Management of Metabolic Syndrome in patients with COPD

1. Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra.Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.

2. 2011 Guidelines on Rhinitis, Asthma & COPD Global Initiatives ARIA, GINA, GOLD Modena, 1-3 march 2011 Management of Metabolic Syndrome in patients with COPD Enrico Clini

3. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Guidelines • Non pharmacological models • Discussion & Future developments

4. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Guidelines • Non pharmacological models • Discussion & Future developments

5. COPD • COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. • Its pulmonary component is characterized by airflow limitation that is not fully reversible. • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. GOLD International Guidelines

6. METABOLIC SYNDROME …. Opinions have varied as to whether the metabolic syndrome should be defined to mainly indicate insulin resistance, the metabolic consequences of obesity, risk for CVD, or simply a collection of statistically related factors …. Alberti KG, et al. Lancet 2005; 366: 1059-1062.

7. The Metabolic Syndrome

8. Obesity and Body Mass Index (BMI) BMI = (kg)/(m)2 Body Mass Index (BMI) provides a more accurate measure of obesity than does weight alone

9. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Guidelines • Non pharmacological models • Discussion & Future developments

10. The American Journal of Medicine (2009) 122, 348-355

12. ■ RESULTS: 43% of COPD patients and 21% of control participants presented 3 or more determinants of the metabolic syndrome.

13. n = 2962 (in- and outpatients) (retrospective - single centre) n = 316 (outpatients) (prospective - 4 centres) Other disease (+ 3.4) Osteoporosis (+2.0) Dislipidaemia (+4.2) Diabetes (-2.3) Coronary disease (+1.6) CHF (-5.8) Hypertension (-3.2) at least one chronic comorbidity: 51% at least one chronic comorbidity: 62% Crisafulli E. et al, ERJ 2010; 36: 1042-1048 Crisafulli E. et al, Thorax 2008;63:487-492 MS (prevalence)56% MS (prevalence)62% PREVALENCE OF COMORBIDITIES IN COPD PATIENTS ADMITTED TO PR

14. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Guidelines • Non pharmacological models • Discussion & Future developments

15. RISK FACTORS Smoke Enviromentalpollution Inactivity Obesity COPD Inactivity Local Bronchial Inflammation Reduced Lung Function Adipose Tissue activation Hypoxya Systemic Inflammation Cytokinesrelease Insuline resistance Atherosclerosis  arterial stiffness  Hypertension Dislipidaemia METABOLIC SYNDROME Courtesy by Mario Malerba (I)

16. Macrophages Leptin Adiponectin FFA Adipocytes Fatgain Obesity Insuline resistance Dislipidaemia Endotelialdysfunction Hypertension IL 1 IL 6 Prostaglandins Endotelin CRP TNF-α NF-kB INFLAMMATION Courtesy by Mario Malerba (I)

17. The Obese: a pulmonary patient • Decrease in lung volumes(TLC-FRC-ERV) • Increase in lung resistances • Increase in PEEPi (supine) • Decrease in MIP (?) • Obesity Hypoventilation Syndrome(OHS) • Obstructive sleep apnea (OSA)

19. Nowbar S, et al. Am J Med 2004; 116: 1-7.

20. Peppard PE, et al. JAMA 2000; 284: 3015-3021

21. 5-yrs mortality 5-yrs mortality and presence of no, 1 ,2 or 3 comorbidities (diabetes, hypertension, CVD) Data from 20,296 subjects aged >45 yrs at baseline in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS).

22. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Guidelines • Non pharmacological models • Discussion & Future developments

23. IDF Recommendations for treating MS Primary intervention Healthy lifestyle promotion. This includes: o calorie restriction (5-10% loss of body weight in the 1st year) o moderate increase in physical activity o change in dietary composition Secondary intervention In people for whom lifestyle change is not enough and who are considered to be at high risk for CVD, drug therapy may be required to treat the metabolic syndrome. Single component of MS (dyslipidemia, elevated BP, insulin resistance and hyperglycemia) should be treated…..

25. Hyperglycaemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease Baker EH, et al. Thorax 2006;61:284-289 Methods: … The patients were grouped according to blood glucose quartile (group 1, <6 mmol/l (n = 69); group 2, 6.0–6.9 mmol/l (n = 69); group 3, 7.0–8.9 mmol/l (n = 75); and group 4, >9.0 mmol/l (n = 71)). For each 1 mmol/l increase in blood glucose the absolute risk of adverse outcomes increased by 15% … independent of age, sex, a previous diagnosis of diabetes, and COPD severity. RR RR Group 3Group 4 Death 1.46 1.97 LoS 2.02 2.92

26. “Poveri….. “…..ma belli” Rehabilitation

28. To improve glycemic control, assist with weight maintenance, and reduce risk of CVD, we recommend at least 150 min/week of moderate-intensity aerobic physical activity and/or at least 90 min/week of vigorous aerobic exercise. Level of evidence: A • … vigorous aerobic and/or resistance exercise … is associated with greater CVD risk reduction. Level of evidence: B • …long-term maintenance of major weight loss, larger volumes of exercise …may be helpful. Level ofevidence: B

32. PROGRAM • Physical activity • Aerobic resistance and strength training • Stretching • Education • Diet • REE assessment + realistic goals • Education • Psychology • Assessment of BED (if any) • Individual and group counseling • Long-term assistance and counseling

33. TRAINING SESSION

34. Am J Respir Crit Care Med 2009; 180: 190-191. N= 166 obese with OSA (Mean age 53, mean BMI 46) • Predictors of BW loss maintenance (2-yr) • Univariate analysis • Early (6-mo) loss of BW • Reduction in Depression score • Multivariate analysis • Early (6-mo) loss of BW

35. Outline • Definitions • Epidemiology • Physiopathology: link between MS & COPD • Inflammatory profile • Mechanical disadvantages • Respiratory problems with obesity • Therapy • Medications • Non pharmacological models • Discussion & Future developments

36. DISCUSSION • Metbolic Syndrome is fairly present in COPD population • There is a complex pathogenetic correlation with physiopathological implications between COPD and MS • Both MS components and COPD require attention for the best treatment • Rehabilitation model including physical activity may be the way forward for effective management of these coexistent conditions

37. FUTURE DEVELOPMENTS • Understand the aetiology of the metabolic syndrome • Investigate the relationship between different constellations of factors to CVD outcomes • Investigate the true impact of effective treatment of all components of the syndrome on CVD risk • Better identification of high risk patients with metabolic syndrome in different populations (COPD…..)