PracticeUpdate Diabetes Best of 2018

EXPERT OPINION 18

My Approach to Triglyceride Levels in Specific Patient Scenarios Interview with Paul D. Thompson MD by Jennifer N. Caudle DO

Dr. Thompson is Physician Co-Director of the Hartford Healthcare Cardiovascular Institute in Hartford, and Professor of Medicine at the University of Connecticut in Storrs, Connecticut.

region, oftentimes the statin alone or the statin in combination with ezetimibe will make their triglycerides look pretty good. If they’re over the 500 region then you’re really going to need something else, like concentrated fish oil with or without a fibrate, fibric acid derivatives. Now the problem is fenofibrate got a bad rap from the ACCORD Lipid Lowering trial. What was that? Diabetics on statin, on statin, put on either a placebo or put on fenofibrate, and if you looked at all that group there was not an improvement in cardiovascular events. But if you looked at the group who had tri- glycerides over 204 and an HDL equal to or less than 34, they got a benefit at the .06 level, so it wasn’t less than .05. So, I’m still concerned about those individuals who have triglycerides over 200 and pay atten- tion to them. We still use fenofibrate in that group to lower the triglyceride levels. Dr. Caudle: That’s very helpful. And you talked about the different levels, sort of your cut- offs at 200, 500, 1,000 and kind of what they mean for you. Let’s just dive deeper a little bit with that. What level of triglycerides should we as clinicians consider high enough to con- fer increased cardiovascular risk? Dr. Thompson: What I do in that instance is I look at ApoB levels because every bad particle has one ApoB. So if your triglycer- ides are elevated because you have a lot of VLDL particles, your ApoB level will be ele- vated as well. So what I do in that instance is I try to get the ApoB level down to where it’s about 10 points above my LDL cholesterol

Dr. Caudle: We’re going to be talking about triglycerides. Now, the 2017 ACE and other guidelines have acknowledged that LDL cho- lesterol levels do not tell the whole story when it comes to cardiovascular risk, that’s some- thing we know. You proposed the idea that triglycerides were becoming a more impor- tant risk factor for coronary artery disease. So, what’s the major take-home message today about the importance of measuring triglycer- ide levels and subsequently treating them? Dr. Thompson: Triglycerides are complex because people have argued about them for a long period of time, and they’ve argued for a bunch of different reasons. One rea- son is that everybody was focusing on HDL because if the triglycerides are high, the HDL is driven low so we ignored triglycer- ides and focused much more on HDL. So, here are the messages that I like peo- ple to know about triglycerides. First of all, every patient with high triglycerides is what I refer to as a diabetic want-to-be, that’s a to and a be, and the reason behind that is it actually takes more insulin to regulate fat metabolism than it does to regulate glucose metabolism. So elevated triglyc- erides are often an early sign of diabetes, so measuring it is very important, and if you see elevated levels...what am I talking about? Over 200 or so. If you see elevated levels, at least through your mind should run the possibility of doing an oral glucose tolerance test to make sure that that person is not pre-dia- betic. Now their glucose and their A1c may

not be off the wall, may not even be that abnormal. Their triglycerides are up. Why? Because it takes more insulin to regulate fat metabolism than it does glucose. So the first thing I like people to know about cardiovascular risk in triglyceride lev- els is exclude the pre-diabetic. You know about 30% of people who show up in a cor- onary care unit with an acute myocardial infarction or unstable angina, or whatever, have pre-diabetes when you look it hard because when you have elevated glucose levels you don’t just glycosylate your hemo- globin A1c, you glycosylate other things like ApoB which makes that lipoprotein particle much more injurious to the endothelium. So let’s talk about levels. Let’s talk about levels in which you get worried. I’m con- cerned about triglyceride levels over 200 mg/dL, that’s where I start to pay attention. Would I like them lower? Yeah, I’d really like them lower. Normal triglyc- eride levels are probably well under 150 and maybe 100, really normal, ideal, but over 200 I start to pay attention. If they’re over 500 that’s where everybody agrees on drug treatment, either with concentrated fish oil or one of the fibric acid derivatives. If they’re over 1000 on a fasting sample, I see that patient right away, and I see that patient right away because of their risk... they’re at risk for life-threatening pancrea- titis, so I like to see them right away. Then the question is what do you treat them with? Well, it depends on the level. If their triglycerides are in the moderate

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