Treatment of metabolic syndrome

There is no generally accepted algorithm for the treatment of metabolic syndrome. The main goal of the treatment is the normalization of metabolic disorders. The recommended algorithm of treatment requires, first of all, weight reduction of 10-15% of the initial, which is an affective agent in the fight against insulin resistance.

Diet in 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 daily calorie intake. It is necessary to exclude digestible carbohydrates, to increase the intake of foods containing hard-to-digest carbohydrates (starch) and non-digestible carbohydrates (dietary fibers).

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Treatment of obesity

Pharmacotherapy of obesity within the metabolic syndrome can begin with a BMI> 27 kg / m2:

• Orlistat - inside before, during or after the main meals 120 mg 3 r / day. Not more than 2 years or
• Sibutramine inside, regardless of food intake, 10 mg 1 p / day (with a decrease in body weight of less than 2 kg during the first 4 weeks of treatment, the dose is increased to 15 mg 1 p / day), not more than 1 year.

Therapy with hypoglycemic drugs

Before the beginning of pharmacotherapy, or along with it, a low-calorie diet is prescribed and a physical exercise regime is selected.

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

1. Acarbose inside with the first gulp of food: 50-100 mg 3 r / day, long, or
2. Metformin inside before breakfast and sleep: 850-1000 mg 2 r / day, long, or
3. Pioglitazone inside, regardless of food intake, 30 mg 1 p / day, long.

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

The effect of acarbose depends on the dose: the higher the dose of the drug, the less carbohydrates are split and absorbed into the small intestine. Begin treatment with a minimum dose of 25 mg and after 2-3 days increase it to 50 mg, and then to 100 mg. In this case, it is possible to avoid the development of side affects.

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

Therapy of dyslipidemia

Treatment of dyslipidemia in the metabolic syndrome includes the fight against insulin resistance, the prevention of the development of concomitant diseases, as well as symptomatic therapy that involves lifestyle changes and the use of anti-lipidemic drugs.

Activities aimed at improving the metabolism of lipids in metabolic syndrome:

• decreased body weight;
• restriction of consumption of easily assimilated carbohydrates;
• limiting the intake of polyunsaturated fats;
• optimization of blood glucose control,
• stopping the use of drugs that can aggravate the violation of lipid metabolism:
  • diuretics;
  • nonselective beta-blockers;
  • drugs with androgenic affect
  • probucol;
  • contraceptive drugs;
• increased physical activity
• cessation of smoking;
• hormone replacement therapy with estrogens in the postmenopausal period.

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

1. Atorvastatin calcium inside, regardless of food intake, 10-80 mg, 1 p / day, prolonged or
2. Simvastatin in the evening, regardless of food intake, 5-80 mg, 1 p / day, long.

In the metabolic syndrome with a predominant increase in the level of triglycerides, it is recommended to use fibrates of the third generation (gemfibrozil). By reducing the synthesis of triglycerides in the liver by inhibiting the synthesis of LDL, gemfibrozil increases peripheral sensitivity to insulin. In addition, it has a beneficial effect on the fibrinolytic activity of the blood, disturbed by the metabolic syndrome:

1. Gemfibrozil inside morning and evening for 30 minutes before meals 600 mg 2 p / day, long.

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

1. Fenofibrate (micronized) inside during one of the main meals of 200 mg 1 p / day, long.

Hypotensive therapy

The treatment of arterial hypertension in the metabolic syndrome is identical to the treatment of arterial hypertension in type 2 diabetes mellitus. Pharmacotherapy should be started in the absence of the effect of changing the patient's lifestyle. At present, ACE inhibitors and angiotensin receptor blockers are recognized as the drug of choice (the dosage is selected individually under the control of blood pressure). The target level of arterial pressure in the metabolic syndrome is 130/80 mm Hg. Art. To reach the target level, many patients have to prescribe at least two drugs. Thus, with the inefficiency of monotherapy with ACE inhibitors or angiotensin receptor blockers, it is advisable to add a thiazide diuretic (in low doses and with caution) or a calcium antagonist (preference is given to prolonged forms). With tachycardia, extrasystole or arrhythmia, cardioselective beta-blockers are also used.

Evaluation of the effectiveness of treatment of metabolic syndrome

The effectiveness of the treatment of the metabolic syndrome is estimated by indicators of blood pressure, glucose and uric acid in the blood serum, lipid profile, decreased BMI. Women of reproductive age are additionally paid attention to the restoration of the menstrual cycle.

[12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]

Complications and side effects of treatment of metabolic syndrome

When using hypoglycemic drugs in women with insulin resistance and anovulatory cycle, the onset of ovulation and pregnancy is possible. The patient should be warned about this and, if necessary, choose a method of contraception.

Despite the fact that lactate acidosis with metformin therapy is extremely rare, it is necessary to strictly take into account all contraindications to the appointment 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 when pain or weakness occurs with the muscles, accompanied by general malaise or fever.

[23], [24], [25], [26], [27], [28], [29], [30]

Errors and unreasonable appointments

When gout should be avoided as far as possible diuretics.

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

[31], [32], [33], [34], [35]

Forecast

With a comprehensive approach to the treatment of metabolic syndrome (taking into account lifestyle changes), the outlook is favorable.

If the correct way of life is not observed (rational nutrition, exercise complex) and drug treatment, there is a high risk of developing myocardial infarction, stroke, type 2 diabetes and diabetic complications, musculoskeletal disorders, pulmonary heart failure, sleep apnea.

[36], [37], [38], [39], [40], [41], [42], [43]