Laboratory confirmation and initial assessment
In the presence of elevated triglyceride values, the first step is to confirm the laboratory result, preferably in the fasting state, especially when values are above four hundred milligrams per decilitre. Recent alcohol intake should also be assessed, given its significant impact on triglyceride levels.
Exclusion of secondary causes
Next, it is essential to systematically exclude secondary causes of hypertriglyceridemia. These include poorly controlled diabetes mellitus, obesity or metabolic syndrome, alcohol consumption, a diet rich in simple sugars, hypothyroidism, chronic kidney disease, pregnancy, inflammatory diseases and medications known to increase triglycerides. Whenever identified, these causes should be corrected as a priority.
Triglycerides between one hundred and thirty-five and four hundred and ninety-nine
When triglycerides are between one hundred and thirty-five and four hundred and ninety-nine milligrams per decilitre, the main objective is to reduce residual cardiovascular risk. Lifestyle intervention should be implemented, including weight control, a balanced diet, reduction of simple sugars, alcohol abstinence and regular physical activity. Statin therapy should be started or optimised according to global cardiovascular risk.
High cardiovascular risk and additional therapy
In patients at high or very high cardiovascular risk, receiving statin therapy, and with persistently elevated triglycerides within this range, icosapent ethyl may be considered with the aim of reducing cardiovascular events.
Triglycerides between five hundred and eight hundred and seventy-nine
When triglycerides are between five hundred and eight hundred and seventy-nine milligrams per decilitre, cardiovascular risk and an increasing risk of pancreatitis coexist. In these cases, intensive lifestyle intervention is required, with complete alcohol abstinence, marked reduction of simple sugars and refined carbohydrates, and strict metabolic control, particularly of glycaemia in patients with diabetes. Statin therapy should be maintained or introduced according to cardiovascular risk, and fenofibrate may be added if triglycerides remain elevated.
Triglycerides equal to or above eight hundred and eighty
When triglycerides are equal to or above eight hundred and eighty milligrams per decilitre, the priority objective becomes prevention of acute pancreatitis. Mandatory measures should be implemented, including a very-low-fat diet, complete alcohol abstinence, intensive glycaemic control and review of potentially aggravating medications, with discontinuation whenever possible. Fenofibrate is first-line therapy.
Metabolic stabilisation and cardiovascular risk
After metabolic stabilisation and reduction of triglycerides to safer levels, statin therapy should be introduced or resumed according to global cardiovascular risk, maintaining LDL cholesterol as the priority therapeutic target.
Suspected familial chylomicronemia
In the presence of persistently very high triglycerides, particularly above seven hundred and fifty milligrams per decilitre, with early onset, suggestive family history or recurrent episodes of pancreatitis, familial chylomicronemia should be considered. In these cases, referral to a specialist centre is indicated and targeted therapy, such as volanesorsen, may be considered.
Reassessment and follow-up
Throughout the pathway, triglycerides should be reassessed after four to six weeks, or earlier in severe situations. Once stabilisation has been achieved, reduction of global cardiovascular risk should again become the main focus of the therapeutic approach, integrated into the overall management of dyslipidaemia.
