Metabolic syndrome medical therapy
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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.
- 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 the drugs of choice.
- However, statins are contraindicated in pregnancy.
Decreased high-density lipoprotein cholesterol (HDL-C)
- Diet (decreased calorie intakes)
- Increased physical activity
- 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) 
- Addition of omega-3 fatty acids also produces beneficial effects.
- Use of drugs that decrease insulin resistance e.g., metformin.  Use of thiazolidinediones is controversial and not FDA approved.
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.
- 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.
- Orchard TJ, Temprosa M, Goldberg R; et al. (2005). "The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial". Annals of Internal Medicine. 142 (8): 611–9. PMC 2505046. PMID 15838067. Unknown parameter
- Suzuki T, Homma S (2007). "Treatment of hypertension and other cardiovascular risk factors in patients with metabolic syndrome". Med Clin North Am. 91 (6): 1211–23, x. doi:10.1016/j.mcna.2007.06.009. PMID 17964917.
- Ito MK (2004). "The metabolic syndrome: pathophysiology, clinical relevance, and use of niacin". Ann Pharmacother. 38 (2): 277–85. doi:10.1345/aph.1D218. PMID 14742767.
- "Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group". Lancet. 352 (9131): 854–65. 1998. PMID 9742977. Unknown parameter
- Nathan DM, Buse JB, Davidson MB; et al. (2006). "Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes". Diabetes Care. 29 (8): 1963–72. doi:10.2337/dc06-9912. PMID 16873813. Unknown parameter
- Smith JP, Haddad EV, Taylor MB; et al. (2012). "Suboptimal inhibition of platelet cyclooxygenase-1 by aspirin in metabolic syndrome". Hypertension. 59 (3): 719–25. doi:10.1161/HYPERTENSIONAHA.111.181404. PMC 3418792. PMID 22311905. Unknown parameter