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Lifestyle Modifications
For people with mildly or moderately high levels of triglycerides lifestyle changes are recommended which can include dietary changes, increased exercise and weight loss This has the added benefit of reducing the risk of cardiovascular disease, as people with hypertriglyceridemia are frequently obese, insulin-resistant or diabetic. Dietary changes can include restricting refined carbohydrate and fat, along with reducing alcohol intake. However a randomised clinical trial on overweight and obese subjects with varying intakes of carbohydrates and fats showed that all diets decreased triglyceride levels similarly. The effectiveness of dietary modification on triglyceride levels may vary between ethnic groups. African Americans have a lower average triglyceride concentration than Caucasians. The OmniHeart Study found a diet of unsaturated fat and protein lowered plasma triglyceride levels more in a Caucasian population compared to African Americans when matching baseline triglyceride levels. Treadmill walking of 60mins can lower fasting, post-prandial T and VLDL triglycercides, demonstrating moderate exercise is sufficient to cause a beneficial effect.

Pharmacology
Medications are recommended in those with high levels of triglycerides, with fibrates being recommended first in patients with severe hypertriglycerideamia and at risk for triglyceride-induced pancreatitis. Other recommended drugs include niacin, n-3 fatty acids and statins.

Fibrates
Fibrates are derivatives of fibric acid and examples include bezafibrate, gemfibrozil and fenofibrate and have been shown to increase HDL cholesterol with persistent reductions in serum levels of LDL and triglycerides. They can lower triglyceride levels by acting on the liver through lowering the availability of fatty acids for triglyceride synthesis In addition, fibrates inhibit hormone sensitive lipase in adipose tissue. Frequent side effects of fibrates are gastrointestinal discomfort, nausea, headache and skin rashes.

Niacin(Nicotinic Acid)
While niacin has been shown to significantly improve triglyceride levels over 2 years there was no simultaneous improvement in cardiovascular risk when added to statins compared to statins alone. Niacin reduces triglyceride synthesis by directly and noncompetitely inhibiting diacylglycerol acyltransferase-2 (DGAT-2) in hepatocytes. The most serious side effect of niacin includes hepatotoxicity while the most common is cutaneous flushing, due to prostaglandin D2 release from skin cells causing vasodilation. Niacin can also precipitate gout due to blocked uric acid excretion and worsen glucose tolerance.

N-3 Polyunsaturated fatty acids / Omega-3 fatty acids
Omega-3 fatty acids are polyunsaturated fatty acids important for normal growth. The main types of omega-3 fatty acids are ALA (derived from plants) and EPA and DPA (most abundantly found in fish). Serum triglyceride level are dose-dependently reduced by omega-3 fatty acids and approximately 3 to 4 g/day of EPA and DPA are required to reduce hypertriglyceridemia by 20-50%. However, patients may experience a ‘fishy burp’ as the oils are released when the capsule dissolves in the stomach.

Statins
It is recommended that statin monotherapy should not be the first line treatment for severe hypertriglyceridemia but can be used for moderate hypertriglyceridemia to modify cardiovascular risk.