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Diabetes aktuell 2013; 11(4): 156-160
DOI: 10.1055/s-0033-1347087
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© Georg Thieme Verlag Stuttgart · New York

Moderne Fettstoffwechseltherapie bei Patienten mit Diabetes mellitus – Was ist neu?

Modern therapy of lipoprotein disorders – what's new?
Markolf Hanefeld
1   Studienzentrum Professor Hanefeld, GWT-TUD GmbH, Dresden
,
Xenia Ganz
1   Studienzentrum Professor Hanefeld, GWT-TUD GmbH, Dresden
2   Medizinische Klinik III, Universitätsklinik Carl Gustav Carus, Dresden
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Publication History

Publication Date:
08 July 2013 (online)

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Fettstoffwechselstörungen sind häufige Begleiter des Diabetes (> 50 %). Sie sind in komplexer Weise mit der Pathophysiologie des Diabetes und der viszeralen Adipositas verknüpft. Erhöhte LDL-Cholesterinwerte, besonders Small-dense-LDL, sind der wichtigste modifizierbare kardiovaskuläre Risikofaktor bei Diabetikern. HDL-Defizite und erhöhte Triglyzeride sind vor allem im Kontext mit dem metabolisch-vaskulären Syndrom Risikoverstärker. Die Diagnostik umfasst deshalb die Lipidtrias: LDL-Cholesterin, Triglyzeride und HDL-Cholesterin, bei vorbestehender kardiovaskulärer Erkrankung auch ApoB und Lp(a). Lebensstilintervention nach den ESC-Leitlinien ist, wie beim Diabetes, die rationelle Basis der Therapie. Typ-2-Diabetes repräsentiert eine kardiovaskuläre Hochrisikogruppe und stellt damit a priori eine Indikation für eine Statintherapie dar, wobei Simvastatin und Atorvastatin die Standardpräparate sind. Das Hypertriglyzeridämie-/Low-HDL-Syndrom bei Diabetes erfordert eine risikoadjustierte multimodale Add-on-Therapie zum Statin oder im Falle einer Statinunverträglichkeit eine Monotherapie. Hierfür stehen zur Zeit Fibrate (Fenofibrat, Bezafibrat) und bei Hypertriglyzeridämie Omega-3-Fettsäuren zur Verfügung. Chylomikronensyndrome erfordern ein striktes Alkoholverbot und eine Fettbeschränkung < 10–20 % der Gesamtkalorien. Während der Nutzen einer Statintherapie als sehr hoch (Evidenzklasse 1a) einzustufen ist, muss die Add-on-Therapie am individuellen Risiko des Patienten bemessen werden. Sie bleibt aber eine klinisch relevante Option einer multimodalen Lipidtherapie im Kontext mit dem metabolisch-vaskulären Syndrom.

Lipoprotein disorders are common companions (> 50 % prevalence) of diabetes. They are in a complex way interrelated with the pathophysiology of dysglycemia and visceral obesity. Increased LDL-Cholesterol in particular small dense LDL are the most important modifyable cardiovascular risk factor in patients with type 2 diabetes. However HDL deficits and increased triglycerides are mainly triggers of cardiovascular risk in patients with metabolic-vascular syndrome. The rational diagnostics therefore implies the lipid-triad: LDL-Cholesterol, triglycerides und HDL-cholesterol. In patients with already existing cardiovascular diseases Apo B and Lp(a) measurement is recommended. Lifestyle intervention according to ESC guidelines is the basis of a rational therapy with no principle difference to recommendations to established diabetes diet and recommendations for fitness training. Type 2 diabetes can be considered as equivalent of cardiovascular disease. Therefore all guidelines recommend a statin therapy as essential part of cardiovascular prevention. Simvastatin and atorvastatin are standard drugs.

The hypertriglyceridemia/low HDL syndrome requires a risk adjusted individualized approach as add-on therapy to statins or as monotherapy if statins are not tolerated. In the case of hypertriglyceridemia/low HDL Fibrates (Fenofibrate, Bezafibrate) are recommended. For hypertriglyceridemia Omega 3 Fatty acids may be beneficial. Chylomicrone syndroms request a strict prohibition of alcohol and restriction of fat intake < 10–20 %.

While the benefit of statin treatment has a evidence level of 1a because of a bulk of data of controlled outcome studies the add-on therapy with fibrates and Omega 3 Fatty acids must be individualized. It remains however a rational option of multimodal lipid therapy in patients with the metabolic vascular syndrome.

Key words

Lipoprotein disorders - diabetes - dysglycemia - obesity
 

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