Managing the risks caused by severe high triglycerides (sHTGs)

An overview of guidelines and consensus pathways

According to the American Heart Association, the American College of Cardiology, 
and multi-society guidelines, it is reasonable to reduce triglyceride levels in adults with 
TG ≥ 500 mg/dL (5.7 mmol/L) to reduce the risk of acute pancreatitis. Reducing TG levels 
is especially important in adults with TG > 880 mg/dL (10.0 mmol/L) due to increased risk for acute pancreatitis at this level.23

For adults, current American College of Cardiology and American Association of 
Clinical Endocrinologists/ American College of Endocrinology Expert Consensus statements recommend lowering fasting TG levels to < 150 mg/dL (1.7 mmol/L) 
to reduce ASCVD risk.2

Initial factors to consider for controlling TG levels2 

  • Evaluate and manage secondary causes
  • Optimize diet and lifestyle interventions for hypertriglyceridemia
  • Implement guideline-directed statin therapy and optimize statin adherence
  • Optimize glycemic control
  • Monitor response to therapy and adherence
  • Conduct clinician-patient discussion of potential benefits, potential harms, 
 and patient preferences
  • Referral to registered dietitian nutritionist
  • Addition of a triglyceride risk-based pharmacological agent

Lifestyle and pharmacologic treatments

Multiple guidelines recognize the central role of lifestyle interventions in reducing 
TG levels in people with sHTG. Such interventions include2:

  • Weight loss in those with overweight or obesity
  • Physical activity
  • Restriction of alcohol consumption
  • Restriction of sugar or refined carbohydrate intake

In patients with very high TG levels (e.g., >500 or 1000 mg/dL), a low-fat diet or even 
extreme fat restriction may be necessary and should be undertaken with the guidance 
of a registered dietitian nutritionist (RD or RDN).2

The American College of Cardiology (ACC) and the National Lipid Association (NLA) have prepared screening questions to help clinicians assess the effects of lifestyle on triglycerides.2

  • How often do you consume sugar-sweetened beverages (soft drinks, fruit drinks, 
sweet tea, or sports/energy drinks)?
  • Do you consume sweets (pastries, desserts, or candy)? If so, how much and how often?
  • Do you drink alcoholic beverages (beer, wine, or spirits)? If so, how much and how often?
  • How often do you consume foods that are deep fried or high in saturated fats (i.e., butter, coconut, and other tropical oils, full-fat dairy products, or fatty red meat) as well 
as pizza?
  • Have you gained weight in the past year? If so, how much weight have you gained?
  • What do you do for physical activity? How often?

Average effects of lifestyle and pharmacologic interventions4,9

InterventionTG Lowering
Alcohol abstinence
Variable. Can lower TGs by as much as 80% in people with elevated 
TG and excess alcohol intake
Weight lossApproximately 8 mg/dL (0.1 mmol/L) per kg weight loss
Dietary modification
15.7 mg/dL (0.18 mmol/L) reduction with plant-based diet enriched 
in protein and unsaturated fat
Aerobic exercise10-20%
ω3-polyunsaturated fatty acids (e.g., fish, flaxseed)10-50%
Dose-dependent; 22-45% reduction in people with baseline 
TG > 250mg/dL
Niacinup to 30%

Nutrition management 

Patients requiring dietary modifications should have access to a Registered Dietitian (RD or RDN) and individualized medical nutrition therapy.2