HyperTAG

• The serum triglyceride concentration can be stratified in terms of population percentiles and/or coronary risk (see 'Definitions, epidemiology, and detection' above):

• Normal <150 mg/dL (1.7 mmol/L)
• Borderline high — 150 to 199 mg/dL (1.7 to 2.2 mmol/L)
• High — 200 to 499 mg/dL (2.3 to 5.6 mmol/L)
• Very high — ≥500 mg/dL (≥5.7 mmol/L)

• Although the contribution of triglycerides to cardiovascular risk has been debated in the past, it now seems clear that elevated triglyceride levels are independently associated with cardiovascular risk, particularly coronary risk. It remains uncertain, however, whether this association is causal, such that hypertriglyceridemia, independent of associated lipoprotein, inflammatory and hemostatic abnormalities, causes atherosclerosis. It is also uncertain whether lowering triglyceride levels reduces risk. (See 'Triglycerides and atherosclerosis' above.)
• There are only limited data regarding which patients with hypertriglyceridemia require treatment and on the choice of therapies. (See 'Management' above.)
• Nonpharmacologic interventions such as weight loss in obese patients, aerobic exercise, avoidance of concentrated sugars and medications that raise serum triglyceride levels, and strict glycemic control in diabetics should be first-line therapy in patients with mild-to-moderate hypertriglyceridemia. Other risk factors for cardiovascular disease, such as hypertension and smoking, should also be addressed. (See 'Nonpharmacologic therapy' above.)
  
  In patients with severe hypertriglyceridemia (fasting triglyceride levels above 1000 mg/dL [11.3 mmol/L]), we suggest a very low fat diet (Grade 2C). (See 'Nonpharmacologic therapy' above.)
• Options for pharmacologic therapy directed at reducing triglycerides include fibrates, nicotinic acid, and fish oil. (See 'Pharmacologic therapy (including fish oil)' above.)
• For patients with mild to moderate hypertriglyceridemia (150 to 500 mg/dL [1.7 to 5.7 mmol/L]), and even in patients with triglyceride levels as high as 1000 mg/dL (11.3 mmol/L), the main indication for therapy is reduction of cardiovascular (CV) risk. In patients where the goal of therapy is CV risk reduction:

• Decisions about initiating pharmacologic therapy should be based on global cardiovascular risk. Nearly all patients with known coronary heart disease (CHD) or a CHD risk equivalent (table 4) will require therapy. (See "Treatment of lipids (including hypercholesterolemia) in primary prevention", section on 'Deciding whom to treat' and "Treatment of lipids (including hypercholesterolemia) in secondary prevention", section on 'Identification of patients at risk'.)
• For patients with a triglyceride level below 500 mg/dL (5.7 mmol/L) in whom pharmacologic therapy is indicated, we suggest treatment with a statin rather than an agent targeted at reduction of triglycerides (Grade 2B). Given the lack of high quality evidence directly comparing statin therapy with other treatment options, a reasonable alternative in such patients would be to treat them with fibrates, nicotinic acid, or fish oil. (See 'Mild to moderate hypertriglyceridemia' above.)
• In patients with CHD or a CHD risk equivalent (table 4) who have moderate hypertriglyceridemia (200 to 500 mg/dL [2.3 to 5.7 mmol/L]) and are intolerant of statin therapy, we suggest treatment with nicotinic acid or a fibrate (Grade 2C). Treatment with fish oil is a reasonable alternative. (See 'Mild to moderate hypertriglyceridemia' above.)
• For patients with a triglyceride level above 500 mg/dL (5.7 mmol/L) in whom pharmacologic therapy is indicated, we suggest treatment with a fibrate (such as fenofibrate), followed by the addition of a statin once the triglyceride levels are brought down (Grade 2C). Fish oil therapy is also an option. A reasonable alternative would be to treat lower-risk patients with a statin alone and to only add triglyceride-directed therapy in patients with CHD or a CHD risk equivalent (table 4). (See 'Severe hypertriglyceridemia' above.)

• In patients without a prior episode of pancreatitis, we suggest initiating pharmacologic therapy to reduce triglycerides with a goal of preventing pancreatitis when the level exceeds 1000 mg/dL (11.3 mmol/L) (Grade 2C). Even at this level of triglyceride elevation, the risk of pancreatitis appears to be quite small. Patients being treated for prevention of pancreatitis will often require combinations of triglyceride-lowering medications (ie, a fibrate, fish oil, nicotinic acid) to reduce the triglyceride level below 1000 mg/dL (11.3 mmol/L). (See 'Severe hypertriglyceridemia' above.)
• The management of patients with hypertriglyceridemia and acute pancreatitis and/or a prior episode of pancreatitis is discussed separately. (See "Hypertriglyceridemia-induced acute pancreatitis".)

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