Rationale for prescription omega-3-acid ethyl ester therapy for hypertriglyceridemia: a primer for clinicians

Very high triglyceride (TG) levels may cause pancreatitis. Elevated TG levels are also often, but not always, a risk factor for atherosclerotic coronary heart disease. Omega-3 fatty acids are polyunsaturated fatty acids found in the oil of fish and other seafood that, when consumed, lower TG levels and reduce the risk of cardiovascular events. Prescription omega-3-acid (P-OM3) ethyl ester is a fish oil formulation that has undergone the rigorous regulatory steps required to obtain US Food and Drug Administration approval as a prescription drug. P-OM3 is derived from marine fish, which are high in omega-3 fatty acids. While omega-3 fatty acids may sometimes increase low- density lipoprotein cholesterol (LDL-C) levels in hypertriglyceridemic patients, non-high-density lipoprotein cholesterol (non-HDL-C) levels are often decreased. This has clinical significance because: 1) non-HDL-C sums the cholesterol carried by atherogenic lipoproteins beyond that of LDL-C alone; 2) non-HDL-C is a better predictor of atherogenic risk compared to LDL-C alone; and 3) after LDL-C treatment goals have been reached, non-HDL-C is a recommended secondary lipid treatment target in patients with persistent TG > or = 200 mg/dl. This paper reviews the U.S. treatment indications for P-OM3, clinical evaluation of hypertriglyceridemic patients, importance of elevated TG levels, relevant TG biochemistry and metabolism, illustrative genetic dyslipidemias, lipid treatment recommendations, fat and fatty acid biochemistry, omega-3 fatty acid biochemistry, and the basis behind recommending omega-3 fatty acids to reduce cardiovascular risk. Finally, this review examines P-OM3's lipid and cardiovascular effects, safety, and tolerability, as well as its practical role in patient management.