Lower triglyceride

Triglycerides of 150 mg/dL (1.70 mmol/L) or greater or active treatment to lower triglycerides. 

Ezetimibe reduces LDL cholesterol by an average of 18% (Table 9-8). However, larger reductions can be seen in some individuals, presumably due to higher absorption of cholesterol. These individuals appear to have a blunted response to statin therapy. Ezetimibe lowers triglycerides by 7% to 9% and modestly increases HDL cholesterol. 

Resins are moderately effective in lowering LDL cholesterol but do not lower triglycerides (Table 9-8). Moreover, in patients with elevated triglycerides, the use of a resin may worsen the condition. This may be due to a compensatory increase in HMG-CoA reductase activity and results in an increase in assembly and secretion of VLDL. The increase in HMG-CoA reductase activity can be blocked with a statin, resulting in enhanced reductions in serum lipids (see section on combination therapy). Resins reduce LDL cholesterol from 15% to 30%, with a modest increase in HDL cholesterol (3% to 5%) (Table 9-8). Resins are most often used as adjuncts to statins in patients who require additional lowering of LDL cholesterol. Since these drugs are not absorbed, adverse effects are limited to the gastrointestinal tract (Table 9-9). About 20%... 

Niacin (vitamin B3) has broad applications in the treatment of lipid disorders when used at higher doses than those used as a nutritional supplement. Niacin inhibits fatty acid release from adipose tissue and inhibits fatty acid and triglyceride production in liver cells. This results in an increased intracellular degradation of apolipoprotein B, and in turn, a reduction in the number of VLDL particles secreted (Fig. 9-4). The lower VLDL levels and the lower triglyceride content in these particles leads to an overall reduction in LDL cholesterol as well as a decrease in the number of small, dense LDL particles. Niacin also reduces the uptake of HDL-apolipoprotein A1 particles and increases uptake of cholesterol esters by the liver, thus improving the efficiency of reverse cholesterol transport between HDL particles and vascular tissue (Fig. 9-4). Niacin is indicated for patients with elevated triglycerides, low HDL cholesterol, and elevated LDL cholesterol.3... 

Omega-3 fatty acids (eicosapentaenoic acid and docosa-hexaenoic acid), the predominant fatty acids in the oil of cold-water fish, lower triglycerides by as much as 35% when taken in large amounts. Fish oil supplements may be useful for patients with high triglycerides despite diet, alcohol restriction, and fibrate therapy. This effect may be modulated thru PPAR-a and a reduction in apolipoprotein B-100 secretion. Omega-3 fatty acids reduce platelet aggregation and have... 

The answer is d, (Katzung, pp 589-590.) Only gemfibrozil acts to lower triglycerides, probably because of increased lipolysis by lipoprotein lipase and decreased lipolysis inside adipocytes, causing a net movement of triglycerides into the cell. 

Lovaza (omega-3-acid ethyl esters) is a prescription form of concentrated fish oil EPA 465 mg and docosahexaenoic acid 375 mg. The daily dose is 4 g/day, which can be taken as four 1-g capsules once daily or two 1-g capsules twice daily. This product lowers triglycerides by 14% to 30% and raises HDL by about 10%. 

Nicotinic acid and its derivatives (pyridylcarbinol, xanthinol nicotinate, acipimox) activate endothelial lipoprotein lipase and thereby lower triglyceride levels. At the start of therapy, a prostaglandin-mediated vasodilation occurs (flushing and hypotension) that can be prevented by low doses of acetyl-salicylic acid. 

These activate lipoprotein lipase which is a key enzyme in degradation of VLDL resulting in lower circulating triglycerides. These drugs lower triglyceride levels by 20-50% with 10-15% decrease in LDL cholesterol and a 10-15% increase in HDL cholesterol. 

In 122 postmenopausal patients with metastatic breast cancer who were randomized to exemestane 25 mg/day (n = 62) or tamoxifen 20 mg/day (n = 60), neither exemestane nor tamoxifen had adverse effects at 8, 24 or 48 weeks on concentrations of total cholesterol, HDL cholesterol, apolipoproteins A1 or B, or lipoprotein a (15). Exemestane lowered triglyceride concentrations while tamoxifen increased them. 

Clofibrate Abitrate, Atromid-S 1.5-2.0 g each day in 2-4 divided doses Lowers triglycerides and VLDL-C may also increase HDL-C levels... 

Additionally, AAS users experience lower triglyceride levels than non-users. High triglyceride levels are also associated with heart disease. Low HDL levels and high LDL levels increase the risk of atherosclerosis, the condition where fatty substances are deposited on the inner walls of arteries. The disruption in blood flow can cause a stroke when blood is prevented from reaching the brain, or a heart attack when blood does not reach the heart muscle. Cholesterol levels return to normal when AAS use stops. The potential development of blood clots also increases with AAS use, which can disrupt blood flow. The changes in cholesterol levels appear to return to the person s baseline levels after AAS discontinuation. 

Increased fatty acid catabolism decreases the concentration of free fatty acids available for export from the liver as circulating triglycerides. This provides a rationale for the lowered triglyceride values. The lowered serum cholesterol concentration apparently results from inhibition of cholesterol synthesis and stimulation of the conversion of cholesterol to bile acids in the liver (Nair and Kurup 1986). 

Fibric acid derivatives (aryloxyisobutyric acids) include the prototypic drug gemfibrozil. These types of drugs are used mainly to lower triglycerides and to increase HDL. A large placebo-controlled primary prevention trial in hypercholesterolemic men showed that patients treated with gemfibrozil had a statistically lower number of myocardial infarctions, but not of deaths from all causes. 

Fiordaliso, M.F., Kok, N., Desager, J.P., Goethals, F., Deboyser, D., Roberfroid, M., and Delzenne, N., Dietary oligofructose lowers triglycerides, phospholipids and cholesterol in serum and very low-density lipoproteins of rats, Lipids, 30, 163-167, 1995. 

While statin drugs can dramatically lower LDL cholesterol, they do very little to raise HDL, to lower triglycerides or lipopro-tein(a), or to improve the other parameters, which I explained earlier, that niacin influences beneficially. There s no doubt in my mind that niacin is the better choice. 

The list of research studies goes on and on, all with favorable results. We now know that the main fish oils, eicosapentanoic acid (EPA) and docohexanoic acid (DHA), work in a number of wonderful ways. These omega-3 fatty acids reduce the formation of blood clots and raise levels of the protective HDL cholesterol while dramatically lowering triglycerides. They prevent heart rhythm disturbances and they lower heart rates. Because heart rate is associated with the risk of sudden death, this association may at least partially explain the lower risk of sudden death among people who regularly eat fish. 

Familial hypoalphalipoproteinaemia may respond to exercise, weight loss, and nicotinic acid a fibrate and/or a statin may be added for a small HDL-raising effect but primarily to lower triglycerides and LDL. 

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