On average, statins bring about a 25% to 55% reduction in LDL-C, a 5% to 10%
increase in HDL-C, and a 10% to 20% decrease in triglycerides. If triglycerides
remain high (150 mg/dl or higher) even after using statins and adherence to the factors
on the Lifestyle Checklist, (e.g. controlling diabetes and weight, a plant-based
diet, exercise, eliminating alcohol), a variety of drugs can be considered.
Two types of non-statin drugs target high triglycerides: fibrates and omega-3-acid ethyl esters.
Fibrates, either fenofibrate (various brands) or gemfibrozil (Lopid), are recommended
for very high levels of triglyceride levels, 500 mg/dl or higher. They reduce triglyceride
levels by 20% to 50% but also raise LDL-C by about 10%. A statin can
be added to fibrates to counteract any increases in LDL-C.
The omega-3 fatty acids found in fatty fish and fish oil interfere with the conversion
of dietary fats into triglycerides. Three forms of omega-3-acid ethyl esters have
been FDA approved for the treatment of high triglycerides that are at a level of 500
mg/dl or higher. Lovaza contains eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA). Epanova contains another form of omega-3 fatty acids. Vascepa
contains only a purified form of EPA (icosapent ethyl).
The REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention
Trial), studied patients on statins with high CVD risk, LDL-C levels
controlled with statin therapy, but who had elevated triglyceride levels (135 to 500
mg/dl). It found that over five years, the risk of major adverse cardiovascular events
was lower by 25% among patients who received 4 g of Vascepa daily than among
those who received a placebo. Vascepa is the first FDA approved drug to both
reduce triglycerides and reduce cardiovascular risk among patients with elevated
triglyceride levels. It is approved as an add-on to maximally tolerated statin therapy.
Patients must also have either established cardiovascular disease or diabetes
and two or more additional risk factors for cardiovascular disease.
In clinical trials, Vascepa was associated with an increased risk of atrial fibrillation
or atrial flutter (irregular heart rhythms) requiring hospitalization. Vascepa was also
associated with an increased risk of bleeding events among patients who were also
taking other medications that increase the risk of bleeding, such as aspirin, clopidogrel,
or warfarin. Patients with allergies to fish or shellfish should be advised about
the potential for allergic reactions. According to a review article in the New England
Journal of Medicine, icosapent ethyl is a proprietary and highly purified form
of EPA, and the findings from REDUCE-IT should not be generalized to assume
that there will be benefits from dietary supplementation with fish oil.
This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel