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Diabetologie und Stoffwechsel 2015; 10(03): 129-140
DOI: 10.1055/s-0035-1553048
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Optionen zur Intensivierung einer Basalinsulintherapie bei Menschen mit Typ-2-Diabetes

Options for Intensifying a Basal Insulin Therapy in Humans with Type 2 Diabetes
B Gallwitz
1   Universitätsklinikum Tübingen, Medizinische Klinik IV, Tübingen
,
S Matthaei
2   Diabetes-Zentrum Quakenbrück, Fachabteilung für Diabetologie, Endokrinologie und Stoffwechsel am Christlichen Krankenhaus Quakenbrück, Quakenbrück
› Author Affiliations
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Publication History

Publication Date:
10 July 2015 (online)

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Zusammenfassung

Einleitung: Bei Menschen mit Typ-2-Diabetes, die eine mit Basalinsulin unterstützte orale Therapie (BOT) erhalten, entsteht häufig die Notwendigkeit zur weiteren Intensivierung der Therapie. In derartigen Situationen sind Glucagon-like-peptide-1-Rezeptoragonisten (GLP-1-RA) wegen ihrer sich ergänzenden Eigenschaften zu Insulin besonders gut für die Kombinationstherapie geeignet.

Methodik: Anhand von Studien zur Intensivierung einer bestehenden Insulintherapie mit den GLP-1-RA Exenatid, Liraglutid oder Albiglutid wird der Stellenwert von GLP-1-RA im Vergleich zu kurz wirksamen Insulinanaloga bei der Intensivierung einer BOT bei Typ-2-Diabetes analysiert.

Ergebnisse: In der Gesamtschau von zehn randomisierten kontrollierten Studien, insbesondere der 4B-Studie zu Exenatid, der BEGIN-VICTOZA-ADD-ON-Studie zu Liraglutid und der HARMONY-6-Studie zu Albiglutid, wurden mit GLP-1-RA und kurz wirksamen Insulinen mindestens gleich gute HbA1c-Reduktionen erreicht. Einzelne Studien zeigen für GLP-1-RA Vorteile hinsichtlich einer um ca. 0,5 – 1,5 mmol/l stärkeren Reduktion des Nüchternblutzuckers, weniger Hypoglykämien, einer deutlich günstigeren Gewichtsentwicklung, einer Reduktion des systolischen Blutdrucks um ca. 4 – 5 mmHg. Dagegen können mit kurz wirksamen Insulinanaloga postprandiale Blutzuckerwerte gezielter beeinflusst und zur Förderung der Therapieadhärenz und -persistenz unerwünschte gastrointestinale Ereignisse zu Therapiebeginn vermieden werden. GLP-1-RA können die Therapieadhärenz im Vergleich zu kurz wirksamen Insulinanaloga verbessern durch Körpergewichtsreduktionen, weniger Hypoglykämien, eine geringe Komplexität der Behandlung und eine höhere Therapiezufriedenheit. Bei bestimmten Patienten mit Typ-2-Diabetes konnte im Verlauf die Insulindosis reduziert oder Insulin abgesetzt werden.

Schlussfolgerung: Der Vergleich von GLP-1-RA und kurz wirksamen Insulinanaloga als Optionen zur Therapieintensivierung bei einer BOT ergibt ein differenziertes Bild, das die Basis für ein individualisiertes therapeutisches Vorgehen bei Patienten mit unzureichend kontrolliertem Typ-2-Diabetes darstellt. Offene Fragen bestehen hinsichtlich langfristiger Auswirkungen auf diabetesbezogene Komplikationen und bezüglich des individuell optimalen Zeitpunktes der erstmaligen Gabe von GLP-1-RA.

Abstract

Introduction: People with type 2 diabetes receiving a basal insulin therapy in combination with oral antidiabetic drugs (BOT) often develop the need for further intensification of treatment. In such situations, Glucagon-like peptide-1 receptor agonists (GLP-1-RA) are particularly suited for a combination treatment because their properties are complementary supportive to insulin.

Methods: The effect of the GLP-1 RA exenatide, liraglutide and albiglutide is analysed and compared with short-acting insulin analogues during intensification of BOT in patients with type 2 diabetes based on trials assessing the intensification of an existing insulin therapy.

Results: GLP-1 RA and short-acting insulins achieved at least equivalent HbA1c reductions in the review of ten randomised controlled trials, especially the 4B trial on exenatide, the BEGIN VICTOZA ADD-ON trial on liraglutide, and the HARMONY 6 trial on albiglutide. Individual trials showed advantages for GLP-1 RA in terms of an approx. 0.5 – 1.5 mmol/l greater reduction of fasting blood glucose, less episodes of hypoglycaemia, a clearly more favourable weight development, a reduction of systolic blood pressure by approx. 4 – 5 mmHg. On the other hand, short-acting insulin analogues are able to affect postprandial blood glucose values more specifically and to avoid adverse gastrointestinal events at the start of treatment if compared to GLP-1 RA which helps to promote treatment adherence and persistence. GLP-1 RA can help to improve treatment adherence compared with short-acting insulin analogues by body weight reduction, less episodes of hypoglycaemia, a lower complexity of treatment as well as a higher treatment satisfaction. Specific patients with type 2 diabetes were able to reduce the insulin dose or discontinue insulin completely in the course of treatment.

Conclusion: The comparison of GLP-1 RA and short-acting insulin analogues as options of treatment intensification in patients on BOT gives a differentiated picture, which is the basis for an individualised therapeutic procedure in patients with inadequate control of their type 2 diabetes. There are open questions regarding the long-term effects of diabetes-related complications and regarding the optimal individual point of time of the first GLP-1 RA administration.

Schlüsselwörter

Typ-2-Diabetes - Insulin - Exenatid - Liraglutid - Albiglutid - Hypoglykämien - Körpergewicht - GLP-1-Rezeptoragonist

Key words

type 2 diabetes - insulin - exenatide - liraglutide - albiglutide - hypoglycaemia - body weight - GLP-1-receptor agonist
 

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