Frühe Insulintherapie im Netzwerk individualisierter Therapie des Typ-2-Diabetes

Die Therapie des Typ-2-Diabetes befindet sich im Umbruch, scheinbar sichere Paradigmen müssen im Licht neuer Studienergebnisse kritisch hinterfragt werden, viele neue Therapieoptionen drängen auf den Markt, oft mit 4 oder mehr Vertretern einer Substanzklasse, jüngstes Beispiel DPPIV-Inhibitoren. Doch für die meisten etablierten Antidiabetika fehlen evidenzbasierte Daten im direkten Vergleich. Die zu Beginn des Jahrhunderts gestarteten Megatrials ADVANCE, ACCORD, VADT haben alle das Ziel, durch verbesserte Glykämiekontrolle, gemessen am HbA_1c, die Inzidenz kardiovaskulärer Endpunkte zu senken, verfehlt [1] [2] [3]. Diabetes-bezogene Komplikationen, Sicherheit und Karzinomrisiko waren dabei nur sekundäre Zielgrößen. In der ACCORD stieg unter intensivierter Therapie die kardiovaskuläre Mortalität sogar um über 21 % an, weshalb diese vorzeitig beendet wurde [2]. So blieb bis zur Publikation der ORIGIN-Daten im Juni diesen Jahres [4] nur die UK-PDS als valide Outcome-Studie, die einen direkten Vergleich von 3 etablierten Therapieoptionen Metformin, Sulfonylharnstoffe und Insulin erlaubte. Nach 11 Jahren ergab sich bei neu diagnostizierten Typ-2-Diabetikern ein signifikanter Benefit für alle 3 Therapien bezüglich mikrovaskulärer Komplikationen. Die Inzidenz kardiovaskulärer Ereignisse und Gesamtsterblichkeit wurde nur durch Metformin signifikant reduziert. Die HbA_1c-Werte unterschieden sich am Ende der Interventionsphase aber nicht signifikant [5] [6]. Seitdem wird Metformin unangefochten in allen Leitlinien als First Line Drug zur Therapie des Typ-2-Diabetes empfohlen [7] [8].

• Literatur

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