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DOI: 10.1055/s-0031-1298791
Therapie von Fettstoffwechselstörungen bei Diabetes mellitus – State of the Art
Therapy of lipid disorders in patients with diabetes – state of the artPublication History
Publication Date:
05 December 2011 (online)
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Der Diabetes mellitus ist heute eine der großen Volkskrankheiten. Die Lebenserwartung der Diabetiker ist im Vergleich zur Normalbevölkerung immer noch vermindert und die Lebensqualität infolge der Spätkomplikationen eingeschränkt [1]. Ursachen sind sowohl die mikroangiopathischen als auch die makroangiopathischen Komplikationen des Diabetes. Eine wichtige Ursache für die im Vergleich zu Gesunden früher auftretende und schwerer verlaufende Arteriosklerose sind die Fettstoffwechselstörungen, die zum Teil pathogenetisch eng mit dem Diabetes assoziiert sind. Wie derzeit der aktuelle Stand zu Diagnostik und Therapie ist, damit beschäftigt sich dieser Artikel.
Lipometabolic disorders raise the cardiovascular risk in patients with diabetes. Therefore an early diagnosis and effective therapy is essential. Pathophysiologically important is the insulin resistance in patients with diabetes type 2, which ist connected to an increase of VLDL and triglycerides and a decline in HDL-cholesterol. In the diagnosis of metabolic disorders fasting total cholesterol, HDL-C, LDL-C and triglycerides and – at least once in a lifetime – Lp (a) must be measured. Further on creatinin, TSH, fasting blood glucose and HbA1c must measured as well.
Before starting a medical therapy creatine kinase, ALAT and GGT (in hypertriglycemia and mixed hyperlipoproteinemia) should be known. Base line therapy consists of nutrition education and weight optimizing. If hypertriglycidemia or mixed lipometabolic disorder are present reduction of consumption of alcoholic beverages or abstinence are important.
Contraindications excluded raise of physical activity leads to a better lipid profile. Further of importance is an euglycemic adjustment of the carbohydrate metabolism. Medical lipidlowering therapy is defined by the existing disturbance of the lipid metabolism. First in line concerning risk is LDL-C and therefore a statin should be preferred, if LDL-C is raised and medical therapy is necessary. Target value in diabetic patients is < 2.6 mmol/l (< 100 mg/dl). In patients with hypertriglycidemia only and without cardiovascular risk complications a fibrate should be given. In patients with elevated levels of LDL-C and triglycerides and low levels of HDL-C a combined lipid lowering therapy is indicated, e. g. a combination of a statin with a nicotinic acid (Tredaptive® 1000 mg/20 mg) or a statin and fishoil.
Integral part of the treatment are examinations for exclusion of coronary artery disease (echo, ergometry and other examinations as necessary), duplex ultrasound examinations of the carotids and if clinical necessary duplex ultrasound examinations of leg arteries.
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Literatur
- 1 Haffner SM, Letho S, Ronnemaa T. Mortality from coronary heart disease in subjects with type 2 diabetes and in non-diabetic subjects with and without prior myocardial infarction. N Eng J Med 1998; 339: 229-234
- 2 Parhofer KG, Geiß H-C. Therapie der diabetischen Dyslipoproteinämie. Diabetologie 2010; 5
- 3 Luley C, Kloer HU. Lexikon Lipoproteine und Arteriosklerose. Basel: Aesopus-Verlag; 1973
- 4 Taskinen MR. Dyslipidemia in insulin resistance: a silent villain?. Atherosclerosis 1999; 144 (Suppl. 01)
- 5 Praxisleitlinie Fettstoffwechselstörungen. Landesärztekammer Sachsen. 2003
- 6 Grundy SM, Cleemann JI, Merz CNB et al. for the Coordinating Committee of the National Cholesterol Education Program: Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatmant Panel III Guidelines. Circulation 2004; 110: 227-239
- 7 Gohlke H, Kübler W, Mathes P. Empfehlungen zur umfassenden Risikoverringerung für Patienten mit koronarer Herzerkrankung, Gefäßerkrankungen und Diabetes. Z Kardiol 2001; 90: 148-149
- 8 Keech A, Simes RJ, Barter P et al. FIELD study investigators: Effects of long term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study); randomised controlled trial. Lancet 2005; 366: 1849-1861
- 9 GISSI-Prevenzione Forschungsgruppe. Nahrungsergänzung mit mehrfach ungesättigten n-3-Fettsäuren und Vitamin E nach Herzinfarkt: Ergebnisse der GISSI-Studie. Lancet 1999; 354: 447-455
- 10 Huttunen J, Manninen V, Manttari M et al. The Helsinki Heart Study: central findings and clinical implications. Ann Med 1991; 23: 155-159
- 11 Ginsberg HN, Elam MB, Lovato LC. Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus: The Accord Study Group. N Engl J Med 2010; 362: 1563-1574