Current Issue - 2006, Volume 1 Number 2 & 3

CASE REPORTS

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A CASE OF METABOLIC SYNDROME

Glycaemic control

Good glycaemic control is important in the management of patient with metabolic syndrome. The goal for HbA1C level is less than 7%. UKPDS 33 had demonstrated a 25% reduction in the risk of microvascular complications in type 2 diabetic patients who had achieved intensive glycaemic control.10  It is also important to identify patients who have impaired glucose tolerance (IGT). One to three quarters of patients with IGT will develop diabetes mellitus within a decade from the time of diagnosis of IGT. The annual progression rates from IGT to diabetes range from 1-10%.10  The Da Qing IGT and Diabetes study showed that diet and exercise led to a significant decrease in the incidence of diabetes mellitus over a 6-year period among those with IGT.11 The Diabetes Prevention Program also showed that lifestyle intervention was more effective than therapeutic intervention, and the incidence of diabetes mellitus is reduced by 58% in those receiving lifestyle intervention compared with 31% in those receiving Metformin in patients with IGT.12 It is therefore important to advise patient to modify their lifestyle early to prevent diabetes mellitus from developing.

Dyslipidemia

Lipid lowering is central to the reduction of morbidity and mortality in patients with diabetes mellitus. The goals of therapy in diabetic patients are to achieve LDL-C <2.59 mmol/L, and HDL-C  ≥1.03 mmo/L and Tg < 1.69 mmo/L.10  Statins are preferred agent for dyslipidemia in diabetics as they improve the prognosis and reduce the risk of recurrent coronary events in these patients as shown in the Scandinavian Simvastatin Survival Study (4S),10 Heart Protection Study (HPS)8  and Cholesterol and Recurrent Events trial (CARE).10

Role of aspirin
Aspirin should be considered in those patients with at least a 10% risk of a coronary event over 10 years.13 It reduces the raised plasminogen activator inhibitor and fibrinogen that is commonly found in patients with metabolic syndrome.5

Management of microalbuminuria
Microalbuminuria, a strong independent risk factor for cardiovascular events, results from endothelial dysfunction and oxidative stress in metabolic syndrome. Treatment with ACE inhibitors, delays mortality in patients with diabetes with microalbuminuria . This benefit occurs regardless of whether patients are hypertensive.14

Insulin sensitizers

Thiazolidinediones decrease hyperglycaemia by improving glucose uptake in muscles and adipose tissue and reducing glucose production. It also decreases triglyceride level and raise high-density lipoprotein cholesterol level. It helps to reduce microalbuminuria and blood pressure.15

Assessment of CVD risk

Metabolic syndrome confers a 2-fold increase in the relative risk for CVD events in individuals without established type 2 diabetes mellitus.16 For individuals with the metabolic syndrome who do not have established CVD or type 2 diabetes mellitus, the absolute 10-year CVD risk is best assessed by Framingham risk scoring.17 Framingham risk scoring system is designed to estimate risk in adults aged 20 and over who do not have heart disease or diabetes mellitus. It is used to determine individual’s 10-year risk of developing CHD (myocardial infarction and coronary death).  The risk factors used in assessment include age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension and cigarette smoking.17 A person’s 10-year risk status will determine the intensity of therapy for each risk factor and, in particular, whether drug therapy should be initiated.16

In this patient, there were few reasons for the success of her management. This patient was highly motivated, responsible and compliant to her treatment and health advices. She was well informed about her conditions and its consequences and was involved in her management plan and decision making process. Continuity of care was also a key element in successfully managing this patient.

CONCLUSION

Metabolic syndrome is common and family physicians need to be aware that they are handling a group of patient with high cardiovascular risks. This case report have highlighted the role of family physician in the management of patients with metabolic syndrome that portrays all principles of family medicine such as the importance of continuity of care, the coordination of patient care, prevention of diseases, modification of disease risk factors, and the importance of patient education for increased awareness of the problems so as to instil autonomy in the patient to take care of their own illness.

REFRENCES

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