Frühe oder kurzzeitige Insulintherapie bei Typ-2-Diabetes: Stellenwert und Risiko-Nutzen-Bilanz im Rahmen individualisierter Therapiekonzepte

Zusammenfassung

Trotz großer Fortschritte in der Qualität der Diabetestherapie wird der Anteil des Diabetes an der Gesamtsterblichkeit in Deutschland mit ca. 20 % angegeben. Diabetesbezogene Komplikationen sind wieder zum Schicksal vieler Patienten (im Besonderen Senioren) mit langer Diabetesdauer geworden. Die Prävention dieser Komplikationen erfordert eine frühe Diagnose sowie eine rasche und konsequente Glykämiekontrolle für den Erhalt und die Remission der residualen B-Zell-Funktion sowie den Schutz des Endothels vor Gluko- und Lipotoxizität. Die glykämische Last gilt für Makro- und Mikroangiopathien im Prinzip gleichermaßen. Mit den bahnbrechenden Ergebnissen der Outcome-Studien mit SGLT2-Inhibitoren und GLP1-Analoga ist sowohl in den Leitlinien als auch in der täglichen klinischen Praxis Bewegung in die Rangfolge der Antidiabetika gekommen. Angesichts dieser sehr positiven Entwicklung muss insofern das Postulat der frühen Insulintherapie im Rahmen einer individualisierten, risikoadjustierten Behandlung überprüft werden. Dieses White Paper demonstriert anhand von gut dokumentierten, kontrollierten Studien, dass bei klinisch kranken Patienten klare Indikationen für eine initiale, intensivierte Insulintherapie bereits zu Beginn des Diabetes gegeben sind. Die Insulintherapie zeigt im Vergleich zu anderen antidiabetischen Behandlungsstrategien den schnellsten Effekt in Bezug auf die Zielerreichung und Glukolipotoxizität. Im Hinblick auf die überwiegende Multimorbidität der Patienten und langanhaltende Remissionen – bis zu 50 % nach 2 Jahren – ist dies außerdem kosteneffektiv. Allerdings sind die Vorteile der frühen Insulintherapie nicht direkt übertragbar auf den langjährigen Diabetes. Jedoch ändert sich da die Situation, wenn nach Ausschöpfung aller Therapieoptionen für orale Antidiabetika und GLP1-Analoga eine weitere Verschlechterung des Diabetes zu beobachten ist oder diabetesbedingte Komplikationen vermehrt auftreten. In diesen Fällen können die positiven Effekte der frühzeitigen Insulinisierung ebenso in Betracht gezogen werden.

Abstract

Despite major advances in the quality of diabetes therapy, the contribution of diabetes to total mortality in Germany is estimated about 20 %. Diabetes-related complications have again become the fate of many (especially elderly) patients with long-term diabetes. Prevention of these complications requires early diagnosis, and a rapid, near to normal glycemic control for the remission and maintenance of residual B-cell function, as well as for the protection of the endothelium from gluco- and lipotoxicity. The glycemic load is in principle equally valid for macroangiopathy and microangiopathy. With the ground-breaking results of the outcome studies with SGLT2 inhibitors and GLP1 analogues, movement has now come into the ranking of antidiabetics in guidelines and daily clinical practice as well. In this eventful, very positive development, the postulate of early insulin therapy must undoubtedly be re-examined as part of an individualised, risk-adjusted treatment. This paper shows with well documented controlled trials that an initial, intensified insulin therapy is indicated already at the onset of diabetes in clinically ill patients. Insulin therapy shows the fastest effect on target attainment and on glucolipotoxicity compared to other antidiabetic treatment strategies. In view of the predominant multimorbidity of patients and long-lasting remissions – up to 50 % after 2 years – this is also cost-effective. Certainly, the benefits of early insulin therapy are not directly transferable to long-term diabetes. However, the situation changes when, once the therapy options with oral therapy and GLP1 analogues have been exhausted, diabetes worsens again or diabetes-related complications occur. In these cases, all the positive effects of early insulinization can be taken into account.

Schlüsselwörter

Typ-2-Diabetes - individualisierte Therapie - frühzeitige Insulintherapie

Key words

type 2 diabetes - individualised therapy - early insulin therapy

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