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Medikamentöse Therapie der diabetischen Retinopathie – Die diabetologische Perspektive

Systemic treatment of diabetic retinopathy—the medical perspective

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Zusammenfassung

Die Primärprävention und Sekundärintervention bei diabetischer Retinopathie stützen sich auf die wesentlichen pathogenetischen Faktoren Blutzucker und Blutdruck, während die Behandlung der Dyslipidämie zur Progressionshemmung umstritten ist. Die Effektstärke der Blutzuckerspiegelsenkung auf die Retinopathie ist moderat, es existiert bei Typ-1-Diabetes ein „point of no return“ (moderate nichtproliferative diabetische Retinopathie), ab dem eine Normalisierung des Blutzuckerspiegels (HbA1c-Zielwert [HbA1c: Glykohämoglobin Typ A1c] 7 %, 53 mmol/mol) keinen Effekt mehr hat. Bei Typ-2-Diabetes (T2D) ist das Wirkfenster der normnahen Einstellung noch kleiner. Am besten profitieren Patienten während der Phase der milden nichtproliferativen diabetischen Retinopathie. Neue Daten zur Behandlung eines T2D erinnern wegen der möglichen Verschlechterung einer vorbestehenden Retinopathie durch abrupte Verbesserung der Stoffwechselkontrolle mit lang wirksamen GLP-1-Rezeptor-Agonisten (GLP-1: „glucagon-like peptide 1“) an die Notwendigkeit, eine Funduskontrolle bei Patienten zu veranlassen, bei denen eine Retinopathie bekannt oder nicht untersucht ist und bei denen eine beträchtliche Senkung des HbA1c (>1 %) innerhalb einer relativ kurzen Zeit (<3 Monate) vorgenommen wird („euglycemic reentry“). Gleiches gilt für Menschen mit T2D vor Bariatrie. Der Effekt der Blutdrucksenkung ist unbestritten, bedarf aber einer individuellen Abwägung. Ziel ist ein Blutdruck von 140/80 mmHg. Eine diabetische Retinopathie erfordert insbesondere bei Hochrisikopatienten eine präzise interdisziplinäre Kommunikation.

Abstract

Primary prevention of and secondary intervention in diabetic retinopathy is based on the main pathogenetic factors, glycemia and blood pressure, whereas targeting dyslipidemia to inhibit progression is controversial. The overall effect of euglycemia on retinopathy is moderate and point of no return exists in type-1 diabetes (moderate non-proliferative diabetic retinopathy) beyond which euglycemia (target hemoglobin type A1c [HbA1c] of 7%, 53 mmol/mol) does not produce any further benefit to the retina. In type-2 diabetes (T2D), the window of opportunity is even smaller. Individuals with mild non-proliferative diabetic retinopathy benefit most. Recent data on the treatment of T2D with long-acting glucagon-like peptide 1 (GLP-1) receptor agonists underline the need to examine the retina due to early worsening in those with a considerable fall in HbA1c (>1%) within a short period of time (<3 months; euglycemic reentry) in the case of preexisting retinopathy or unknown status. The same applies for T2D patients prior to bariatric surgery. The effect of blood pressure control is undisputed, but requires consideration on a case-by-case basis. Blood pressure according to Riva-Rocci (RR) of 140/80 mm Hg should be aimed for. Diabetic retinopathy demands precise communication between disciplines, particularly in the case of high-risk patients.

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  1. Universitätsmedizin Mannheim, 5. Medizinische Klinik, Sektion Endokrinologie, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    Hans‑Peter Hammes

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H.-P. Hammes weist auf folgende Beziehungen hin: Beratung: Novo-Nordisk, MSD; Vortragstätigkeit: Novartis, Bayer, Sanofi, Heidelberg Engineering

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Hammes, H. Medikamentöse Therapie der diabetischen Retinopathie – Die diabetologische Perspektive. Diabetologe 14, 568–576 (2018). https://doi.org/10.1007/s11428-018-0372-5

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