Evidence-Based Reviews

Metabolic syndrome: 5 risk factors guide therapy

Current Psychiatry. 2005 April;4(4):73-88

References

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2. Isomma B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24:683-9.

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4. Lakka HM, Laaksonen DE, Lakka TA, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002;288:2709-16.

5. National Institutes of Health: Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults (Adult Treatment Panel III). Executive summary of the Third Report of the National Cholesterol Education Program (NCEP). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.

6. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care 2004;27:596-601.

7. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. National Institutes of Health. Obes Res 1998;6(suppl 2):51S-209S.

8. Darwin D. Metabolic syndrome: time for action. Am Fam Physician 2004;69:2875-82.

9. Maki KC. Fibrates for treatment of the metabolic syndrome. Curr Atheroscler Rep 2004;6:45-51.

10. Boden WE. Therapeutic implications of recent ATP III guidelines and the important role of combination therapy in total dyslipidemia management. Curr Opin Cardiol 2003;18:278-85.

11. Showers JR. Effects of statins on the vasculature: implications for aggressive lipid management in the cardiovascular metabolic syndrome. Am J Cardiol 2003;91(suppl):14B-22B.

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13. American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care 2003;26(suppl 1):S80-S82.

14. Derosa G, Cicero AF, Bertone G, et al. Comparison of the effects of telmisartan and nifedipine gastrointestinal therapeutic system on blood pressure control, glucose metabolism, and the lipid profile in patients with type 2 diabetes mellitus and mild hypertension: a 12-month, randomized double-blind study. Clin Ther 2004;26:1228-36.

15. Diabetes prevention program research group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

16. Buchanan T, Xiang A, Peters R, et al. Prevention of type 2 diabetes by treatment of insulin resistance: comparison of early vs. late in the TRIPOD study [abstract]. Diabetes 2002;51(suppl 2):A35.-

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18. Fagard RH. Exercise characteristics and blood pressure response to dynamic physical training. Med Sci Sports Exerc 2001;33(6 suppl):S484-S492.

19. Thompson PD, Crouse SF, Goodpaster B, et al. The acute versus the chronic response to exercise. Med Sci Sports Exerc 2001;33(6 suppl):S438-S445.

20. Katzmarzyk PT, Leon AS, Wilmore JH, et al. Targeting the metabolic syndrome with exercise: evidence from the HERITAGE Family Study. Med Sci Sports Exerc 2003;35:1703-9.

21. Littrell KH, Hilligoss NM, Kirshner CD, et al. The effects of an educational intervention on antipsychotic-induced weight gain. J Nurs Scholarsh 2003;35:237-41.

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Table 4

Atypical antipsychotics and their propensity for causing metabolic abnormalities

Drug	Weight gain	Hyperglycemia	Dyslipidemia
Clozapine	High	High	High
Olanzapine	High	High	High
Risperidone	Medium	Medium	Low
Quetiapine	Medium	Medium	High
Aripiprazole	Low	Low	Low
Ziprasidone	Low	Low	Low
Source: Reference 6

Targeted pharmacotherapy. Wait another 3 to 6 months to see if the medication change and weight loss/exercise interventions reduce metabolic risk factors. If they don’t, work with the patient’s primary care physician to manage hypertension, dyslipidemia, and obesity (Table 3).

Although no agents are approved for treating metabolic syndrome per se, medications targeted at individual symptoms are becoming the standard of care. Controlling blood pressure, HDL, and LDL in patients with metabolic syndrome can reduce risk for coronary heart disease by >50%.²⁵ Insulin-sensitizing agents and metformin in combination with lifestyle changes or used alone have been shown to delay onset of type 2 diabetes (Table 3).

CASE CONTINUED: 10 LBS IN 10 WEEKS

At her follow-up visit, Ms. S and her psychiatrist discuss her increased risk for diabetes and cardiovascular disease. She meets criteria for metabolic syndrome (low HDL, elevated blood pressure, and increased waist circumference).

Ms. S agrees to try a formal diet program with set menus, along with group support at her local community center. She also commits to walking 30 minutes three to four times a week with a target heart rate of 100 beats per minute. Although both quetiapine and lithium carry considerable risk of weight gain, she and her psychiatrist decide to wait at least 3 months before considering a medication change, as she is stable on this combination.

Ms. S schedules a follow-up visit with her primary care physician to ensure that she sticks to her weight loss and exercise programs. In the interim, the primary care physician and psychiatrist agree that her goal will be to lose 10 lbs over 10 weeks.

Related resources

National Alliance for the Mentally Ill. Hearts and Minds Program, a booklet and program geared toward raising awareness regarding diabetes, diet, exercise, and smoking. Download at www.nami.org.
Centers for Disease Control and Prevention: Body mass index formula for adults. http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-adult-formula.htm.
National Heart, Lung and Blood Institute body mass index calculator. http://www.nhlbisupport.com/bmi/bmicalc.htm.
Keck PE Jr, Buse JB, Dagago-Jack S, et al. Managing metabolic concerns in patients with severe mental illness. A special report. Postgraduate Med 2003;1-92.

Drug brand names

Aripiprazole • Abilify
Clozapine • Clozaril
Metformin • Glucophage
Olanzapine • Zyprexa
Orlistat • Xenical
Quetiapine • Seroquel
Risperidone • Risperdal
Sibutramine • Meridia
Ziprasidone • Geodon

Disclosure

Dr. Bermudes is a speaker for Bristol-Myers Squibb Co. and Pfizer Inc.