Reasoning GP · Algorithm · 1-page summary
High triglycerides in adults
For: adults with a raised triglyceride (TG) result, in hours or OOH. Not for: raised cholesterol alone or familial hypercholesterolaemia (use those protocols). Pregnancy with severe TG → obstetric and lipid-specialist co-management.
Core rule: raised TG at any level with severe abdominal pain or vomiting is acute pancreatitis until proven otherwise — do not wait for a repeat. Without symptoms, TG ≥10 mmol/L is about pancreatitis prevention; below that, it is about overall CVD risk (statin first).
0Stop — act now — before repeating any lipids
- Severe epigastric pain radiating to the back + nausea or vomiting, any TG level (pancreatitis can occur below 10 mmol/L, especially after fasting or vomiting) → Same-day hospital, 999 if unwell. Do not wait for a repeat fasting profile.
- TG >20 mmol/L with abdominal pain, vomiting or systemic illness, or chylomicronaemia with acute symptoms → Same-day hospital
- Hyperglycaemic symptoms, vomiting, abdominal pain or acute illness → capillary glucose and blood ketones now; ketones raised, DKA/HHS suspected or unwell → Same-day hospital, 999 if very unwell. HbA1c does not exclude an acute emergency.
- Very high TG can mask pancreatitis: a normal amylase or lipase does not exclude it when the picture fits — the hospital team decides.
1Triage by TG level — no pain or vomiting (NICE NG238)
| TG (mmol/L) | Action |
|---|---|
| <4.5 | Assess overall CVD risk; manage LDL-C/non-HDL-C, usually with a statin where indicated. Routine |
| 4.5–9.9 | Fasting repeat if non-fasting or LDL-C unreliable; find secondary causes; risk tools may underestimate CVD risk. Non-HDL-C >7.5 → specialist advice. |
| 10–20 | Review secondary causes urgently; fasting repeat after 5 days but within 2 weeks. Still >10 → specialist advice. |
| >20 | Not explained by excess alcohol or poor glycaemic control → Urgent specialist review |
2Screen — one row is enough
- Chylomicronaemia: fasting TG >20 + eruptive xanthomata, lipaemia retinalis or recurrent pancreatitis → Urgent specialist lipid assessment. Never manage solely in primary care.
- Milky (lipaemic) sample: TG almost certainly >10 → repeat; symptomatic → Same-day assessment
- Nephrotic syndrome (heavy proteinuria, oedema, low albumin), any TG → Urgent nephrology discussion; severe oedema, AKI, thrombosis, infection or instability → Same-day hospital
- Pregnancy: TG can reach pancreatitis-risk levels → obstetric and lipid-specialist co-management.
- Previous TG-induced pancreatitis: specialist-agreed target; alcohol abstinence; steatorrhoea → gastroenterology.
3Assess — secondary causes first
☐ Alcohol units (AUDIT-C), sugary drinks, weight, diabetes symptoms, family history of premature CVD or pancreatitis ☐ Drugs: corticosteroids, thiazides, beta-blockers, isotretinoin, PI antiretrovirals, oestrogen (OCP/HRT) ☐ BMI, waist, BP, xanthomata, fundi ☐ Lipids (fasting if TG ≥4.5), HbA1c + fasting glucose, TSH, LFTs + GGT, renal function + urinalysis
TG >4.5: calculated LDL-C is unreliable — use non-HDL-C. ApoB is not routine in primary care.
4Classify — only once blocks 0–2 are answered
- Secondary (most common) — uncontrolled diabetes, hypothyroidism, obesity, alcohol, CKD, nephrotic syndrome, pregnancy, drugs → treat the cause, then recheck TG.
- Metabolic syndrome — central obesity, low HDL, raised BP or glucose → lifestyle first.
- Familial — hypertriglyceridaemia (TG usually 3–10) or combined hyperlipidaemia (TG and LDL raised; family history of premature CVD → lipid clinic).
- Chylomicronaemia (familial or multifactorial) — TG >20, pancreatitis → specialist (block 2).
- Uncertain — unexpected or discordant result → fasting repeat; act on the confirmed band in block 1.
5Treat today — doses: SPC, local formulary
- Lifestyle: no sugary drinks or fruit juice, less refined carbohydrate; avoid or cut alcohol (abstain if TG severely raised or after pancreatitis); weight loss; regular aerobic activity. TG >10 → specialist-directed low-fat diet with a dietitian.
- CVD risk: statin first for LDL-C/non-HDL-C. Do not routinely prescribe a fibrate solely for CVD prevention.
- Fenofibrate: only on specialist advice for persistent or severe TG; renal function and LFTs first; avoid in severe renal impairment and pregnancy. Never gemfibrozil with a statin.
- Icosapent ethyl 2 g twice daily: consider only within TA805 — established CVD, on a statin, fasting TG ≥1.7, LDL-C >1.04 to ≤2.60; review AF and bleeding risk.
6Refer routinely
- Specialist advice: TG still >10 on fasting repeat; TG 4.5–9.9 with non-HDL-C >7.5 mmol/L.
- Dietitian: TG >10, recurrent pancreatitis, suspected chylomicronaemia, pregnancy, significant diabetes or renal disease.
- Lipid clinic: mixed dyslipidaemia with QRISK3 >10% and uncertain cause; suspected familial combined hyperlipidaemia.
7Never reassure by
- A normal amylase or lipase when TG is very high and the picture fits pancreatitis.
- A TG below 10 mmol/L in a patient with pain and vomiting.
- A normal calculated LDL-C when TG is >4.5 mmol/L.
- A low QRISK3 in mixed dyslipidaemia or metabolic syndrome.
- A normal HbA1c in an acutely unwell, vomiting patient.
- Oily fish or over-the-counter fish oil as treatment for severe TG.
8Safety-net — say it, then document it
999 “Severe pain in the centre or top of your tummy, or being sick — call 999 or go to A&E. Don't wait for the repeat blood test.” Same day: “Very thirsty, passing a lot of urine, losing weight or feeling unwell — contact us today for a sugar and ketone check.”
TG >10: explain pancreatitis risk, triggers (alcohol, high-fat meals, uncontrolled diabetes) and book the fasting repeat. Remote or OOH: any TG with abdominal pain or vomiting → same-day hospital assessment, not a repeat test.
✓Safe to leave primary care only if — all five, documented
No pain, vomiting or acute illness (block 0)
Glucose and ketones checked if symptomatic
TG band set; fasting repeat booked if 10–20
Secondary causes, CVD risk and non-HDL-C reviewed
Pancreatitis safety-net given; specialist route chosen
Summary of the full Reasoning GP high triglycerides algorithm, which holds the detail, causes, drug cautions and evidence. Sources: NICE NG238, NG104, TA805, HST13; fenofibrate and Vazkepa SPCs; MHRA; local formulary. Clinical reference — follow local lipid pathways and check doses in the SPC and your local formulary.