Class: Antilipemic Agents, Miscellaneous
VA Class: CV350
Chemical Name: EPA ethyl ester: (all-Z)-5,8,11,14,17-Eicosapentaenoic acid ethyl ester. DHA ethyl ester: (all-Z)-4,7,10,13,16,19-Docosahexaenoic acid ethyl ester.
Molecular Formula: EPA ethyl ester: C22H34O2. DHA ethyl ester: C24H36O2
CAS Number: 86227-47-6
Brands: Lovaza, Omtryg
Medically reviewed on November 6, 2017
Uses for Omega-3-acid Ethyl Esters
Adjunct to dietary therapy to reduce triglyceride concentrations in adults with severe hypertriglyceridemia (triglyceride concentration ≥500 mg/dL).1 2 8 16 Efficacy in reducing risk of pancreatitis or risk of cardiovascular morbidity or mortality in these patients not established.1 2 8 16
Has been used as monotherapy to reduce high (200–499 mg/dL) triglyceride concentrations† in adults.2 13 However, because most of these patients are expected to receive statins as initial therapy,2 4 some experts state that efficacy should be further evaluated in patients receiving concomitant statin therapy.2 Preliminary data indicate additive effects on reduction of triglyceride and VLDL-cholesterol concentrations when used with statins.2 8 9 13 14 15
Prevention of Cardiovascular Events
ACC/AHA cholesterol guideline states that nonstatin drugs (e.g., omega-3-acid ethyl esters) do not provide acceptable atherosclerotic cardiovascular disease (ASCVD) risk reduction benefits compared to their potential for adverse effects in the routine prevention of ASCVD.350 May be useful as adjuncts to statin therapy in high-risk patients (e.g., patients with ASCVD, LDL-cholesterol concentrations ≥190 mg/dL, or diabetes mellitus) who have a less-than-anticipated response to statins, are unable to tolerate even a less-than-recommended intensity of a statin, or are completely intolerant to statin therapy.350 Select nonstatin drug based on favorable benefit-risk ratio (i.e., demonstrated benefit of ASCVD risk reduction outweighs risks of adverse effects and drug interactions) and patient preferences.350
Omega-3-acid Ethyl Esters Dosage and Administration
Omtryg: 4.8 g daily as a single dose or in 2 equally divided doses.16
Prevention of Cardiovascular Events
For primary prevention†, AHA suggests consumption of a variety of fish (preferably fatty fish such as herring, mackerel, salmon, sardines, or tuna) at least twice weekly and inclusion of oils and foods rich in α-linolenic acid (e.g., canola/flaxseed/soybean oils, flaxseeds, English walnuts) in diet.3
For secondary prevention†, AHA suggests consumption of approximately 1 g of a combination of EPA and DHA daily, preferably through dietary means (i.e., consumption of fatty fish); if intake cannot be achieved with diet alone, may consider supplements, but only in consultation with a clinician.3
Third Report of the National Cholesterol Education Program (NCEP) (Adult Treatment Panel [ATP] III) did not recommend specific amount of omega-3 fatty acids for daily intake but does support AHA's recommendation to include fish in diet.4 Higher dietary intakes (1–2 g daily) identified by ATP III as an option for secondary prevention, but more definitive clinical trials required before such high dosages can be strongly recommended for either primary or secondary prevention.4
No special population recommendations at this time.13
Cautions for Omega-3-acid Ethyl Esters
Obtained from the oil of several fish sources.1 16 Not known whether patients with hypersensitivity to fish and/or shellfish are at increased risk of allergic reactions; therefore, use with caution in such patients.1 13 16
Increases in ALT concentrations without a concurrent increase in AST concentrations reported in some patients.1 16 Monitor ALT and AST concentrations periodically during therapy in patients with hepatic impairment.1 16
Recurrent Atrial Fibrillation or Flutter
Recurrent atrial fibrillation or flutter reported in patients with symptomatic paroxysmal or persistent atrial fibrillation receiving omega-3-acid ethyl esters.1 16 17 Clinical importance unknown; however, possible association between use of the drug and more frequent recurrences of symptomatic atrial fibrillation or flutter in such patients, especially within 2–3 months of initiation of therapy.1 16
Prior to initiating therapy, evaluate lipoprotein profiles to confirm the presence of persistent hypertriglyceridemia.1 13 16 During therapy, obtain lipoprotein profiles periodically to monitor clinical response (i.e., reduction in triglyceride concentrations) or adverse effects (i.e., excessive increases in LDL-cholesterol concentrations).1 16
Prior to initiating therapy, vigorously attempt to control serum triglyceride concentrations with appropriate dietary regimens, exercise, weight reduction, and treatment of any underlying disorder that might be the cause of triglyceride abnormalities (e.g., diabetes mellitus, hypothyroidism).1 16
Prolongation of Bleeding Time
Prolongation of bleeding time observed with omega-3 fatty acids;1 10 however, such prolongation has not exceeded normal limits and was not associated with clinically important bleeding episodes.1 16 Blood testing is not required; however, monitor patients for manifestations of bleeding prior to and during therapy.13 350 (See Interactions.)
Common Adverse Effects
Interactions for Omega-3-acid Ethyl Esters
Drugs Affecting Coagulation
Drugs Metabolized by Hepatic Microsomal Enzymes
Free forms of EPA and DHA cause modest inhibition of CYP isoenzymes 1A2, 2A6, 2C9, 2C19, 2D6, 2E1, and 3A in vitro.2 13 However, because free forms of EPA and DHA are undetectable in systemic circulation (<1 µM), clinically important interactions with drugs metabolized by the CYP enzyme system not expected to occur in humans.1 2 16
HMG-CoA reductase inhibitors (statins) (i.e., atorvastatin, rosuvastatin, simvastatin)
Omega-3-acid Ethyl Esters Pharmacokinetics
Following oral administration of Omtryg capsules under fasted conditions, peak concentration or AUC of total plasma EPA decreased by 20- or 80-fold, respectively, and peak concentration or AUC of total plasma DHA decreased by 2- or 4-fold, respectively, compared with administration under fed conditions (with a high-fat, high-calorie meal).16
Oral administration of omega-3-acid ethyl esters results in substantial, dose-dependent increases in EPA content in serum phospholipids and less substantial, non-dose-dependent increases in DHA content.1 9 16
EPA and DHA, collectively known as marine-derived omega-3 fatty acids (n-3 fatty acids), are long-chain, polyunsaturated fatty acids (PUFAs) obtained primarily from marine sources such as fatty fish (e.g., herring, mackerel, salmon, sardines, tuna).3 10 12
Mechanism of action not completely understood; may inhibit diacylglycerol O-acyltransferase, increase mitochondrial and peroxisomal β-oxidation in the liver, decrease lipogenesis in the liver, and increase plasma lipoprotein lipase activity.1 2 16
Advice to Patients
Importance of taking Omtryg capsules with meals.16
Importance of taking omega-3-acid ethyl esters as prescribed.1 16 If a dose is missed, take the dose as soon as it is remembered.1 16 If one day of omega-3-acid ethyl esters therapy is missed, do not double the dose.1 16
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Omega-3-acid Ethyl Esters Capsules
AHFS DI Essentials. © Copyright 2018, Selected Revisions November 6, 2014. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
1. GlaxoSmithKline. Lovaza (omega-3-acid ethyl esters) capsules prescribing information. Research Triangle Park, NC; 2014 May.
2. Reliant Pharmaceuticals, Inc. Omacor (omega-3-acid ethyl esters) formulary dossier. Liberty Corner, NJ; 2005 Aug 28.
3. Kris-Etherton PM, Harris WS, Appel LJ et al. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. An American Heart Association Scientific Statement from the Nutrition Committee. Circulation. 2002; 106:2747-57. http://www.ncbi.nlm.nih.gov/pubmed/12438303?dopt=AbstractPlus
4. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Adult Treatment Panel III Report. From AHA web site. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm
5. Hooper L, Thompson RL, Harrison RA et al. Omega 3 fatty acids for prevention and treatment of cardiovascular disease (Cochrane Review). In: The Cochrane Library. Issue 2, 2005. Chichester, UK: John Wiley & Sons, Ltd.
6. Harris WS, Ginsberg HN, Arunakul N et al. Safety and efficacy of Omacor in severe hypertriglyceridemia. J Cardiovasc Risk. 1997; 4:385-91. http://www.ncbi.nlm.nih.gov/pubmed/9865671?dopt=AbstractPlus
7. Pownall HJ, Brauchi D, Kilinc C et al. Correlation of serum triglyceride and its reduction by omega-3 fatty acids with lipid transfer activity and the neutral lipid compositions of high-density and low-density lipoproteins. Atherosclerosis. 1999;143:285-97.
8. Anon. Omega-3 polyunsaturated fatty acids (Omacor) for hypertriglyceridemia. Med Lett Drugs Ther. 2005; 47:91-2. http://www.ncbi.nlm.nih.gov/pubmed/16267495?dopt=AbstractPlus
9. Durrington PN, Bhatnagar D, Mackness MI et all. An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia. Heart. 2001; 85:544-8. http://www.ncbi.nlm.nih.gov/pubmed/11303007?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1729738&blobtype=pdf
10. Stone NJ. Fish Consumption, fish oil, lipids, and coronary heart disease. An American Heart Association Science Advisory from the Nutrition Committee. Circulation. 1996; 94:2337-40. http://www.ncbi.nlm.nih.gov/pubmed/8901708?dopt=AbstractPlus
11. Studer M, Briel M, Leimenstoll B et al. Effect of different antilipidemic agents and diets on mortality. Arch Intern Med. 2005; 165:725-30. http://www.ncbi.nlm.nih.gov/pubmed/15824290?dopt=AbstractPlus
12. Harris WS. Fish oil supplementation: evidence for health benefits. Cleve Clin J Med. 2004;71:208-10, 212, 215-8.
13. Reliant Pharmaceuticals, Liberty Corners, NJ: Personal communication.
14. Chan DC, Watts GF, Barrett PHR et al. Regulatory effects of HMG CoA reductase inhibitor and fish oils on apolipoprotien B-100 kinetics in insulin-resistant obese male subjects with dyslipidemia. Diabetes. 2002; 51:2377-86. http://www.ncbi.nlm.nih.gov/pubmed/12145148?dopt=AbstractPlus
15. Nordoy A, Bonaa KH, Nilsen H et al. Effects of simvastatin and omega-3 fatty acids on plasma lipoproteins and lipid peroxidation in patients with combined hyperlipidemia. J Intern Med. 1998; 243:163-70. http://www.ncbi.nlm.nih.gov/pubmed/9566646?dopt=AbstractPlus
16. Trygg Pharma Inc. Omtryg (omega-3-acid ethyl esters) capsules prescribing information. Arlington, VA; 2014 Apr.
17. Kowey PR, Reiffel JA, Ellenbogen KA et al. Efficacy and safety of prescription omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: a randomized controlled trial. JAMA. 2010; 304:2363-72. http://www.ncbi.nlm.nih.gov/pubmed/21078810?dopt=AbstractPlus
350. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; :. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
352. Eckel RH, Jakicic JM, Ard JD et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63:2960-84. http://www.ncbi.nlm.nih.gov/pubmed/24239922?dopt=AbstractPlus
356. Miller M, Stone NJ, Ballantyne C et al. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011; 123:2292-333. http://www.ncbi.nlm.nih.gov/pubmed/21502576?dopt=AbstractPlus
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