Zusammenfassung
Hintergrund
Viele Patienten mit Diabetes mellitus leiden auch an Fettstoffwechselstörungen. Diese Dyslipoproteinämie (erhöhte Triglyzerid-; erniedrigte HDL-Cholesterin-Werte [HDL: „high density lipoproteins“]; kleine, dichte LDL-Partikel [LDL: „low density lipoproteins“]) stellt den wichtigsten Verknüpfungspunkt zwischen Diabetes und vorzeitiger Atherosklerose dar.
Therapie
Eine konsequente Behandlung der Fettstoffwechselstörung reduziert das kardiovaskuläre Risiko. Primäres Ziel dabei ist die Absenkung des LDL-Cholesterin-Werts. Diabetespatienten mit nachgewiesener Atheroskleroseerkrankung oder zusätzlichen Risikofaktoren oder Endorganschäden sollten einen LDL-Cholesterin-Spiegel <70 mg/dl (<1,8 mmol/l) bzw. einen Non-HDL-Cholesterin-Wert <100 mg/dl (<2,6 mmol/l) erreichen. Bei Patienten mit Diabetes, aber ohne die oben angeführten Charakteristika sollten ein LDL-Cholesterin-Wert <100 mg/dl (<2,6 mmol/l) bzw. eine Non-HDL-Cholesterin-Konzentration <130 mg/dl (<3,4 mmol/l) erzielt werden. Hierfür sollten neben Lebensstilmaßnahmen und Blutzuckerspiegeleinstellung in sequenzieller Folge Statine, Statine mit Ezetimib und eine Kombination von Statinen mit Ezetimib und PCSK9-Inhibitoren (PCSK9: Proproteinkonvertase Subtilisin/Keksin Typ 9) eingesetzt werden. Als Ultima ratio kommt die LDL-Apherese in Frage. Bezüglich der oft vorhandenen Hypertriglyzeridämie stehen Lebensstilmaßnahmen und die Einstellung des Blutzuckerspiegels im Vordergrund. Bei Patienten mit sehr hohem Risiko kann trotz unklarer Endpunktstudienlage eine Kombination mit Fibraten bzw. Omega-3-Fettsäuren erwogen werden.
Ausblick
Neue Medikamente zur Behandlung der Dyslipoproteinämie werden entwickelt, müssen aber in Endpunktstudien untersucht werden, bevor sie in der klinischen Praxis eingesetzt werden können.
Abstract
Background
Many patients with diabetes mellitus are characterized by changes in lipid metabolism. Typical dyslipoproteinemia (elevated triglycerides, low HDL cholesterol [HDL: high-density lipoproteins], small dense LDL particles [LDL: low-density lipoproteins]) is the most important link between diabetes mellitus and premature cardiovascular disease.
Treatment
Rigorous treatment of elevated lipids reduces cardiovascular morbidity and mortality. The primary goal is the reduction of LDL cholesterol. In diabetes patients and established cardiovascular disease or additional risk factors or end-organ damage, the LDL cholesterol level should be <70 mg/dl (<1.8 mmol/l) with a non-HDL cholesterol value <100 mg/dl (<2.6 mmol/l). In patients with diabetes but without the above mentioned characteristics, the LDL cholesterol value should be <100 mg/dl (<2.6 mmol/l) and the non-HDL cholesterol value <130 mg/dl (<3.4 mmol/l). To achieve these targets, statins, statins with ezetimibe, or a combination of statins with ezetimibe and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors should be sequentially used in addition to lifestyle modification and glucose control. LDL apheresis is available as a “last resort” form of therapy. Concerning the hypertriglyceridemia which is very often present, lifestyle modification and glucose control are the most important treatment modalities. In patients with very high risk, a combination with fibrates and/or ω‑3-fatty acids can be considered despite the lack of convincing outcome data.
Future
New medications for the treatment of dyslipoproteinemia are currently being developed but must be evaluated in outcome trials before they can be used in clinical practice.
Abbreviations
- ACCORD:
-
„Action to control cardiovascular risk in diabetes“
- ADA:
-
„American Diabetes Association“
- AIM-HIGH:
-
„Atherothrombosis intervention in metabolic syndrome with low HDL/high triglycerides“
- ANGPTL3:
-
„Angiopoietin-like 3“
- Apo:
-
Apolipoprotein
- CETP:
-
Cholesterinestertransferprotein
- EAS:
-
„European Atherosclerosis Society“
- ESC:
-
„European Society of Cardiology“
- FOURIER:
-
„Further cardiovascular outcomes research with PCSK9 inhibition in subjects with elevated risk“
- G-BA:
-
Gemeinsamer Bundesauschuss
- HDL:
-
„High density lipoproteins“
- HMG-CoA:
-
Hydroxymethylglutaryl-Koenzym A
- HPS2-THRIVE:
-
„Treatment of HDL to reduce the incidence of vascular events HPS2-THRIVE“
- IDL:
-
„Intermediate density lipoproteins“
- IMPROVE-IT:
-
„Improved reduction of outcomes: vytorin efficacy international trial“
- LDL:
-
„Low density lipoproteins“
- LPL:
-
Lipoproteinlipase
- NPC1L1:
-
„Niemann-Pick C1-like protein 1“
- ODYSSEY outcomes:
-
„Evaluation of cardiovascular outcomes after an acute coronary syndrome during treatment with alirocumab“
- ORIGIN:
-
„Outcome reduction with an initial glargine intervention“
- PCSK9:
-
Proproteinkonvertase Subtilisin/Keksin Typ 9
- RNA:
-
Ribonukleinsäure
- si-RNA:
-
„Small interfering RNA“
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K. G. Parhofer gibt folgende Interessenkonflikte an: Vortragshonorare, Honorare für Advisory Board Tätigkeit, Honorare für DMC-Tätigkeit und/oder Forschungsunterstützung von folgenden Unternehmen: Aegerion, Berlin-Chemie, Boehringer-Ingelheim, MSD, Regeneron, Roche, Sanofi.
Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.
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Parhofer, K.G. Diabetes Update 2017 – Lipide. Diabetologe 13, 313–321 (2017). https://doi.org/10.1007/s11428-017-0233-7
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DOI: https://doi.org/10.1007/s11428-017-0233-7