Metabolic syndrome medical therapy


 * Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [mailto:psingh@perfuse.org]

Overview
Metabolic syndrome is formed by a constellation of medical disorders that increases one's risk for cardiovascular disease and diabetes. It effects a large number of people in a clustered fashion. Management of metabolic syndrome involves dietary modifications, exercise and drug therapy for the complications (diabetes, stroke, angina, myocardial infarction) found associated with these conditions.

Treatment

 * The first line treatment is change of lifestyle (i.e., caloric restriction, physical activity, weight loss). However, drug treatment is frequently required for complications that are seen with them.

Hypertension

 * BP goal- 140/90 or 130/80 in diabetics (JNC 7 guidelines).
 * Angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) should be preferred over diuretics or beta-blockers in these patients.

Elevated low-density lipoprotein cholesterol (LDL-C)

 * The goal is to get the LDL down to < 100 mg/dl.
 * Statins are drug of choice.
 * Statins are however contraindicated in pregnancy.

Decreased high-density lipoprotein cholesterol (HDL-C)

 * Diet (decreased calorie intakes)
 * Increased physical activity
 * Niacin
 * Cholesteryl ester transfer protein (CETP) inhibitors (torcetrapib) and (anacetrapib) are currently investigational agents and the clinical benefits associated with the documented raising of HDL levels are unproven.

Elevated Triglycerides

 * Fibric acid
 * Niacin (however at higher doses (>1500 mg/d) it may exacerbate hyperglycemia)
 * Addition of omega-3 fatty acids also produces beneficial effects.

Diabetes

 * Use of drugs that decrease insulin resistance e.g., metformin . Use of thiazolidinediones is controversial and not FDA approved.

Cardiovascular risk

 * Aspirin therapy may be helpful in the primary prevention of cardiovascular complications.

Trial supportive data
===Study on the effects of metformin and life-style changes on the incidence of metabolic syndrome === 1) Source & year - Ann Intern Med. 2005

2) Study question – The effect of intensive lifestyle intervention and metformin therapy on the syndrome's incidence and resolution

3) Study design – Randomized controlled trial

4) Study Population – 1711 participants

5) Study period – 3.2 years

6) Interventions - Metformin, 850 mg twice daily, or intensive lifestyle intervention designed to achieve and maintain a 7% weight loss and 150 minutes of exercise per week.

7) Study results –
 * 53% of participants (n = 1711) had metabolic syndrome at baseline
 * Results of Log-rank test
 * Incidence of the metabolic syndrome was reduced by 41% in the lifestyle group (P < 0.001) and by 17% in the metformin group (P = 0.03) compared with placebo.
 * 3year cumulative incidences were 51%, 45%, and 34% in the placebo, metformin, and lifestyle groups, respectively.

8) Study conclusion - Lifestyle intervention and metformin therapy reduces the development of metabolic syndrome.