SUN-236 - Lipid Overload and the Fish Oil Fix: A Case of Severe Hypertriglyceridemia

Introduction: Hypertriglyceridemia is defined as a fasting serum triglyceride (TG) level of 150 mg/dL or higher and affects nearly one-third of adults in the United States. Severe hypertriglyceridemia, typically defined as TG levels above 1,000 mg/dL, is associated with an increased risk of acute pancreatitis, with an estimated 5% risk at these levels. While elevated TG levels have been associated with atherosclerotic cardiovascular disease, a direct causal relationship remains unclear. Management includes dietary fat restriction, weight loss, and avoidance of alcohol. Pharmacologic therapy is generally initiated when TG levels exceed 500 mg/dL, most commonly with fibrates or high-dose omega-3 fatty acids such as icosapent ethyl. Evidence supporting the use of icosapent ethyl in severe hypertriglyceridemia remains limited. We present a case of severe hypertriglyceridemia with a marked reduction in TG levels following initiation of icosapent ethyl.

Case Report: A 38-year-old male with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia presented for an annual physical examination. Routine laboratory testing revealed severe hypertriglyceridemia with a TG level of 1,236 mg/dL. Low-density lipoprotein cholesterol could not be calculated due to the markedly elevated TG level. This represented a significant increase from the prior year, when TG was 125 mg/dL and LDL cholesterol was 40 mg/dL. The patient reported a family history of hypertriglyceridemia and preferred a simplified, “natural” treatment regimen. After discussion of therapeutic options, he was initiated on icosapent ethyl at a dose of 2 grams twice daily and counseled on dietary fat restriction and lifestyle modification. At three-month follow-up, repeat lipid testing demonstrated a marked reduction in TG levels to 154 mg/dL, with an LDL cholesterol level of 132 mg/dL. This improvement occurred with icosapent ethyl monotherapy in the absence of statin therapy.

Discussion: Omega-3 polyunsaturated fatty acids, including eicosapentaenoic acid, lower serum TG levels primarily through reduced hepatic triglyceride synthesis and decreased very low-density lipoprotein secretion. Prescription formulations, such as icosapent ethyl, provide standardized, high-purity dosing compared to over-the-counter products. While prior studies have demonstrated modest TG reductions in mild to moderate hypertriglyceridemia, data in severe hypertriglyceridemia remain limited. In this case, initiation of icosapent ethyl was associated with greater than 80% reduction in TG levels with concomitant dietary modification

Conclusion: High-dose icosapent ethyl may result in substantial triglyceride reduction in patients with severe hypertriglyceridemia. Further research is needed to determine whether this improvement translates into reduced risk of hypertriglyceridemia-associated pancreatitis.

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