What are the ways to lower triglycerides in a 46-year-old?

Question

Hi doctor.

I am 46, and my triglyceride levels are dangerously high at 890 mg/dL despite being on Fenofibrate 145 mg daily for six months. My total cholesterol is 310 mg/dL, HDL is low at 32 mg/dL, and LDL cant even be calculated because triglycerides are so high. I had pancreatitis three months ago from the high triglycerides that put me in the hospital for a week on IV fluids and pain medications.

My endocrinologist thinks it is related to insulin resistance and PCOS, which I have had since my 20s. My A1C is 6.8 %, showing prediabetes, and fasting glucose is usually 140 to 160 mg/dL. I tried a strict low-fat diet and lost 15 pounds, but my triglycerides barely came down.

I am also on Metformin 2000 mg daily and Spironolactone 100 mg for PCOS symptoms. My periods are still irregular every 35 to 50 days, and I am struggling with infertility. I have been trying to conceive for three years. The fertility specialist says high triglycerides and metabolic syndrome are preventing ovulation. I tried omega-3 supplements 4 grams daily, which helped a little.

My dad had a heart attack at 52, and my mom has diabetes. really worried about having another pancreatitis attack or heart disease. What else can bring down these high triglycerides? Can I safely get pregnant with levels this high?

Thanks.

Answer 1

Hello,

\Welcome to icliniq.com.

I can understand your concern.

Your 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, the patient is 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.
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 your LDL (low-density lipoprotein) is high and HDL (high-density lipoprotein) 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. Insulin resistance and PCOS (polycystic ovarian syndrome) contribute to dyslipidemia, and hence it is highly recommended to treat these conditions aggressively under the close observation of your endocrinologist and gynecologist.

It is crucial to treat high lipids before conceiving, as hypertriglyceridemia can further worsen during pregnancy. Also, routine medications can not be used in pregnancy as they can cause harm to the product of conception. 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 history of pancreatitis, family history of heart disease, uncontrolled blood lipids and insulin resistance, it is very crucial to keep an eye on health indicators.

I hope this information is helpful to you.

Thanks.