Multimodale Lipidtherapie bei Diabetes

 

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Zusammenfassung

Die Dyslipoproteinämie bei Diabetes repräsentiert eine komplexe Pathophysiologie atherogener Lipoproteinfraktionen, die eng mit der Dysglykämie und den Komorbiditäten, besonders der viszeralen Adipositas verknüpft sind. Die Diagnostik umfasst deshalb die Triglyzeride, Cholesterin, LDL-Cholesterin und HDL-Cholesterin, ggf. Apo B und Lp(a) als Grundlage einer differenzierten Betrachtung des Lipidrisikos und einer multimodalen Therapie. Da Typ-2-Diabetiker a priori eine Hochrisikogruppe für kardiovaskuläre Erkrankungen darstellen, empfehlen nationale und internationale Leitlinien eine strikte Kontrolle der Lipidtrias mit LDL-Cholesterin < 70 mg/dl, Triglyzeriden < 150 mg/dl und HDL-Cholesterol > 40 mg/dl bei Männern resp. > 50 mg/dl bei Frauen. Lebensstil-Intervention mit Gewichtsreduktion und physischer Konditionierung ist als Basistherapie eine primäre, effektive und sichere Option für die Senkung erhöhter Triglyzeride, verbunden mit moderatem Anstieg des HDL-Cholesterins. LDL-Cholesterin wird dadurch nur marginal gebessert. Statine sind aufgrund ihres umfassend dokumentierten präventiven Nutzens bei Typ-2-Diabetikern obligat. Es bleibt aber auch bei LDL-Cholesterinwerten im Zielbereich unter 100 mg/dl ein hohes „Lipidrestrisiko“. Hier setzt die multimodale Therapie als Add-on ein oder im Fall einer Statinunverträglichkeit als Monotherapie. Hierfür stehen 3 Substanzgruppen zur Verfügung: Fibrate, Nikotinsäure, Omega-3-Fettsäuren, für die allerdings nur wenige evidenzbasierte Daten aus kontrollierten Outcomestudien zur Verfügung stehen. Bei dieser komplexen Lage ist eine individualisierte Therapie erforderlich, die sich an der Pathophysiologie, dem Typ der Fettstoffwechselstörung und dem globalen Risiko des Patienten orientiert. Der vorliegende Review möchte eine Anleitung zur risikoadjustierten, rationellen, multimodalen Lipidtherapie vermitteln.

Abstract

Dyslipoproteinemia in patients with diabetes represents a complex pathophysiology of atherogenic lipoprotein fractions which are strongly influenced by quality of glycemic control and visceral obesity. Therefore the diagnostic comprise total cholesterol, LDL-cholesterol, triglycerides and HDL-cholesterol, eventually complmented by apoB and Lp(a) as basis of risk estimation and of multimodale integrated therapy. Since type 2 diabetes already itself is a major cardiovascular risk factor national and international guideline recommend strict control of all three parameters of the lipid triad: LDL-cholesterol < 70 mg/dl, triglycerides < 150 mg/dl and HDL-Cholesterol in males of > 40 mg/dl and females > 50 mg/dl. Lifestyle intervention with reduction of overweight and appropriate physical exercise is in any case an essential effective and safe part of treatment of hypertriglyceridemia/low HDL, with little effect on LDL-cholesterol. Guidelines recommend statins in patients with type 2 diabetes since they represent a high risk group for cardiovascular disease with class Ia evidence from randomized trials. However despite LDL-cholesterol levels < 100 mg/dl under statin treatment there remains a high lipid risk in the case of diabetic dyslipidemia. Therefore patients with low HDL/hypertriglyceridemia syndrome need an add-on therapy to completely correct the lipid triad. There are three classes of drugs with cardioprotective potentials: fibrates, nicotinic acid derivatives and omega 3 fatty acids. There exist only inconsistent data on cardiovascular outcome for add-on therapy to statins in patients with diabetes. Therefore an individualized decision based on pathophysiology and global risk estimation is essential. This review presents a guide to individualized risk adjusted treatment of multimodale lipidtherapy of patients with diabetes.

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