Metabolic syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]

Overview

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

Medical Therapy

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

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.

Supportive Trial Data

Study on the effects of metformin and life-style changes on the incidence of metabolic syndrome

• 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.
  • 3year 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.