to the editor: The article, “Management of Hypertriglyceridemia,” in the May 1, 2007, issue of American Family Physician addresses an important topic.¹ However, many of the therapy suggestions discussed do not reflect current standards of care and may be misleading.

First, the authors have given statins the preeminent position by listing them first in their choice of pharmacologic agents for treating patients with high triglycerides. Statins are not the first-line agents. In patients with triglyceride levels higher than 500 mg per dL (5.65 mmol per L), the first priority should be lowering their triglycerides, not their low-density lipoprotein cholesterol.² Initial therapy should always begin with fibrates, extended-release niacin (which has fewer side effects and a better safety profile compared with immediate-release and sustained-release niacin), and fish oil (at least 3,000 mg of eicosapentaenoic acid/docosahexaenoic acid daily). When used alone or in combination, all three of these agents are more efficacious in lowering triglyceride levels than statins.

The authors' algorithm¹ (Figure 1²) is f lawed and can be misleading if followed in practice. Although they have referenced a publication of the National Cholesterol Education Program (NCEP),² their recommendation is not consistent with NCEP guidelines. The figure implies that dietary therapy and “aggressive” body weight reduction alone might effect a 50 percent or more lowering of triglyceride levels in patients with serum triglyceride levels higher than 1,000 mg dL (11.30 mmol per L). Many such persons have a genetic hyperlipidemia, such as Type V hyperlipoproteinemia, and drug therapy must be undertaken immediately (along with lifestyle measures) to expeditiously reduce serum triglyceride levels to lower than 500 mg per dL. In patients with diabetes and insulin resistance, insulin therapy with a basal insulin and multiple doses of short-acting insulin injections at mealtime will substantially impact postprandial lipemia, as patients with diabetes and high fasting triglyceride levels risk further elevation in serum triglyceride levels after a mixed meal.³ Bile acid sequestrants are contraindicated in those with high triglyceride levels, as these agents cause further elevation in serum triglyceride levels. Oral agents that impact prandial glucose regulation may be less effective in this situation.⁴

In my clinic, a common and recurrent theme is the practice of prescribing high-dose statins to treat high triglyceride levels, and then adding on a fibrate as a second-line agent. This combination often results in complications and eventual withdrawal of all drug therapy, and could be avoided if therapy was initiated with fibrates and niacin rather than statins. Rosuvastatin (Crestor), as opposed to other statins, may have a slight advantage in lowering of triglyceride levels on a weight-for-weight basis; in general, however, statin use should be limited to recalcitrant cases after initial use of fibrates, niacin, and fish oil, and after ensuring patient adherence.