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  • Metabolic Syndrome: When to Add Pharmacological Treatment

    Metabolic syndrome is a group of risk factors (linked to insulin resistance and adipose tissue dysfunction) that increases the risk for coronary heart disease, type 2 diabetes, stroke, fatty liver, and cancer. Although guidelines are available, metabolic syndrome remains underdiagnosed; therefore, we should aim for early diagnosis and interventions targeting risk reduction. Metabolic syndrome can manifest in a number of ways, including abdominal obesity, reduced HDL cholesterol, hypertriglyceridemia, hyperglycemia, and hypertension. Patients may experience chest pain or shortness of breath, which can suggest there is a rise of cardiovascular and other complications; acanthosis nigricans, hirsutism, peripheral neuropathy, and retinopathy can appear in patients with insulin resistance and hyperglycemia or with diabetes mellitus; and xanthomas or xanthelasmas can occur in patients with severe dyslipidemia.

    According to the guidelines from the National Heart, Lung, and Blood Institute and the American Heart Association, patients should have at least three out of five risk factors to be diagnosed with metabolic syndrome:

    • Fasting glucose ≥100 mg/dL (or receiving drug therapy for hyperglycemia)
    • Blood pressure ≥130/85 mmHg (or receiving drug therapy for hypertension)
    • TGs ≥150 mg/dL (or receiving drug therapy for hypertriglyceridemia)
    • HDL cholesterol <40 mg/dL in men or <50 mg/dL in women (or receiving drug therapy for reduced HDL cholesterol)
    • Waist circumference ≥102 cm (40 in) in men or ≥88 cm (35 in) in women; if Asian American, ≥90 cm (35 in) in men or ≥80 cm (32 in) in women

    Treatment of metabolic syndrome requires a multidisciplinary team, including physicians, nutritionists, and health educators. Changes in diet and exercise habits are the initial means for treating metabolic syndrome, but when lifestyle modifications fail, pharmacological treatment may be needed:

    • Cholesterol
      • Statins: For high LDL cholesterol levels
      • Niacin: Consider for low HDL cholesterol
      • Fibrates: Consider as adjunct in overweight patients with high TG levels and low HDL cholesterol
      • Niacin and fibrates: Consider for high TGs when lifestyle changes are not effective
    • Hyperglycemia
      • Metformin: Insulin-sensitizing agent; data show that metformin can be used with peroxisome proliferator-activated receptor agonists (fibrates and thiazolidinediones) and lifestyle changes to reverse pathophysiologic changes of metabolic syndrome
    • Preventive cardiovascular treatment
      • Aspirin: Might be helpful in the primary prevention of cardiovascular complications in a subset of individuals
    • High blood pressure
      • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: Can be prescribed (in addition to lifestyle modifications) to aim for a blood pressure of <130/80 mmHg in patients with an augmented intermediate risk (10-year risk, ≥6%)

    Labeling information on thousands of drugs, including those used as to address metabolic syndrome, is available on PDR.net. Please update or register your PDR profile to receive alerts and other critical drug information from PDR via email. Also, look for information from PDR within your eRx workflow. Drug safety information, updates about dosing and formulary, patient support programs, and savings opportunities display on your screen as you prescribe, at no cost to you or your patients. To learn more about PDR services in your eRx/EMR/EHR workflow, email us at EHR-info@PDR.net.

    Salvatore Volpe, MD, FAAP, FACP, CHCQM
    Chief Medical Officer