How much fish oil should i take for high triglycerides

Approximately 27 percent of adult Americans have elevated (≥ 150 mg/ dL) fasting triglycerides (TG).1 This commonly encountered dyslipidemia is an important indicator of the presence of atherogenic lipoprotein particles and may be considered a modifiable risk factor for cardiovascular disease.2 While genetic defects are responsible for familial forms of hypertriglyceridemia, secondary causes of hypertriglyceridemia often can be attributed to dietary factors (e.g. very low-fat diets, overconsumption of simple carbohydrates, excessive alcohol intake), medications (e.g. oral estrogen, glucocorticoids, protease inhibitors) and certain disease states that alter lipid metabolism (e.g. nephrotic syndrome, metabolic syndrome, uncontrolled diabetes, hypothyroidism, obesity).3 These secondary causes should be addressed prior to or in conjunction with the implementation of corrective therapy (e.g. omega-3 fatty acids (n-3 FA), fibrates, niacin).

Marine-derived n-3 FA (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]), otherwise known as “fish oil,” generally is devoid of clinically important drug interactions and represents an effective means to help correct alterations in TG production and metabolism.4,5

In general, a total daily dose of 1 gram of EPA and/or DHA can be expected to result in a 5 to 10 percent lowering of TG.2 Several manufacturers market OTC fish oil supplements of varying quality, so clinicians should encourage patients to use United States Pharmacopeia (USP) verified formulations that assure purity and potency. In the past, the most commonly marketed dose of OTC fish oil contained only 300 mg of combined DHA plus EPA per capsule,9 thus requiring in excess of nine capsules a day to achieve clinically meaningful results. Fortunately, highly concentrated “double- or triple- strength” formulations are now widely available, generally contain 684–900 mg of combined DHA plus EPA per capsule, and sell in the range of $10 to $15 per bottle. (Table 1) It may be helpful to initiate therapy at two capsules daily and titrate to effect as tolerated. For patients who have difficulty swallowing large capsules, highly concentrated liquid formulations are available, albeit at an increased cost.

The 2013 American College of Cardiology/ American Heart Association (ACC/AHA) guideline on the treatment of blood cholesterol recommends that clinicians evaluate patients for gastrointestinal disturbances when EPA and/or DHA are used for the management of severe hypertriglyceridemia.3 Eructation, with a fishy aftertaste, and dyspepsia are common side effects reported by patients taking fish oil supplements. Fishy aftertaste may be minimized by storing capsules in the freezer or using enteric- coated formulations10 to help prevent capsule dissolution in the esophagus and stomach, thereby minimizing belches. Of note, the manufacturers of prescription formulations recommend storage at room temperature.6,7 Other strategies to help improve tolerability include taking fish oil prior to meals or at bedtime or using flavored formulations.

Patients may inquire about krill oil because of the reported lack of fishy aftertaste, smaller capsule size and potential for lower pill burden since krill oil may have better bioavailability than fish oil.11

Unfortunately, few studies have compared krill oil to fish oil for TG lowering.  A single study compared varying doses (1–3 gm/d) of a specific krill oil formulation (unspecified amount of DHA/EPA) to standard fish oil (900 mg/d of DHA/EPA).  A significant reduction in TG (~28 percent) was reported with 2–3 gm/d of krill oil as compared to a non-significant 3.2 percent reduction with fish oil.12 Alternatively, Ulven et al. reported comparable TG lowering between krill oil (543 mg/d DHA/ EPA) and fish oil (864 mg/d DHA/EPA).13 More studies are needed to determine how krill oil compares to fish oil, especially when administered in equipotent doses.

Shellfish allergies do not preclude the use of fish oil, although safety in this patient population has not been established.

Our experience has been that such patients tend to be hesitant out of fear of experiencing allergic reactions. One option clinicians have is to consider n-3 FA products derived from algae sources. Disadvantages are that these products are not as readily available and tend to be costly. Krill oil should be avoided in those with shellfish allergies, because it contains a shellfish allergen.14

The collective clinical experience of our practice has been that omega-3 fish oil is a cost-effective means by which to treat elevated triglycerides. Educating patients on how to read product labels, focusing on the amount of EPA and/or DHA content per capsule rather than the amount of fish oil concentrate, helps to ensure that adequate doses of omega-3 fatty acids are employed. Adherence to therapy should be assessed at each lipid panel review and verification of appropriate dose/formulation should be documented whenever feasible.

Disclosure statement: There are no disclosures to report.

References are listed on page 34 of the PDF.

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