Diabetische Dyslipoproteinämie: jenseits von LDL

Zusammenfassung

Angesichts der dramatischen Zunahme des Diabetes mellitus Typ 2 wird eine adäquate Therapie der diabetischen Dyslipoproteinämie zur Prophylaxe kardiovaskulärer Erkrankungen immer wichtiger. Zentrales pathogenetisches Charakteristikum dieser Fettstoffwechselstörung ist eine Erhöhung der Plasma-Triglyzeride. Die triglyzeridreichen Lipoproteine selbst sind nicht atherogen; sie werden allerdings zu Restpartikeln (Chylomikronen-Remnants und VLDL-Remnants) abgebaut. Über den durch Cholesterylester-Transferprotein (CETP) vermittelten Lipidtransport entstehen atherogene kleine dichte LDL-Partikel (sdLDL), und das HDL-Cholesterin wird gesenkt. Alle diese Faktoren bewirken ein deutlich erhöhtes kardiovaskuläres Risiko. Abgesehen von Allgemeinmaßnahmen wie Gewichtsreduktion und Diät ist eine spezifische, durch eine robuste Datenlage begründete Therapie der diabetischen Dyslipoproteinämie schwierig. Weder für Fibrate noch für Nikotinsäure liegen derzeit überzeugende Endpunktstudien vor, die einen primären Einsatz dieser Medikamente rechtfertigen würden. Vor diesem Hintergrund ist ein zielwertgerechter Einsatz von Statinen zur Senkung des LDL-Cholesterins mit dem Ziel der größtmöglichen Reduktion des kardiovaskulären Risikos die Basis der Therapie der diabetischen Dyslipoproteinämie. Der Einsatz anderer Lipidsenker kann im Einzelfall erwogen werden.

Summary

Diabetes mellitus type 2 is reaching epidemic proportions in western societies. The treatment of diabetic dyslipidemia to prevent cardiovascular disease is of increasing clinical and scientific interest. In the pathogenesis of this disease plasma triglycerides play a central role. Triglyceride rich particles by themselves are not considered atherogenic; however, they are hydrolysed to chylomicron and VLDL remnant particles. Furthermore, mediated by cholesteryl ester transfer protein (CETP), atherogenic small dense LDL particles (sdLDL) emerge, and HDL cholesterol decreases. All these factors yield into a significantly increased atherogenesis and cardiovascular risk. Weight reduction and low fat diets have shown positive effects in general, but a specific therapy to treat diabetic dyslipidemia is still missing. Studies so far have failed to show a reliable benefit for fibrates and for nicotinic acid. Thus, statin therapy to decrease LDL cholesterol to target is the essential treatment for diabetic dyslipidemia to reduce cardiovascular risk. Other lipid lowering drugs can be added optionally.

Schlüsselwörter

Triglyzeride - Diabetes - Dyslipoproteinämie - Therapie - small dense LDL - Remnants - HDL

Keywords

triglyzerides - diabetes - dyslipidemia - therapy - small dense LDL - remnants - HDL

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