Transcript Diapositiva 1 - Progetto LIBRA

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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
Villa Pineta s.r.l.
Ospedale Privato Accreditato
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Guidelines
 Non pharmacological models


Discussion & Future developments
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Guidelines
 Non pharmacological models


Discussion & Future developments
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
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.
The Metabolic Syndrome
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
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Guidelines
 Non pharmacological models


Discussion & Future developments
The American Journal of Medicine (2009) 122, 348-355
■ RESULTS: 43% of COPD patients and 21%
of control participants presented 3 or more
determinants of the metabolic syndrome.
PREVALENCE OF COMORBIDITIES IN COPD PATIENTS
ADMITTED TO PR
0%100%
n = 2962
n = 316
(in- and outpatients)
(retrospective - single centre)
(outpatients)
(prospective - 4 centres)
9,1
9,1
0% 80%
9,3
9,3
10,9
10,9
6,6
8,6
8,6
9,1
9,3
14,7 14,7
38,4 38,4
8,6
13,3 13,3
14,4 14,4
12,1
12,1
9,3
10,9
10,9
14,7
14,7
0% 40%
0% 0%
9,1
7,5
13,3
13,3
14,4
14,4
0% 60%
0% 20%
38,4
38,4
6,6
6,6
6,6
7,5
7,5
7,5
at least one
chronic
comorbidity:
51%
THORAX
2008
THORAX
THORAX
2008
THORAX
20082008
Crisafulli E. et al, Thorax 2008;63:487-492
MS (prevalence) 62%
8,9
8,9
35,2
35,2
35,2 35,2
8,9
8,9
12,1 12,1
10,9 10,9
at least one
chronic
comorbidity:
62%
2010
ERJERJ
2010
ERJ 2010
Crisafulli E. et al, ERJ 2010; 36: 1042-1048
MS (prevalence) 56%
8,6
Other
disease
(+ disease
3.4)
Other
disease
OtherOther
disease
10,9 10,9
Osteoporosis
(+2.0)
Osteoporosis
Osteoporosis
Osteoporosis
Dislipidaemia
(+4.2)
Dislipidaemia
Dislipidaemia
Dislipidaemia
Diabetes
Diabetes
Diabetes
(-2.3)
Diabetes
Coronary
Coronary
Coronary
Coronary
disease
(+1.6)
disease
disease
disease
CHFCHF
CHF(-5.8)
CHF
Hypertension
Hypertension
Hypertension
Hypertension
(-3.2)
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Guidelines
 Non pharmacological models


Discussion & Future developments
RISK FACTORS
Smoke
Enviromental pollution
Inactivity
Obesity
Adipose Tissue
activation
COPD
Inactivity
Local Bronchial
Inflammation
Reduced Lung
Function
Hypoxya
Cytokines release
Systemic Inflammation
Insuline resistance
Atherosclerosis  arterial stiffness  Hypertension
Dislipidaemia
METABOLIC SYNDROME
Courtesy by Mario Malerba (I)
Adipocytes
Adiponectin
FFA
IL 1
IL 6
Prostaglandins
Macrophages
Endotelin
CRP
TNF-α  NF-kB
INFLAMMATION
Leptin
Fat gain
Obesity
Insuline resistance
Dislipidaemia
Endotelial dysfunction
Hypertension
Courtesy by Mario Malerba (I)
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)
Nowbar S, et al. Am J Med 2004; 116: 1-7.
Peppard PE, et al. JAMA 2000; 284: 3015-3021
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).
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Guidelines
 Non pharmacological models


Discussion & Future developments
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…..
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)).
Death
LoS
RR
RR
Group 3
Group 4
1.46
2.02
1.97
2.92
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.
Rehabilitation
“Poveri…..
“…..ma belli”
1. 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
2. … vigorous aerobic and/or resistance exercise … is associated
with greater CVD risk reduction. Level of evidence: B
3. …long-term maintenance of major weight loss, larger volumes of
exercise …may be helpful. Level ofevidence: B
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
TRAINING SESSION
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
Outline

Definitions

Epidemiology

Physiopathology: link between MS & COPD
Inflammatory profile
 Mechanical disadvantages
 Respiratory problems with obesity


Therapy
Medications
 Non pharmacological models


Discussion & Future developments
DISCUSSION
 Metbolic Syndrome is fairly present in COPD
population
 There is a complex pathogenetic correlation
with physiopathological
COPD and MS
implications
between
 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
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…..)