Therapie von Fettstoffwechselstörungen bei Diabetes mellitus – State of the Art

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 HbA_1c 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.

Key words

Insulin resistance - diagnosis of lipid disorders - target values - principals of therapy in diabetic patients

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