Triglycerides (Hypertriglyceridemia)

 

Hypertriglyceridemia is associated with increased cardiovascular risk and,at very high levels (>10mmol/l), a risk of acute pancreatitis.

Triglyceride concentrations are acutely sensitive to lifestyle factors—particularly alcohol intake, dietary carbohydrate load, activity levels and weight change.

The lipid team have produced this easy to follow flow chart on the management of Hypertriglyceridemia which can be found in the adult lipid management pathways document.

 

The key points from this flow chart are below

• For all patients with raised non fasting triglycerides
  • Recheck aFASTING sample (within 5-14 days if initial test >10)
  • Consider secondary causes
    • Obesity
    • Poorly controlled diabetes
    • Alcohol
    • Nephrotic syndrome
    • Hypothyroidism
    • Pregnancy
    • Medications (e.g. Oestrogen, tamoxifen, immunosuppressants, HIV medications)

• If secondary to alcohol excess or poorly controlled diabetes, address these first and recheck/ monitor before considering fibrate therapy or referral to lipid clinic
   
• QRISK can still be used to assess 10 year risk however persistent hypertriglyceridemia is not accounted for in CVD risk calculators and is a significant independent risk factor.

 

Investigations required with referral

• CVD & Lipid history 
• Bloods including:
  • Lipid profile
  • FASTING lipid profile
  • Liver profile
  • TSH
  • Renal profile
  • HbA1c

 

 

Management Optimization & Referral

Lifestyle & dietary changes 

Hypertriglyceridemia is particularly sensitive to lifestyle and dietary modification, with rapid changes from:

• reducing alcohol intake
• reducing refined carbohydrates, sugars and dietary fats
• weight loss
• optimized glycemic control
• regular exercise

 

Fibrates

• Consider fibrate therapy if fasting triglycerides >10 mmol/LAND not secondary to alcohol or poor glycemic control
• Consider contraindications and renal function (see flow chart/BNF for prescribing guidance).
• If myopathy symptoms while on fibrate – stop and check CK and U+Es
  • Very rare but serious risk of rhabdomyolysis
• Combination with statin increases the risk of myopathy. 
• Hold fibrate if AKI from other cause
• Monitor LFTs 3 monthly for the first year and then periodically
  • Discontinue if transaminases >3x ULN or clinical concern over increased levels³

 

Advice & Guidance

There is a Lipid Advice & Guidance service available for complex or unclear cases

 

Referral Criteria

Referral thresholds in the table below are based on:

 

Repeat fasting triglyceride measurements not secondary to excess alcohol intake or uncontrolled diabetes

*Consider A&G if patients do not meet referral criteria but above they also have a non-HDLc of >7.5

 

Patient information

• HEART UK - The Cholesterol Charity
• https://www.heartuk.org.uk/cholesterol/triglycerides

 

References

• NICE Clinical Knowledge Summary (CKS): Lipid modification – CVD prevention
  National Institute for Health and Care Excellence (NICE). Lipid modification – CVD prevention. Available at: https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/
• NHS England (Accelerated Access Collaborative). Summary of national guidance for lipid management for primary and secondary prevention of cardiovascular disease (CVD) (lipid management pathway v6). Available at: https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2020/04/lipid-management-pathway-v6.pdf
• NICE BNF. Fenofibrate. Available at: https://bnf.nice.org.uk/drugs/fenofibrate/

 

Page Review Information

Review date:           27 March 2026
Next review date:    27 March 2028
Clinical editors:        Dr Jack Munro Berry – RMS GP
Contributors:           Dr Rachel Cooper – Consultant Clinical Biochemist