Insulintherapie bei Diabetes mellitus Typ 2: patientenzentriert, rechtzeitig, nutzen-risiko-bilanziert; Standortbestimmung 2019 nach dem ADA/EASD-Konsensus 2018

Zusammenfassung

Erhöhte Blutzucker- und Fettsäurespiegel schädigen die residuale B-Zell-Regeneration und -Funktion (Glukolipotoxizität) und vermindern die Insulinempfindlichkeit von Muskulatur, Fettgewebe, Leber und Endothel der Gefäßwand. Chronische Hyperglykämie triggert in einem komplexen circulus vitiosus proatherogene und inflammatorische Prozesse, die die Morbidität und Mortalität erhöhen. Die rechtzeitige nutzen-risiko-basierte Therapie mit Insulin schützt nachhaltig die B-Zellen und kann die Progression des Diabetes wesentlich verzögern. Damit verbunden ist eine signifikante Senkung der Inzidenz diabetesbezogener Komplikationen. Langzeitstudien mit intensivierter Glykämiekontrolle und Insulin haben zu der Empfehlung geführt, den HbA_1c-Wert von Anfang an unter 6,5–7,0 % zu halten, unter Vermeidung von Hypoglykämien. Die Zielkorridore für Blutzucker und HbA_1c-Wert sollten an die individuelle Lebenssituation, eine realistische Einschätzung der Nutzen-Risiko-Bilanz und die Möglichkeiten des Patienten angepasst werden. Langwirksame Basalinsuline ermöglichen einen einfachen Einstieg in die Diabeteskontrolle zu jedem Zeitpunkt der Entgleisung. Dies gilt, wenn Metformin, orale duale oder Triple-Therapien und GLP-1-Rezeptoragonisten nicht länger ausreichen, um die Zielkorridore für Blutzucker und HbA_1c-Wert einzuhalten. Rechtzeitiger Einsatz von Insulin ist besonders indiziert für Subtypen mit schwerem Insulinmangel, Patienten mit diabetesbezogenen Komplikationen sowie Individuen mit chronischen Infekten und/oder Sarkopenie. Rechtzeitiger Einsatz von Insulin ist effektiver, sicherer und auch kostengünstiger, da dies hilft, Polypharmazie zu vermeiden.

Abstract

Chronic hyperglycemia and elevated fatty acids exert harmful effects on B-cell function, B-cell regeneration, and apoptosis. Furthermore, glucolipotoxicity increases insulin resistance of muscles, adipose tissue, liver, endothelial cells, and of the vascular wall. Thus, chronic hyperglycemia triggers in a vicious cycle proatherogenic and inflammatory processes.

Timely risk/benefit-adjusted treatment with insulin is the most effective medication for treating glucolipotoxicity and to protect B-cells. Insulin can be used to control glucose levels and HbA_1c at any time of disease duration and HbA_1c level respectively at start of intervention. Clinical studies under real-world conditions and large-scale, long-term, prospective trials have shown that early as well as timely use of insulin to keep HbA_1c at target levels below 7 % has beneficial effects on diabetes-related diseases. In older and multimorbid patients, targets must be adapted to real life conditions, risk/benefit balance, and the expectations of our patients. Long-acting basal insulins allow an easy entry to control HbA_1c and glucose levels on target at any time and stage of the disease. This is valid for all steps of oral treatment with or without GLP-1-receptor agonists according to recent ADA/EASD recommendations. Timely use of insulin is strongly indicated in subgroups of type 2 diabetes with severe insulin deficit, patients with early diabetes-related diseases and in individuals with sarcopenia and/or chronic infections.

In conclusion: Timely use of insulin with patient-centered indication is an effective and safe option for maintenance of glucose control on target. It improves resilience, prevents diabetes-related complications and is thus also cost-effective.

Schlüsselwörter

Typ-2-Diabetes - Insulintherapie - individualisierte Therapie

Key words

type 2 diabetes - insulin therapy - individualised therapy

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