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  Triglycerides (TG) and HDL Screening

In adults over the age of 20 years, a fasting lipid profile should be obtained every 5 years including: total

cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides. Only total cholesterol and HDL-cholesterol are

 accurate in a non-fasting state. Patients need to be advised to fast for 10-12 hours prior to having their fasting

panel drawn for an accurate measurement of triglycerides.

Step 1: Identify Common Causes

Common Causes of Elevated TG:

• Overweight/Obesity

• Physical Inactivity

• Cigarette Smoking

• Excess Alcohol Intake

• Very High Carbohydrate Diet (> 60% of total energy)

• Diseases:

Type 2 Diabetes, Chronic Renal Failure, Nephrotic Syndrome

• Certain Drugs:

Corticosteroids, Protease Inhibitors for HIV, Beta-Adrenergic

Blocking Agents, Estrogens

• Genetic Factors

Common Causes of Low HDL:

• Elevated TG

• Overweight/Obesity

• Physical Inactivity

• Cigarette Smoking

• Very High Carbohydrate Diet (> 60% of total energy)

• Type 2 Diabetes

• Certain Drugs:

Beta Blockers, Anabolic Steroids, Progestational Agents

• Genetic Factors

Step 2: Perform Clinical Assessment

• Height, Weight, BMI, Waist Circumference

• Fasting Lipid Panel

• CV Exam

• Lifestyle: Physical Activity, Diet, Alcohol, Smoking

• Acanthosis Nigricans

• Past Medical History: Pancreatitis, Renal Disease,

Liver Disease, Vascular Disease, Diabetes,

Thyroid Disease, Cushings Syndrome, HIV, PCOS

• Family History of CVD and Lipid Disorders

• Medications (Prescription & OTC)

For Very High TG (≥ 500 mg/dL):

• Abdominal Pain/Tenderness to Palpation

• Hepatomegaly, Splenomegaly

• Cutaneous Flushing, Dry Skin, Pruritis, Xanthomas

Step 3: Assess for Metabolic Syndrome

Diagnosis = Any 3 of the Following Criteria:

• Waist Circumference ≥ 40” in Men

≥ 35” in Women

• TG ≥ 150 mg/dL

• HDL < 40 mg/dL in Men

< 50 mg/dL in Women

• BP ≥ 130/85 mm Hg

• Fasting Glucose ≥ 100 mg/dL

LDL goal is first-line treatment. When LDL goal is achieved, if TG ≥ 200 mg/dL, treat Non-HDL-C.

Non-HDL-C: • Secondary target of drug therapy when TG ≥ 200 mg/dL

• Represents: triglyceride-rich lipoproteins—considered atherogenic

• Sum of LDL & VLDL cholesterol is a target of cholesterol lowering therapy

• Total cholesterol minus HDL = non-HDL-cholesterol

ATP III Guidelines

Triglycerides (mg/dL)

Less than 150 Normal

150–199 Borderline High

200–499 High

Greater than or equal to 500 Very High

HDL (mg/dL)

Less than 40 Low (Men)

Less than 50 Low (Women)

Greater than or equal to 60 Optimal

When lab is drawn to test TG, fasting 10 –12 hours is required.

Non-HDL-C goal

is 30 mg/dL higher

than the LDL target

Data adapted from ATP III Final Report. Circulation. 2002

ATP III 2004 and 2005 Updates

Or on Drug Rx


Preventive Cardiovascular

Nurses Association

Elevated Triglycerides & Low HDL A Quick Look at Therapies

Step 5: Pharmacologic Therapy (refer to PDR for contraindications)

Agents Lipid Effects Adverse Effects

Immediate Release

(Crystalline) Nicotinic Acid

(1.5–3 g)

Extended Release

Niaspan (1–2 g)

LDL-C  5%–25%

HDL-C  15%–35%

TG  20%–50%

Flushing, Hyperglycemia, Hyperuricemia (or gout),

Upper Gastrointestinal Distress, Hepatotoxicity

Tips for Decreasing Side Effects:

• Take extended release formula at bedtime

• Take with food (light snack)

• Pre-medicate with aspirin (30 min. before)

• Avoid hot spicy foods, hot beverages, and alcohol


Tricor (145 mg)

Lofibra (200 mg)

Antara (200 mg)


Lopid (600–1200 mg)

LDL-C . 5%–20%

(may . in pts

with high TG)

HDL-C . 10%–20%

TG . 20%–50%



Myopathy (especially when combined with statins)

Increased Creatinine

OTC Fish Oil

Consume 2–4 g of EPA

plus DHA daily in capsules

Prescription Fish Oil

Lovaza* 4 g daily

1 g capsules

(2 BID with Meals)

TG . 20–40%

TG . 45%

HDL . 9%

Gas (belching, flatulence), abdominal discomfort,

loose stools. Caution for those with fish allergies.

Tips for Decreasing Side Effects:

• Take with meals

• Increase dose gradually

• To reduce belching, store in the refrigerator

or freezer and swallow cold

* Only indicated for very high TG Supported by an independent educational grant from Abbott Laboratories

Physical Activity:

• Regular, moderate-intensity physical activity

• Minimum 30-minutes, preferably 60 minutes

(may be broken up into segments)

• 5 days/week, preferably daily

Diet Modification:

• Caloric restriction for weight loss

• Choose high-fiber carbohydrates (avoid refined grains)

• Limit simple sugars

• Increase fruits & vegetables to 4-6 servings/day

• Choose monounsaturated fats: canola, olive, or peanut oil

• Avoid trans fat and limit saturated fats to < 7% total calories

• Add Omega 3 fatty acids: fish, flax seed, nuts

Alcohol & Smoking:

• Limit alcohol intake (avoid completely for TG ≥ 500 mg/dL)

• Complete smoking cessation

Follow-up Assessment (4-8 weeks):

• First line therapy should be initiated with follow-up assessment of lipids and lifestyle in 4–8 weeks.

A Note on First Line Therapy:

• Borderline high TG (150–199 mg/dL) are not a direct target of drug therapy. Lifestyle changes

including routine physical activity and diet modifications are considered first line therapy.

• High TG (200–499 mg/dL) also utilize lifestyle changes as first line therapy. Statins may be

used alone in high doses, or in low to moderate doses combined with fibrates or niacin to

achieve non-HDL targets.

• Very high TG (≥ 500 mg/dL) utilize lifestyle changes including low-fat diet (≤ 15% total calories from fat), weight


physical activity, and drug therapy including fibrates, niacin, or omega 3 fatty acids.

Step 4: Support Lifestyle Change

Omega 3 Fatty Acids Niacin Fibrates