421.3 🩺 內科專科考前版

421.3.0.1 📌 䞀頁重點

  • 22E updates:
    • Resmetirom (Rezdiffra, FDA 2024) — first FDA-approved NASH drug; THRβ agonist
    • Tirzepatide (Zepbound) for obesity (FDA 2023) — best-in-class weight loss
    • AACE 2024 obesity guideline: bariatric surgery for BMI 32-35 + comorbidity (lower than 35)
    • Setmelanotide (Imcivree) for MC4R pathway monogenic obesity
    • PREVENT calculator (2023) replaces Pooled Cohort Equation
    • TIRZEPATIDE in HFpEF + obesity (SUMMIT 2024 NEJM)
  • Taiwan: 國健眲 MetS 篩檢蚈畫 (40-64 yr); DAROC + Taiwan Lipid + Endocrine + Liver society 指匕; 健保 metformin/SGLT2/GLP-1 條件; tirzepatide + resmetirom 自費 倚

421.3.0.2 🌟 Pearls (12)

  1. Asian WC threshold lower (90/80) than US (102/88) — important for Asian populations
  2. Visceral fat better marker than BMI alone (CT-based VAT preferred research)
  3. Adiponectin inversely correlates with MetS severity (anti-inflammatory)
  4. Lipotoxicity (free fatty acids in muscle, liver) drives IR
  5. MetS + HFpEF strong association; tirzepatide SUMMIT 2024
  6. NAFLD-NASH-fibrosis-cirrhosis spectrum + HCC end-stage
  7. MAFLD vs NAFLD terminology evolving (metabolic-associated)
  8. Resmetirom: only FDA-approved NASH drug (thyroid receptor β agonist; 80 or 100 mg/d)
  9. GLP-1 / tirzepatide for NASH: significant histologic improvement (off-label trials positive)
  10. Bariatric NAFLD: durable remission of NASH in many
  11. MetS + cancer: independent association; mechanism: hyperinsulinemia, IGF-1, inflammation
  12. MetS + dementia: vascular contribution + amyloid pathology link

421.3.0.3 📍 Taiwan + 健保

421.3.0.3.1 篩檢
  • 國健眲 MetS 篩檢 (40-64 yr free)
  • 健保 lipid panel + glucose + LFT + Cr + UACR + uric acid 充分
  • 健保 OGTT 條件
  • 健保 liver US, FibroScan 條件
421.3.0.3.2 Drugs
  • 健保 ACE-i / ARB
  • 健保 statin (multiple)
  • 健保 ezetimibe + PCSK9 inhibitor 條件
  • 健保 metformin
  • 健保 SGLT2 條件 (CV/CKD)
  • 健保 GLP-1 RA 條件 (CV/HbA1c criteria)
  • Tirzepatide (Mounjaro/Zepbound) 自費 倚 (健保條件 expanding)
  • 健保 pioglitazone
  • 健保 phentermine (短期, 條件)
  • 健保 orlistat
  • 健保 fenofibrate
  • 健保 allopurinol, febuxostat
  • 健保 finerenone (DM + CKD + albuminuria)
  • Resmetirom (Rezdiffra) 自費 (新, 條件 expanding for NASH)
  • Setmelanotide 自費 (rare 眕病)
421.3.0.3.3 Bariatric Surgery
  • 健保 bariatric for BMI ≥ 37.5 (or 32.5 + comorbidity, NHIA 2020)
  • Roux-en-Y, sleeve gastrectomy 倚
421.3.0.3.4 孞會 + 指匕
  • TES + Taiwan Lipid Society + DAROC + Taiwan Liver Society
  • AACE 2024 Obesity + MetS
  • ADA 2026
  • AASLD NAFLD/NASH 2023
  • IDF MetS Definition

421.3.0.4 🎓 內專必懂 (12)

  1. MetS criteria + Asian threshold
  2. Pathophysiology (IR + visceral + adipokine)
  3. Workup comprehensive
  4. Lifestyle foundation (weight 5-10%)
  5. Each component drug ladder
  6. Obesity drug spectrum + tirzepatide best class
  7. Bariatric surgery indications + types
  8. NAFLD-NASH-fibrosis spectrum + treatment ladder
  9. Resmetirom (NASH) 22E
  10. MetS + HFpEF + tirzepatide (SUMMIT)
  11. MetS + cancer association
  12. MAFLD/NAFLD terminology + future

421.3.0.5 ⚙ NAFLD / NASH Detailed Workup + Treatment (內專)

Diagnosis:
- Fatty liver: > 5% hepatic steatosis (US, MRI-PDFF gold)
- NAFLD: hepatic steatosis without other cause (alcohol, drug, viral)
- NASH: NAFLD + inflammation + ballooning (biopsy)
- Fibrosis F0-F4: F4 = cirrhosis

Non-invasive Workup:
- LFT (ALT > AST in NAFLD typical; reverse in cirrhosis)
- FIB-4 score: age + AST + ALT + platelets
  - < 1.3: low fibrosis risk
  - 1.3-2.67: indeterminate
  - > 2.67: high risk → image
- ELF (Enhanced Liver Fibrosis) test
- FibroScan / MR elastography
- Liver biopsy: gold standard but selected

Treatment Ladder:
1. Lifestyle (foundation): weight loss 5-10% (NAFLD); 7-10% (NASH); ≥ 10% (fibrosis improvement)
2. Mediterranean diet + exercise + alcohol abstain
3. Drug therapy:
   - Resmetirom 80-100 mg/d (FDA 2024, biopsy-proven NASH F2-F3)
   - GLP-1 RA (semaglutide 2.4 mg, off-label) — significant histologic
   - Tirzepatide off-label (SYNERGY-NASH ongoing)
   - Vit E 800 IU/d (non-DM, biopsy-proven NASH)
   - Pioglitazone (off-label, T2DM + NASH)
4. Bariatric surgery: BMI ≥ 35 + NASH; durable resolution in many
5. Liver transplant: end-stage cirrhosis / HCC

Surveillance:
- HCC screening: q6 mo if cirrhosis (US + AFP)
- Repeat fibrosis assessment q1-3 yr

421.3.0.6 ⚙ Bariatric Surgery Decision (內專, AACE 2024)

Indications (AACE 2024):
- BMI ≥ 35 (regardless of comorbidity)
- BMI 32-35 + comorbidity (T2DM, HTN, NASH, OSA)
- BMI 32-35 in Asian patients (lower threshold per ethnicity)

Procedures:
- Roux-en-Y gastric bypass (RYGB):
  - ~ 25-30% weight loss
  - T2DM remission ~ 60-80%
  - NAFLD/NASH improvement
  - Risks: dumping syndrome, gallstone, anastomotic complications
- Sleeve gastrectomy (LSG):
  - ~ 20-25% weight loss
  - Most common globally now
  - Less complex
  - Risks: GERD worsening
- Adjustable gastric band (older, less used)
- Biliopancreatic diversion (rare, severe obesity)

Pre-operative:
- Multidisciplinary team (surgeon, endocrine, nutrition, psych)
- Nutritional assessment + supplementation
- Comorbidity optimization
- Patient education + commitment
- Psych eval

Post-operative:
- Lifelong vitamin/mineral supplementation (B12, iron, Ca/D, multi)
- DEXA for bone (especially RYGB)
- Annual labs
- Dumping syndrome education
- Weight regain prevention
- Hypoglycemia (post-RYGB; see Ch 418)

421.3.0.7 ⚙ Pediatric MetS Considerations

- Increasingly recognized
- BMI > 95th percentile + 2 of: TG ↑, HDL ↓, BP ↑, glucose ↑
- Lifestyle 1st (family-based)
- Pharmacotherapy: limited (metformin off-label)
- GLP-1 (liraglutide, semaglutide) approved for pediatric obesity (≥ 12 yr)
- Bariatric surgery: ASMBS guidelines for severe pediatric obesity
- Long-term outcome better with early intervention

⚠ AI 草皿。