How to treat hypertriglyceridemia in women in their late 40s?

Question

Hi doctor,

My 46-year-old wife has extremely high triglycerides at 890 mg/dl, and we cannot get them down no matter what we try. She was diagnosed with severe hypertriglyceridemia three years ago after routine blood work for her annual physical. She tried a strict low-fat diet, lost 25 pounds, exercises five times per week, but her levels stay above 600. She is on the maximum dose of Fenofibrate and added fish oil supplements, but still too high. Her HDL cholesterol is very low at 28, and her LDL is 165, which the cardiologist says increases her heart attack risk.

The lipidologist wants to start her on prescription omega-3, but insurance would not cover it. She also developed gestational diabetes during her last pregnancy four years ago, and now her fasting glucose is 118, which is prediabetic. Her periods became irregular, and she has dark patches on her neck and armpits, which the doctor says might be insulin resistance. Family history is bad - her dad had a heart attack at 52, and her mom has diabetes. I am really scared she is going to have a heart attack because high triglycerides run in her family. Can this condition cause pancreatitis? Her sister was hospitalized with pancreatitis last year.

Thanks.

Answer 1

Hello,

Welcome to icliniq.com.

I can understand your concern.

Your wife's triglyceride level is very high. Extremely high triglyceride levels, especially those above 1000 mg/dL, can indicate either a genetic predisposition, such as familial hyperlipidemia, or a secondary cause. These secondary causes include uncontrolled diabetes, obesity, a sedentary lifestyle, renal disease, nephrotic syndrome, metabolic syndrome, or hypothyroidism. Certain medications, like beta-blockers, thiazide diuretics, some antipsychotics, and steroids, can also elevate triglyceride levels.

At such a high level, patients are susceptible to various complications, including pancreatitis, coronary artery disease (CAD), and peripheral artery disease (PAD).

While LDL (often called bad cholesterol) has a direct relationship with CAD and PAD, data also show that patients with elevated triglyceride levels are prone to ischemic heart disease and PAD. Hypertriglyceridemia is usually asymptomatic, but when levels are extremely high, patients may develop xanthomas. These are lipid accumulations under the skin that appear as bumps. Lipids can also accumulate in your eyes (lipemia retinalis), cause pancreatitis, and increase your susceptibility to ischemic heart disease.

Treatment primarily involves lifestyle modifications such as:

Daily walking and exercise.
Weight loss.
Smoking cessation.
Limiting alcohol consumption.
Eating more fruits and vegetables.
Avoid oily and greasy foods.
Incorporating vegetable oils into your diet.
Limiting refined sugars and carbohydrates.
Consuming more fiber.
Medications to treat high triglycerides include fibrates such as Gemfibrozil or Fenofibrate.

Other options include niacin, omega-3 fatty acids, and statins as an add-on therapy. Since her LDL (bad cholesterol) is 165 mg/dL, which is high, and HDL (good cholesterol) is 28 mg/dL, which is low, I suggest starting 20 mg of Rosuvastatin as an add-on therapy. While statins primarily reduce LDL, they also have a moderate effect on triglycerides. You could also take Gemfibrozil 600 mg twice daily instead of Fenofibrate, as switching to Gemfibrozil may yield better results.

Plasmapheresis is another option if medical therapy has failed or produced only a partial response. This procedure is typically performed in acute settings and generally after a trial of medications. Finally, if all the above measures fail and the very high triglyceride level is causing harm, surgical interventions like gastric bypass surgery are an option. With the significant family history, uncontrolled blood lipids, and signs of insulin resistance, it is very crucial to keep an eye on health indicators.

I hope this information is helpful to you.

Thanks.