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Therapie des Diabetes mellitus Typ 2 und kardiovaskuläre Komplikationen

Was ist evidenzbasiert?

Treatment of type 2 diabetes mellitus and cardiovascular complications:

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  • Klinische Pharmakologie
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Kardiovaskuläre Komplikationen verkürzen das Leben von Typ-2-Diabetikern maßgeblich. Die chronische Hyperglykämie ist nur ein Faktor, der zur Entstehung von makrovaskulären Komplikationen beiträgt. Erhöhte HbA1c-Werte weisen auf diesen Zustand hin. Unklar ist, inwieweit die therapeutische HbA1c-Senkung das kardiovaskuläre Risiko verringert. Eine positive Evidenz in Bezug auf kardiovaskuläre Endpunkte ist für Lebensstilmodifikationen, Acarbose und Metformin zu erkennen. Insulinotrope Substanzen (Sulfonylharnstoffe, Glinide, Insulin) haben ein erhöhtes Risiko für Hypoglykämien und Gewichtszunahme, was möglicherweise die kardiovaskuläre Morbidität und Mortalität negativ beeinflusst. Dies gilt besonders für kardial vorbelastete Patienten. Bei den neueren Substanzen wie den Glitazonen gibt es positive Zeichen für den Einsatz von Pioglitazon bei Patienten ohne Herzinsuffizienz. Für die Inkretin-Therapeutika (Exenatid, Sitagliptin) liegen bisher keine Studien mit kardiovaskulären Endpunkten vor. Zusammenfassend legen die vorliegenden Studien und pathophysiologischen Überlegungen den Schluss nahe, dass zur Verhinderung kardiovaskulärer Komplikationen möglichst früh, d. h. im prädiabetischen Stadium, therapiert werden sollte. Nichtinsulinotrope Substanzen führen in der Regel zu keinen Hypoglykämien und sind daher bei kardial vorbelasteten Patienten zu bevorzugen. Über die Hyperglykämiebehandlung hinaus ist die Behandlung klassischer kardialer Risikofaktoren entscheidend.

Abstract

Cardiovascular events are the main life-threatening complications in patients with type 2 diabetes. Chronic hyperglycaemia is thought to be only one factor contributing to the development of macrovascular disease. Elevated glycosylated haemoglogin is indicative for this condition. It is, however, not clear whether therapeutic lowering of glycosylated haemoglobin will lead to a reduction in cardiovascular risk. Lifestyle modifications, acarbose and metformin apparently reduce cardiovascular events and should therefore be the mainstay of type 2 diabetes therapy. Insulin-elevating substances (sulphonylureas, meglitinides and ultimately insulin) impose a higher risk for hypoglycaemic episodes and weight gain with potentially harmful effects especially on patients with established cardiovascular disease. Of the newer drugs, pioglitazone has been shown to reduce cardiovascular risk, but may negatively affect patients with heart failure. Modulators of the incretin system (exenatide, sitagliptine) have not yet been investigated for cardiovascular outcome. Taken together, available studies suggest that a reduction of cardiovascular risk depends crucially on early therapeutic interventions, the use of non-insulin-releasing substances, prevention of hypoglycaemias and treatment of classic cardiovascular risk factors.

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  1. Institut für Experimentelle und Klinische Pharmakologie und Toxikologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland

    M. Tiburcy &  W.-H. Zimmermann

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  1. M. Tiburcy
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  2. W.-H. Zimmermann
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Correspondence to M. Tiburcy or W.-H. Zimmermann.

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Tiburcy, M., Zimmermann, WH. Therapie des Diabetes mellitus Typ 2 und kardiovaskuläre Komplikationen. Kardiologe 2, 417–429 (2008). https://doi.org/10.1007/s12181-008-0119-4

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