which is the narrowing or blockage of the coronary arteries), and peripheral artery disease (PAD is the narrowing of the peripheral arteries). While LDL (low-density lipoprotein), also known as bad cholesterol, has a direct relationship with CAD and PAD, studies also show that patients with elevated triglyceride levels are prone to ischemic heart disease and PAD.

Hypertriglyceridemia (a high triglyceride level) is usually asymptomatic, but when levels are incredibly high, patients may develop xanthomas. These are lipid accumulations under the skin that appear as bumps. Lipids can also accumulate in the eyes, known as lipemia retinalis, cause pancreatitis, and increase susceptibility to ischemic heart disease.

Treatment primarily involves lifestyle modifications such as daily walking and exercise, weight loss, smoking cessation, limiting alcohol intake, eating more fruits and vegetables, avoiding oily and greasy foods, using vegetable oils, limiting refined sugars and carbohydrates, and increasing dietary fiber intake.

Medications used to treat high triglycerides include fibrates such as Gemfibrozil or Fenofibrate. Other options include Niacin, Omega-3 fatty acids, and statins as add-on therapy. Since your sister's LDL is high and HDL (high-density lipoprotein) is low, I suggest starting Rosuvastatin 20 mg as add-on therapy. Although statins primarily reduce LDL levels, they also have a moderate effect on lowering triglyceride levels.

Niacin may also be considered, as fibrates have already been tried, but the dose should be gradually increased due to the risk of side effects. Fish oil can be replaced with Omega-3 fatty acid preparations, which may be more beneficial as they contain essential active components.

Plasmapheresis (a medical procedure that removes a patient's blood plasma) is another option if medical therapy has failed or produced only a partial response. This procedure is usually reserved for acute settings and is considered after a trial of medications. If all measures fail and very high triglyceride levels continue to cause harm, surgical interventions such as gastric bypass surgery may be considered.

Given the strong family history, uncontrolled lipid levels, weight gain, and diabetes, it is essential to monitor health indicators closely. Blood sugar control is crucial, and if oral medications are ineffective, insulin therapy may be beneficial.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.