Metabolic syndrome, a combination of risk factors, such as obesity, glucose impaired tolerance, hypercholesterolemia and elevated blood pressure have become rampant in the world today. The paper analyses a case study of a patient named R.S. It looks at both the pharmacological and non-pharmacological interventions.
Key words: Metabolic Syndrome, Obesity, Hypercholesterolemia
The primary diagnosis for R.S namely is metabolic syndrome. The patients does not meet strict requirements for arterial hypertension, diabetes mellitus type II or atherosclerosis, but he is obese and some of his findings are borderline (to be discussed in detail below). Hypertension is a disease caused by inconsistent levels of the systolic and diastolic pressure levels. In other words, there is high blood pressure. His blood glucose level is high normal, which suggests some ‘readiness’ for metabolic disorders. Atherosclerosis results when fats, mostly cholesterol accumulate in the arteries. Cholesterol plaques obstruct vessel lumen and slow blood flow through them. As soon as a blood clot appears on the plaque surface, blood supply to the heart declines leading to cardiac arrest. In R.S. these disease do not reach diagnostic criteria, but in combination, these borderline changes appear as risk factors and place the patient at risk to develop life-threatening conditions.
There are several findings that made me believe Mr R.S. suffers from metabolic syndrome.
Obesity is easily recognized – simply divide mass in kg by height in m2 as follows
Body Mass Index = mass in kg / height in m2
The BMI should be compared to the World Health Organization reference table. The patient’s BMI is 35.1, which corresponds to severe obesity. It could be genetically acquired or posed by the lifestyle of this individual – his job pattern predict low activities.
Glucose tolerance impairment. Fasting glucose level indicated 116mg/dl, while normally sugar must not be above 110mg/dl. However, according to the current recommendations, diabetes develops when fasting glucose is ≥ 126 mg/dL (ADA, 2014). However, blood glucose criteria in metabolic syndrome > 100 mg/dL (Grundy et al., 2005)
Arterial hypertension is diagnosed when blood pressure rises above 150/60 mmHg in adults >60 years old (JNC, 2014). But criteria for metabolic syndrome is ≥130/85 mmHg (Grundy et al., 2005).
The case scenario mentioned no complaints regarding atherosclerosis (chest pain, ischemic stroke, etc.), but according to the current guidelines, reduced cholesterol HDL-C
In conclusion, the patient has five of five needed requirements for the diagnosis of metabolic syndrome.
Alanine Aminotransferase (ALT) 52u/l above normal 0-35U/L. Aspartate Aminotransferase is 53U/L, which high from 0-35U/L. I believe elevated liver enzymes may be explained by hepatosis associated with metabolic syndrome.
There are non-pharmacological interventions that are indicated in metabolic syndrome. The goal of these interventions is to reduce the risk of atherosclerotic burden thus providing better prognosis and avoiding dangerous complications. It is necessary that he observes dietary modification and take part in physical activity to reduce BMI. Dietary modification’s main purpose is to ensure the cutting done if excessive fat intake. In essence, proper and well balanced diet is an appropriate health recommendation. It is also apparent that the patient needs to get involved in physical activities to avoid his sedentary lifestyle. Consequently, physical exercise such as taking part in aerobics and walking among others are necessary. For instance, R.S should decide to walk instead of travelling every morning as he goes to work. There is also need for him to change his lifestyle behaviors such as drinking and smoking. These behaviors have shown negative effect on patients with his condition. It is advisable that he should do away with drinking completely.
The following pharmacotherapy should be prescribed: statin, aspirin and an ACE inhibitor.
Atorvastatin is a cholesterol-reducing agent. It blocks synthesis of cholesterol through acting in the liver. Because cholesterol is synthesized at night, Atorvastatin should be prescribed in the evening so that its peak activity develops when liver enzymes are most active. According to the current guidelines in lipid-lowering therapy, a male patient under 75 years old with LDL-C ≥190 mg/dL without clinical evidence of atherosclerosis should receive high-intensity statin therapy. A high-intensity statin regimen means Atorvastatin should be prescribed in the dose 80 mg daily. The lipid panel should be repeated 4-12 weeks later and than every 3 to 12 months as clinically indicated. Statin therapy is lifelong until side effects develop. Dosage may be lowered when LDL-C drops by 50% (Stone et al., 2013).
Aspirin is an anti-thrombocyte drug that prevents clot formation on the cholesterol plaque and recommended for intake by the metabolic syndrome guidelines (Grundy et al., 2005). It is prescribed once a day 80 mg during or shortly after meals. Aspirin damages thrombocytes and they cannot clot, but also damages the stomach lumen. Moreover, the patient had peptic ulcer long ago, so I believe he must undergo endoscopy to state the stomach condition. Should the mucus of the stomach be undamaged, he can start aspirin on a life-long basis.
ACE inhibitors are among the first line drugs for arterial hypertension in the obese (JNC 8, 2014). Moreover, Captopril may have anti-inflammatory properties and benefit in altered lipid profile (Grundy et al., 2005). I suggest this patients has elevations of his blood pressure above 140/90 mmHg occasionally because he has other contributing factors (job type, coffee, obesity). Captopril is a short acting drug that lowers blood pressure when it occasionally rises. Captopril is administrated orally up to three times a day, tablet 25 mg. He may carry Captopril in his pocket and take when blood pressure elevates.
There is primary education that R.S needs to take for the sake of his health. First and foremost, he needs education on how to take care his drugs consistently. This is essential in the management of hypertension. Inconsistent drug intake has been known to lead to resistance. Moreover, he needs to be taught on how to use the test kit to assess his blood pressure. The test is necessary for monitoring his progress. Secondly; the patient needs to be aware of how to develop therapeutic lifestyle changes. For instance he needs to reconsider, the form of exercises that he needs, the right dietary intake, and the social behaviors such as drinking that he needs to stop. His diet should be well balanced with lots of vegetable and fruits. He ought to avoid food rich in fat content. Junk foods are no go zone for him.
The goals of the pharmacotherapy are as follows: First and foremost, the aim of the drug is to prevent blood pressure elevations. Secondly, the medications administered for atherosclerosis aims at increasing the HDL while at the same time reducing LDL to the desirable levels. It is important to state that high levels of HDL-C are required for this patient. Thirdly, his blood needs to carry low risk of thrombosis to prevent a heart attack more effectively.
The effectiveness of this therapy can be evaluated by monitoring the wellbeing of the patient. For instance, the patient can have routine checkups to assess his BMI. It is expected that with therapeutic life changes, his BMI is likely to fall below 35, and consistently get to the required level of 25. A decline in weight is a sure sign for effectiveness of non-pharmacological therapy. Secondly, while he may be performing the self-monitoring blood glucose, it is appropriate to monitor the blood glucose level. If it is <110mg/dl, then the therapy is effective. Routine blood tests can be done to determine the LDL-C, HDL-C. Thirdly, arterial blood pressure diary might be recommended to state his pressure control progress.
Rosuvastatin can be an alternative to Atorvastatin (Stone et al., 2013). Rosuvastatin is administrated 20 mg once a day in the intense-regimen with the same rules as for Atorvastatin. Should aspirin provoke allergy or fail to suit the patient, Clopidogrel can be administrated. Clopidogrel also blocks thrombocyte aggregation into a clot. Clopidogrel is taken once a day 75 mg regardless of meal time because it does not irritate the stomach mucus so badly as aspirin. Captopril is a short-acting agent. A long-acting agent can be prescribed. Losartan is an angiotensin receptor blocker. Captopril blocks synthesis of angiotensin, while Losartan blocks its action in the tissues. Losartan is prescribed once a day, 50 mg (JNC 8, 2014).
The medication than can be prescribed is Atorvastatin (Lipitor) 80 mg once daily in the evening. Aspirin (Bayer Aspirin, Acetyl Salicylic Acid) 81 mg once daily during meals. Caprtopril (Capoten, 25 mg three times a day or as required.