Manajemen Sindroma Metabolik Pada Lansia Lisa Baru

CURRICULUM VITAE
Data Pribadi
Nama
: dr. Lisa Kurnia Sari, M.Sc., SpPD
Tempat dan Tanggal Lahir : Yogyakarta, 26 Juli 1978
Alamat Rumah
: Jl. Supadi No. 8, Yogyakarta 55224
Telpon
: 0816-68-1296
Email
: [email protected]
Pekerjaan
: Dokter Penyakit Dalam RSU. Bethesda Lempuyangwangi
Dokter Penyakit Dalam RS. Bethesda
Staf Pengajar Fakultas Kedokteran UKDW Yogyakarta
Pendidikan Formal
1. Spesialis Penyakit Dalam Program Pendidikan Dokter Spesialis Penyakit Dalam
Universitas Gadjah Mada Yogyakarta (2004 2010)
2. Master (S2, MSc) Program Studi Ilmu Kedokteran Klinik Fakultas Kedokteran
Universitas Gadjah Mada Yogyakarta (2004 2010)
3. Sarjana S1 (Dokter) Pendidikan Dokter Fakultas Kedokteran Universitas Gadjah
Mada Yogyakarta (1996 2003)
4. SMA Negri III Yogyakarta (1993 1996)
5. SMP Negri V Yogyakarta (1990 1993)
6. SD St. Yoseph Muntilan (1984 1990)
Management of Metabolic
Syndrome in Elderly
Geriatric Update : Geriatric Problem in Daily Practice
Auditorium Koinonia, 2nd November, 2013
Lisa Kurnia Sari

RS. Bethesda Lempuyangwangi
Yogyakarta
The I of Geriatric Medicine

Immobility
Irritable colon
Instability
Isolation
Incontinence
Inanition
Insanity
Impecunity
Iatrogenic
Insomnia
Infection
Impaired
vision and
hearing
Immune
deficiency
Impotence
Burns et al., 2006. Geriatric Medicine for Old-Age Psychiatrists. Taylor &
Prevalence of the Metabolic Syndrome Among US Adults :

Findings From the Third National Health and Nutrition Examination Survey
47.000.000 adults had (23%)

metabolic syndrome in US
50
Prevalence (%)
45
Men (n=4265)
Women (n=4559)
40
35
30
25
20
15
10
5
0
20-29
30-39
40-49
50-59
60-69
70
Age, Year
Ford ES et al. JAMA 2002;287:356-
Abnormalities included in the metabolic syndrome
Metabolic Syndrome increase the risk of

any cardiovascular events, coronary
events, and cerebrovascular events
among elderly individual.
Metabolic Syndrome and Risk of Cancer
Gender
Men
Women
Cancer Sites
Liver
Colorectal
Bladder
Endometrial
Pancreatic
Breast
postmenopausal
Rectal
Colorectal
RR
1.43
1.25
1.10
1.61
1.58
1.56
1.52
1.34
Esposito et al., 2012. Metabolic Syndrome and Risk of Cancer A Systematic Review and Meta-Analysis.
Approach to The Management of

Metabolic Syndrome in Geriatric
Patients
STEP
Obtain Data
STEP
1
STEP
Assess Risk Factors
STEP
2
Identify Co-Morbid Condition
STEP
Set Priority and Therapeutic
3
Target
STEP
4
STEP
Choose Therapeutic Options
STEP
Discuss with Patients or
5
STEP
Caregivers
STEP
6
STEP
Do Comprehensive Therapy
STEP
Follow-Up and Monitor
7
STEP
Treatment
8
STEP
1
Obtain Data
Patients Data
Anamnesis
Vital Sign
Blood Pressure
Physic Diagnostic
Waist Circumference
Electrocardiography
Laboratory
Blood Glucose (Fasting, Post-prandial, HbA1C)
Total Cholesterol, HDL, LDL, Triglyceride
Liver Function Test
Renal Function Test (Including Estimated GFR)
Creatinine Kinase
Radiology
Chest X-ray
Etc
STEP
2
Assess Risk Factors
Identify presence of clinical

atherosclerotic disease that
confers high risk for coronary
heart disease (CHD) events (CHD
risk equivalent)
Determine presence of major
risk factors (other than LDL)
Asses cardiovascular risk
http://www.nhlbi.nih.
STEP
2
Assess Risk Factors
Identify presence of clinical

atherosclerotic disease that confers
high risk for coronary heart disease
(CHD) events (CHD risk equivalent)
Clinical Coronary Heart Disease
Symptomatic Carotid Artery Disease
Peripheral Arterial Disease
.
Abdominal Aortic Aneurysm
Diabetes Mellitus
STEP
2
Assess Risk Factors
Determine presence of major

risk factors (other than LDL)
STEP
2
Assess Risk Factors
http://www.nhlbi.nih.
STEP
3
Identify Co-Morbid Condition
Kidney Failure
Liver Disease
Hypoproteinemia
Myopathy
STEP
4

Target
STEP
4

Target
STEP
4

Target
STEP
4

Target
STEP
4

Target
STEP
4

Target
Mancia et al., 2013. 2013 ESH/ESC Guidelines for the management of arterial hypertension. J
STEP
5
How to manage metabolic

syndrome?
Non
Pharmacologic
+/-
Pharmacologic
Central obesity
Impairment of glucose
metabolism
Increased blood pressure
Dyslipidemia
STEP
5
Lifestyle Modification
Diet
Physical Exercise
Smoking Cessation
Stress Reduction
Weight Control
Behaviour Change
Nutritional Genomics
Guide to activities management

At least 30 minutes of
moderate-intensity exercise
on most (and preferably) all
days of the week
Moderate intensity: 50-60%
of maximum capacity brisk
walk 15-20 min per mile
(Exercise Zone based on
maks HR)
Exercise plan may require modification for certain

patients with complications
NHLBI. www.nhlbi.nih.gov.
Guide to activities management

American College of Sport Medicine
Zone 50-60%
Zone 60-70%
Zone 70-80%
cardiovascular
Zone 80-100%
: exercise and daily activity

: weight control
: aerobic and
: competition
If older than 40 y.o : 208 (0,7 X age)

The goal of physical activity in
management of DM is increasing Basal
Metabolic Rate (BMR)
Food Recomendation
Eat Less of These
Coconut, Margarine/butter,
Cheese, Oils/fats rich in
saturated fat
Eat More of These
Avocado, Nuts, Olives, Oils

unsaturated, Fish, Chicken lean, Fruits,
Vegetables
STEP
5
Charles Eugster, 93 years old
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witzerland
http://news.xin.msn.com/en/singapore/article.aspx?cp-documentid=4419980
STEP
5
STEP
5
PERKENI, 2011
STEP
5
PERKENI, 2011
STEP
5
STEP
5
STEP
5
STEP
5
STEP
5
STEP
5
STEP
5
Therapy
LDL
HDL
Bile acid
sequestrants
7-10%
10-18%
3%
Neutral or
Poor
Nicotinic acid
10-20%
10-20%
14-35%
30-70%
Poor to
reasonable
Fibrates
(gemfibrozil)
19%
4-21%
11-13%
30%
Good
19-37%
25-50%
4-12%
14-29%
Good
13%
18%
1%
9%
Good
Statins*
Ezetimibe
TG
Patient
tolerability
TC
Effect of Lipid-modifying Therapies
Recent Coronary prevention Studies

with Statin
1. Lancet 2002;360:7-22; 2. Lancet 2002;360:1623-30; 3. JAMA

2002;288:2998-3007;
4. Lancet 2003;361:1149-58.
STEP
5

Management of Very High
Triglycerides
(>500 mg/dl)
Goal of therapy: Prevent acute pancreatitis

Very low fat diets (< 15% of caloric intake)
Triglyceride-lowering drug usually required (fibrate
or nicotinic acid)
Reduce triglycerides before lowering LDL
If a patient also has a high risk for a cardiovascular
event, LDL-lowering therapy should be considered.
STEP
5
Clinical Reviews
STEP
5
Lipophilicity vs. Hydrophilicity
Lipophilic statins penetrate muscle more easily than

hydrophilic statins
Associated with a higher incidence of adverse effects,
particularly myopathy, although reports of muscle toxicity,
including rhabdomyolisis have been reported with all statins.1
Simvastatin is the most lipophilic
statinlovastatinatorvastatin.
Hydrophilic statins include pravastatin and fluvastatin.
Rosuvastatin is relatively hydrophilic. 3(p.139)
Although hydrophilic statins have a lower association with
adverse effects, they generally require higher dosing to be
efficaciouswith the exception of rosuvastin.3 Higher doses,
in turn, may be associated with adverse effects.
STEP
5
Protein-binding
Protein binding also plays a role in
the potential for adverse effects of
statins.
Statins other than pravastatin are
highly protein bound.
Decreases in serum protein levels,
often seen in frail older adults may
result in higher concentrations
and higher toxicity.
STEP
5
Statin in Elderly
Older chronological age in and of itself should not
exclude patients from receiving therapy,
especially if an otherwise healthy older patients
remaining years of life may benefit from
prevention of the morbidity associated with a
coronary event.
Kidney function should be tested before
treatment. There is an increase risk of myopathy
when GFR decreased.
Elderly with AMI
Scandinavian Simvastatin Survival Study

CARE (Cholesterol and Recurrent Events) Trial
LIPID (Long Term Intervention with Pravastatin in Ischemic
Disease) Trial
HPS (Heart Protection Study)
STEP
5
NKF Recommendations
for Statin Dose Adjustment in CKD
Adjust for reduced GFR (mL/min/1.73 m2)
3090
<30
<15
Atorvastatin
No adjustment
No adjustment
No adjustment
Pravastatin
No adjustment
No adjustment
No adjustment
Simvastatin
No adjustment
Starting dose 5 mg daily in patients with

severe kidney disease
Lovastatin
No adjustment
Fluvastatin
No adjustment
Rosuvastatin
No adjustment
Use doses >20 mg/day cautiously

in patients with GFR <30
No dose adjustments needed for mild to
moderate kidney disease; use caution in
patients with severe kidney disease;
fluvastatin not studied at doses
>40 mg in these patients
Starting dose 5 mg and NOT to exceed 10 mg
in patients with GFR <30
National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl

2):S1-S180
How to Titrate dose or switch to

another statin
Some adverse effects associated with statin drugs are

dosage-related (eg, myopathy/rhabdomyolysis), and with
some statins, liver dysfunction may increase with increased
dosage
If statin tolerability is a concern, a combination of drugs at
lower dosages may be effective
STEP
6

Caregivers
http://www.getrealaboutseafood.com/health-
STEP
6

Caregivers
Special Consideration
Drug side effects

Drug preference
Poly-pharmacy
Patient adherence
Prognosis
Social support
STEP
7
Do Comprehensive Therapy
STEP
8

Treatment
Follow-up and Monitoring
Reassessing patients lipid status 6 weeks after

therapy initiation and again at 6-week intervals until
the treatment goal is achieved.
Thereafter, that patients be tested at 6- to 12-month
intervals.
The specific interval should depend on patient
adherence to therapy and lipid profile consistency.
If adherence is a concern or the lipid profile is
unstable, the patient will probably benefit from
biannual assessment
STEP
8

Treatment
Follow-Up Recomendation
Lipids
6 weeks after start / change of dose (levels reach steady
state within 6 weeks of start/change of medication)
Long-term follow-up every 6-12 months
AST / ALT (0.5 3% incidence)

Get baseline
Use with caution if AST/ALT > 3 x normal
At 12 weeks after initiation or change in dose (FDA)
CK (< 0.5% incidence)

Get baseline
Check only if symptomatic with myalgias (ATP III guideline)
More attention in elderly patient
Treat The Patient

NOT Laboratory Test Report
TAKE HOME MESSAGES

Metabolic Syndrome increase the risk of
any cardiovascular events, coronary
events, and cerebrovascular events among
elderly.
The purpose of metabolic syndrome
treatment in elderly is to reduce mortality
and morbidity.
The target of metabolic syndrome
treatment should be adjusted individually,
based on patients condition.
Thank You

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CURRICULUM VITAE

Lisa Kurnia Sari

The I of Geriatric Medicine

Prevalence of the Metabolic Syndrome Among US Adults :

47.000.000 adults had (23%)

Ford ES et al. JAMA 2002;287:356-

Abnormalities included in the metabolic syndrome

Metabolic Syndrome increase the risk of

Metabolic Syndrome and Risk of Cancer

Approach to The Management of

Assess Risk Factors

Identify presence of clinical

Assess Risk Factors

Identify presence of clinical

Assess Risk Factors

Determine presence of major

Assess Risk Factors

Identify Co-Morbid Condition

Set Priority and Therapeutic

Set Priority and Therapeutic

Set Priority and Therapeutic

Set Priority and Therapeutic

Set Priority and Therapeutic

Set Priority and Therapeutic

Choose Therapeutic Options

How to manage metabolic

Choose Therapeutic Options

Guide to activities management

Exercise plan may require modification for certain

Guide to activities management

: exercise and daily activity

If older than 40 y.o : 208 (0,7 X age)

Eat More of These

Avocado, Nuts, Olives, Oils

Choose Therapeutic Options

Charles Eugster, 93 years old

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Choose Therapeutic Options

Effect of Lipid-modifying Therapies

Recent Coronary prevention Studies

1. Lancet 2002;360:7-22; 2. Lancet 2002;360:1623-30; 3. JAMA

Choose Therapeutic Options

Goal of therapy: Prevent acute pancreatitis

Choose Therapeutic Options

Choose Therapeutic Options

Lipophilicity vs. Hydrophilicity

Lipophilic statins penetrate muscle more easily than

Choose Therapeutic Options

Choose Therapeutic Options

Scandinavian Simvastatin Survival Study

Choose Therapeutic Options