Metabolic syndrome medical therapy

Metabolic syndrome is formed by a constellation of medical disorders that increases the risk of developing cardiovascular disease and diabetes mellitus. It affects 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.

• The first line of treatment is a change of lifestyle (i.e, caloric restriction, physical activity, weight loss). However, drug treatment is frequently required to prevent complications of metabolic syndrome.^[1]

• 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.^[2]

• The goal is to get the LDL down to < 100 mg/dl.
• Statins are the drugs of choice.
• However, statins are contraindicated in pregnancy.

• 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.

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

• Use of drugs that decrease insulin resistance e.g., metformin.^{[1] [4]} Use of thiazolidinediones is controversial and not FDA approved.^[5]

• Aspirin therapy may be helpful in the primary prevention of cardiovascular complications.^[6]

• SOURCE and YEAR: Ann Intern Med. 2005

• OBJECTIVE: The effect of intensive lifestyle intervention and metformin therapy on the syndrome’s incidence and resolution

• METHOD: Randomized controlled trial

• STUDY POPULATION: 1711 participants

• STUDY PERIOD: 3.2 years

• 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.

• 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.
  • 3 year cumulative incidences were 51%, 45%, and 34% in the placebo, metformin, and lifestyle groups, respectively.

• CONCLUSION: Lifestyle intervention and metformin therapy reduces the development of metabolic syndrome.

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