Triglycerides Treatment

Decisions on when to treat cholesterol abnormalities can be based on two factors: lipid levels (total cholesterol levels, LDL levels, and HDL levels,) and the presence of additional risk factors, as follows.

Desirable lipid levels:

Total cholesterol:

For total cholesterol, desirable levels are below 200 mg/dL. Total cholesterol is considered "borderline high risk" at levels between 200 and 239, and "high risk" at levels above 240.

LDL cholesterol:

Optimal LDL levels are less than 100 mg/dL. Near optimal levels are between 100 and 129 mg/dL. Levels between 130 and 159 are considered "borderline high risk;" and levels between 160 and 189 are considered "high-risk;" and levels of 190 and above are considered "very high risk."

HDL cholesterol: HDL cholesterol levels below 41 mg/dL are considered low.

Additional risk factors that modify cholesterol goals:

   - cigarette smoking
   - diabetes
   - hypertension (high blood pressure)
   - low HDL cholesterol
   - family history of premature heart disease
   - age greater than 45 in men, or greater than 55 in women
   - 10-year risk of heart attack greater than 20% (The 10-year risk is calculated from a formula that takes into account the individual's the lipid levels, and the other "additional risk factors" on this list.

Based on these two items (i.e., lipid levels and presence of additional risk factors) treatment is recommended as follows:

What about treatment for high triglycerides?

The new guidelines that came out 4 years ago (May, 2001,) for the first time, recommend treating patients who have elevated triglyceride levels.  This recommendation is based on recent analyses strongly suggesting that triglycerides are indeed an independent risk factor for coronary artery disease.  The decision to treat is generally based on the triglyceride levels themselves.  Normal triglyceride levels are less than 150 mg/dL.  Borderline high levels are 150-199 mg/dl. High levels are 200 - 499 mg/dL, and very high triglyceride levels are greater than 500 mg/dL. 

For people with borderline or high triglyceride levels, treatment should emphasize weight reduction, proper diet and exercise. In some people with metabolic syndrome medical treatment may be necessary along with proper diet and exercise.

What is metabolic syndrome (syndrome X)?

"Metabolic syndrome" is a recently-recognized set of features that are often seen together, and that, when present, indicate a significantly increased risk of developing cardiac disease.  Metabolic syndrome includes the following 5 features: 1) abdominal obesity (that is, excess fat distributed in the waist - the so-called "spare tire;" for men, a waist size of 40 inches and for women, a waist size of 35 inches); 2) elevated triglyceride levels; 3) low HDL cholesterol levels; 4) hypertension; 5) fasting glucose levels greater than 109 mg/dL.  The new cholesterol treatment guidelines now recognize the presence of metabolic syndrome as a  significant indicator of high risk of heart disease.  Patients with metabolic syndrome need to be aggressively treated for their obesity, hypertension, and their lipid disorders. 

What other "special circumstances" deserve attention?

Patients with very high LDL cholesterol levels (greater than 189 mg/dL): These patients often have a genetic form of lipid disorder. Not only do they have a high risk of premature heart disease without aggressive therapy, but also their family members should be screened for elevated cholesterol levels, and those with high cholesterol levels also need to be treated.

How are elevated cholesterol and triglycerides treated?

The primary method of treating elevated cholesterol (and triglycerides) is with proper diet, exercise, and weight loss. Patients who are obese can often significantly reduce their LDL cholesterol and triglyceride levels by losing weight.

Cholesterol levels should be re-measured 3 - 6 months after undertaking these non-pharmaceutical efforts.

What drugs are used to treat cholesterol and triglycerides?

These drugs include four major categories:

Bile acid binding resins: Cholestyramine and cholestipol – these drugs prevent the cholesterol in bile (the digestive product secreted from the gallbladder) from being reabsorbed in the gut. Their side effects include intestinal gas and gallstones, which significantly limit their usefulness. The bile acid binding resins can also cause a decrease in absorption of other drugs, and vitamin deficiencies. In addition, these drugs can occasionally cause significant increases in triglyceride levels.

Niacin:

Niacin is one of the B vitamins. When used in large doses, it can significantly reduce LDL cholesterol and increase HDL cholesterol, by mechanisms that are poorly understood. Its major side effects include skin flushing and severe itching, along with gastrointestinal disturbances. Nicacin is very effective, but because of side effects tends to be poorly tolerated.

Fibric acid derivatives:

Gemfibozil and clofibrate are fibric acid derivatives. The chief benefit of these drugs is that they lower triglycerides. Their ability to reduce LDL cholesterol is much more modest. They can cause gastrointestinal side effects and gallstones.

Statins:

Several statin drugs are now on the market, including lovastatin, pravastatin, atorvastatin and simvastatin. These drugs inhibit the liver enzyme HMG-CoA reductase, which significantly reduces the production of cholesterol by the liver. These drugs result in a significant reduction in LDL cholesterol, with a modest decrease in triglycerides, and a modest increase in HDL cholesterol. They tend to be well-tolerated in general, but can cause elevations in liver enzymes (which therefore need to be monitored). They can also cause a muscle disorder which can be severe in rare individuals. The muscle disorder (myopathy) is particularly likely when statins are used in combination with gemfibrozil.  

Of these drug choices, the statins are not only more effective than other categories, they also tend to be much better tolerated. Furthermore, evidence is accumulating that the aggressive use of statins can actually arrest the progression of coronary artery disease, and in some circumstances can be used instead of more invasive procedures such as angioplasty.

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