Konsequenzen eines Wechsels von Glukose- zu HbA1c-basierten Kriterien für die Diabetesdiagnose: Ein narratives Review aus epidemiologischer Sicht

Zusammenfassung

Die American Diabetes Association (ADA) empfiehlt einen HbA1c-Wert ≥ 6,5 % als alternatives Kriterium für die Diagnose des Typ-2-Diabetes (T2DM), das International Expert Committee aus Experten von ADA, EASD und IDF sieht den HbA1c sogar als glukosebasierten Kriterien überlegen an. Eine Auswertung bisher vorliegender epidemiologischer Studien zeigt, dass ein Wechsel von glukose- zu HbA1c-basierten Kriterien gravierende Folgen hätte – beispielsweise für die Diabetesprävalenz in der Bevölkerung. In den meisten Studien sinkt die Prävalenz des T2DM – teilweise deutlich – ab, wenn die Diabetesdiagnose auf dem Kriterium HbA1c ≥ 6,5 % und nicht mehr auf dem oralen Glukosetoleranztest (OGTT) beruht. Die Sensitivität des HbA1c für Diabetesfälle, die nach glukosebasierten Kriterien diagnostiziert wurden, schwankt in den bisherigen Studien zwischen 17 und 78 %, der positive prädiktive Wert zwischen 15 und 98 %: Beides zeigt eine teilweise sehr geringe Überlappung der nach Glukose- beziehungsweise HbA1c-Kriterien definierten Diabetespopulationen an. Auch die Prävalenz des Prädiabetes variiert je nach gewähltem Kriterium (WHO 1999, ADA 2003, HbA1c 5,7–6,4 %, HbA1c 6,0–6,4 %) erheblich, die Überlappung der nach unterschiedlichen Kriterien als prädiabetisch identifizierten Populationen ist in der Regel gering. Personen, die nur per OGTT eine Diabetesdiagnose erhalten haben, haben nach ersten Analysen ein etwas ungünstigeres metabolisches Profil als Personen, die nur anhand des HbA1c diagnostiziert wurden. Es fehlen Langzeitstudien, die zeigen, ob Probanden, die nach den Glukose- beziehungsweise dem neuen HbA1c-Kriterium diagnostiziert wurden, unterschiedliche Risiken für Komplikationen aufweisen. Auch die in Deutschland durchgeführte KORA-Studie zeigt, dass mit HbA1c- und mit Glukosemessungen Diabetesdiagnosen für unterschiedliche Populationen gestellt werden.

Abstract

The American Diabetes Association (ADA) recommends HbA1c ≥ 6.5 % as an alternative criterion for the diagnosis of type 2 diabetes (T2DM). The International Expert Committee with ADA, EASD, and IDF experts even considers HbA1c as superior to glucose-based criteria for the diagnosis of diabetes. A review of present epidemiological studies shows that switching from glucose to HbA1c criteria would have serious consequences, for instance for the prevalence of diabetes in the population. In most studies the prevalence of T2DM decreased, sometimes dramatically, with diagnosis of diabetes by HbA1c ≥ 6.5 % instead of the oral glucose tolerance test (OGTT). In studies published so far, the sensitivity of HbA1c for the identification of diabetes cases diagnosed with glucose-based criteria ranged from 17 to 78 %, the positive predictive value ranged from 15 to 98 %, indicating sometimes very small overlap of populations defined as diabetic by glucose or HbA1c criteria. Prevalence of prediabetes also varied considerably when different criteria (WHO 1999, ADA 2003, HbA1c 5.7–6.4 %, HbA1c 6.0–6.4 %) were used, there was little overlap of the populations with prediabetes by different criteria. Subjects having a diagnosis of diabetes only by OGTT showed a somewhat more adverse metabolic profile than subjects diagnosed only by the HbA1c criterion. There is still a lack of prospective data showing whether subjects diagnosed with diabetes by either glucose criteria or by the new HbA1c criterion have different risks of complications. The German KORA study also gave evidence that different populations are diagnosed with diabetes by applying HbA1c and glucose criteria.

Schlüsselwörter

Typ-2-Diabetes - Prädiabetes - HbA1c - oraler Glukosetoleranztest - Diabetesdiagnose

Key words

type 2 diabetes - prediabetes - glycosylated hemoglobin A - oral glucose tolerance test - diagnosis of diabetes

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