Aspekte der modernen Diabetesbehandlung – Einfluss, Nachweis, Beurteilung und Vermeidung von Glukoseexkursionen

Durch randomisierte, kontrollierte Studien wie die DCCT oder UKPDS ist belegt, dass der die durchschnittliche Glukosekonzentration repräsentierende HbA_1c-Wert die Güte der Glukosestoffwechseleinstellung im Hinblick auf die Diabetesprognose einerseits gut beschreibt, andererseits aber in seiner Aussage begrenzt ist. Insbesondere reflektiert er keine Glukoseexkursionen und bietet dadurch auch keine Aussage zum Hypoglykämierisiko. Verschiedene experimentelle Untersuchungen legen aber den Schluss nahe, dass Glukoseexkursionen einen wesentlichen Einfluss auf die Entwicklung von vaskulären Schäden haben, sodass deren Vermeidung bis zum Beweis des Gegenteils als notwendig anzusehen ist. Durch die Verfügbarkeit des kontinuierlichen Glukosemonitorings (CGM) können Glukoseschwankungen seit einigen Jahren lückenlos aufgezeichnet und folglich bei der Therapieoptimierung berücksichtigt werden. Um aus den CGM-Profilen unmittelbar Schlussfolgerungen für die Diabetesprognose ziehen zu können, wurde das ”Glukosepentagon“-Modell entwickelt, für welches allerdings noch keine klinische Validierung erfolgte. Da es den HbA_1c-Wert beinhaltet, erweitert es diesen im Sinne der glykämischen Variabilität. Therapeutisch gibt es eine Reihe von Optionen für die Minimierung der glykämischen Variabilität, die abschließend zusammengefasst sind.

It has been demonstrated through randomized, controlled studies such as DCCT or UKPDS that the average glucose concentration represented by the HbA_1c value adequately describes on the one hand the efficacy of glucose metabolism control whereas, on the other hand, it has only limited information content. In particular it does not reflect glucose excursions and thus provides no information on the risk of hypoglycemia. Various experimental studies, however, strongly suggest that glucose excursions have a very considerable influence on the development of vascular damage; accordingly there avoidance should be considered as necessary as long as there is evidence to the contrary. With the availability of continuous glucose monitoring (CGM) in the past few years deviations in glucose concentration can be recorded over time and thus be taken into account in therapy optimization. In order to be able to obtain direct conclusions on the diabetic prognosis from the CGM profiles, the ”glucose pentagon“ has been developed it has as yet not been validated clinically. Since it includes the HbA_1c value it extends this in the sense of glycemic variability. Several therapeutic options are available to minimize glycemic variability and these are summarized in the concluding text.

Key words

Diabetes - glycemic variability - continuous glucose monitoring - ”glucose pentagon“

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