Treatment of metabolic syndrome

There is no generally accepted algorithm for treating metabolic syndrome. The main goal of treatment is to normalize metabolic disorders. The recommended treatment algorithm requires, first of all, a weight loss of 10-15% of the initial weight, which is an effective means of combating insulin resistance.

Diet for metabolic syndrome

To achieve the goal, it is necessary to follow a low-calorie rational diet and perform a set of physical exercises. The proportion of fats should not exceed 25-30% of the daily calorie intake. It is necessary to exclude easily digestible carbohydrates, increase the consumption of products containing hard-to-digest carbohydrates (starch) and indigestible carbohydrates (dietary fiber).

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Treatment of obesity

Pharmacotherapy for obesity in the context of metabolic syndrome can be started at BMI > 27 kg/m2:

• Orlistat - orally before, during or after main meals 120 mg 3 times a day for no more than 2 years or
• Sibutramine orally, regardless of food intake, 10 mg once a day (if body weight decreases by less than 2 kg during the first 4 weeks of treatment, the dose is increased to 15 mg once a day), for no more than 1 year.

Therapy with hypoglycemic drugs

Before or alongside drug therapy, a low-calorie diet is prescribed and a physical activity regimen is selected.

Considering that the basis of the mechanism of development of metabolic syndrome is insulin resistance, the drugs of choice are hypoglycemic agents.

1. Acarbose orally with the first sip of food: 50-100 mg 3 times a day, long-term, or
2. Metformin orally before breakfast and bedtime: 850-1000 mg 2 times a day, long-term, or
3. Pioglitazone orally, regardless of food intake, 30 mg 1 time per day, long-term.

According to the established tradition in many countries, the average daily dose of metformin does not exceed 1000 mg, while the results of the UKPDS study recognized 2500 mg/day as an effective therapeutic dose of the drug in patients with type 2 diabetes. The maximum daily dose of metformin is 3000 mg. It is recommended to conduct metformin therapy with a gradual increase in the dose under the control of blood glucose levels.

The effect of acarbose depends on the dose: the higher the dose of the drug, the less carbohydrates are broken down and absorbed in the small intestine. Treatment should be started with a minimum dose of 25 mg and after 2-3 days increased to 50 mg, and then to 100 mg. In this case, the development of side effects can be avoided.

In the absence of the desired effect, alternative drugs should be used - sulfonylurea derivatives and insulin. It should be emphasized that these drugs can be prescribed for metabolic syndrome only in the case of decompensation of type 2 diabetes mellitus, despite the maximum doses of metformin and compliance with the diet and exercise regimen. Before deciding on the appointment of sulfonylurea derivatives or insulin, it is advisable to begin the combined use of metformin and acarbose or pioglitazone and rosiglitazone in the doses indicated above.

Therapy for dyslipidemia

Treatment of dyslipidemia in metabolic syndrome includes combating insulin resistance, preventing the development of concomitant diseases, as well as symptomatic therapy, which involves lifestyle changes and the use of antilipidemic drugs.

Activities aimed at improving lipid metabolism in metabolic syndrome:

• weight loss;
• limiting the consumption of easily digestible carbohydrates;
• limiting the consumption of polyunsaturated fats;
• Optimization of blood glucose control,
• discontinuation of medications that may worsen lipid metabolism disorders:
  • diuretics;
  • non-selective beta blockers;
  • drugs with androgenic effect
  • probucol;
  • contraceptive drugs;
• increasing physical activity
• smoking cessation;
• estrogen replacement hormone therapy in the postmenopausal period.

The drug of choice for metabolic syndrome with a predominant increase in TC and LDL are statins. Preference should be given to long-acting drugs, the effect of which is manifested in the case of using low doses. Almost all researchers consider them the drugs of choice in the treatment of lipid metabolism disorders in patients with type 2 diabetes. Treatment should be started with a minimum dose (5-10 mg), with a gradual increase and under control of blood cholesterol levels:

1. Atorvastatin calcium orally, regardless of food intake, 10-80 mg, 1 time per day, long-term or
2. Simvastatin orally in the evening, regardless of food intake, 5-80 mg, 1 time per day, long-term.

In metabolic syndrome with predominantly increased triglyceride levels, it is recommended to use third-generation fibrates (gemfibrozil). By reducing triglyceride synthesis in the liver and inhibiting LDL synthesis, gemfibrozil increases peripheral insulin sensitivity. In addition, it has a beneficial effect on the fibrinolytic activity of the blood, impaired in metabolic syndrome:

1. Gemfibrozil orally in the morning and evening 30 minutes before meals 600 mg 2 times a day, long-term.

In metabolic syndrome with dyslipidemia and hyperuricemia, the drug of choice is fenofibrate, which helps reduce the level of uric acid in the blood by 10-28%.

1. Fenofibrate (micronized) orally during one of the main meals 200 mg 1 time per day, long-term.

Antihypertensive therapy

Treatment of hypertension in metabolic syndrome is identical to treatment of hypertension in type 2 diabetes mellitus. Drug therapy should be started when lifestyle changes are ineffective; the drugs of choice are currently ACE inhibitors and angiotensin receptor blockers (the dosage is selected individually under blood pressure monitoring). The target blood pressure level in metabolic syndrome is 130/80 mm Hg. To achieve the target level, many patients have to be prescribed at least two drugs. Thus, if monotherapy with ACE inhibitors or angiotensin receptor blockers is ineffective, it is advisable to add a thiazide diuretic (in low doses and with caution) or a calcium antagonist (preference is given to prolonged forms). Cardioselective beta-blockers are also used for tachycardia, extrasystole or arrhythmia.

Evaluation of the effectiveness of treatment of metabolic syndrome

The effectiveness of metabolic syndrome treatment is assessed by blood pressure, serum glucose and uric acid levels, lipid profile, and BMI reduction. In women of reproductive age, additional attention is paid to the restoration of the menstrual cycle.

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Complications and side effects of metabolic syndrome treatment

When using hypoglycemic drugs in women with insulin resistance and anovulatory cycle, ovulation and pregnancy may occur. The patient should be warned about this and, if necessary, a contraceptive method should be selected.

Although lactic acidosis is extremely rare during metformin therapy, it is necessary to strictly take into account all contraindications to the use of this drug.

Pioglitazone should be used with caution in patients with edema.

When using acarbose, flatulence, gastrointestinal discomfort, and diarrhea often occur. To avoid such phenomena, it is recommended to start treatment with small doses.

The use of statins carries a certain risk of developing myopathy and rhabdomyolysis, so patients should immediately inform the doctor if they experience muscle pain or weakness accompanied by general malaise or fever.

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Errors and unjustified appointments

In gout, diuretics should be avoided whenever possible.

ACE inhibitors and angiotensin receptor blockers are not recommended for women planning pregnancy.

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Clinical guidelines for the management of metabolic syndrome

Clinical guidelines for managing metabolic syndrome may change over time, and they may differ by region and health care organization. Here are general principles for managing metabolic syndrome that are often recommended:

1. Lifestyle changes:

   • Diet: Review your diet to reduce saturated fat, trans fat, and sugar. Increase your intake of vegetables, fruits, whole grains, low-fat dairy, and protein. Limit salt and high-calorie snacks.
   • Physical activity: Try to maintain an active lifestyle. Moderate aerobic exercise and strength training can help control metabolic parameters.
   • Weight Loss: If you are overweight or obese, work on losing weight to achieve and maintain a healthy weight.
   • Healthy Sleep: Maintain a regular sleep schedule and try to get enough sleep (7-9 hours a night).

2. Drug therapy:

   • In some cases, your doctor may prescribe medications to lower your blood pressure, cholesterol, or blood sugar levels. The use of medications is decided on an individual basis.

3. Regular medical monitoring:

   • Visit your doctor to monitor your health and treatment effectiveness. Conduct recommended medical examinations and tests.

4. Giving up bad habits:

   • Stop smoking and limit or abstain from alcohol.

5. Stress Management:

   • Learn relaxation and stress management techniques such as meditation, yoga, or deep breathing.

6. Support and Lifestyle:

   • Get support from loved ones, friends, or professional counselors in managing stress and making lifestyle changes.

7. Individualized approach: Your metabolic syndrome management plan should be individually tailored to your needs and risks.

It’s important to discuss your metabolic syndrome management plan with your doctor, as treatment strategies may vary depending on your condition and risks. Your doctor will be able to provide you with the best recommendations and monitor your health over time.

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