Diabetes und Schlaganfall – eine schwierige Beziehung, akut, wie im Langzeitbereich

Zusammenfassung

Der Diabetes mellitus ist für Neurologen, die sich mit dem Schlaganfall beschäftigen, aus zweierlei Gesichtpunkten von klinischem Interesse. In der Akutphase eines Hirninfarktes ist eine optimierte Kontrolle des Blutzuckers prognostisch relevant, zweitens ist eine optimale Behandlung erhöhter Blutzuckerwerte langfristig als modifizierbarer Risikofaktor entscheidend. Aufgrund fehlender Evidenz wurde die intensivierte Blutzuckersenkung durch intravenöse Insulingabe als Standardverfahren auf der Stroke-Unit durch ein moderateres Behandlungsregime abgelöst. Aktuell wird bei geringer bis mäßiger Hyperglykämie über 200 mg / dl zunächst eine subkutane Insulingabe favorisiert, erst bei mehr als 6 erforderlichen Gaben wird eine intravenöse Insulindauerinfusion empfohlen. Obwohl epidemiologisch eine Korrelation zwischen Höhe des HbA1c und der Häufigkeit zerebraler Infarkte besteht und ausreichend Präparate zur effektiven Senkung des HbA1c vorliegen, führten die Ergebnisse der großen Interventionsstudien (ACCORD, ADVANCE, V-ADT) zu widersprüchlichen Empfehlungen zur Höhe der Blutzuckersenkung. Aus der Nachbeobachtung der UKPDS sowie der Steno-2-Studie liegen uns positive Daten für eine frühzeitig begonnene Behandlung vor. Dies hat zu einem Umdenken in der Diabetesbehandlung geführt. Statt der generellen Festlegung auf einen, für alle Diabetiker gültigen optimalen HbA1c-Wert, sind Behandlungsempfehlungen, die auch Erkrankungsdauer, Komorbiditäten und Nebenwirkungen der Antidiabetika berücksichtigen, von einer größeren Individualisierung geprägt. Neben der frühzeitig begonnenen Behandlung muss vor allem ein multimodaler Therapieansatz mit Berücksichtigung der Komplexizität eines möglichen metabolischen Syndroms erfolgen, wie Studien zur Effektivität einer Lebensstiländerung und Blutdrucksenkung bei Typ-2-Diabetes gezeigt haben.

Abstract

The diabetic metabolic state has two different implications for the neurologist engaged in stroke treatment. An ideal treatment of diabetes mellitus is of enormous concern due to its significance as a risk factor for emerging atherosclerotic diseases such as stroke, as well as in acute stroke, owing to its relevance for the clinical outcome. Intensified blood glucose lowering regimens using i. v. insulin are currently being replaced by a more liberal therapy on the Stroke Unit. Blood glucose levels beyond 200 mg% will be treated by fractionated s. c. insulin administration, only in the case of failure is i. v. continuous insulin to be used. In spite of available epidemiological data for the correlation between glycated haemoglobin and stroke prevalence, as well as the existence of numerous drugs effective in reducing HBA1c, many intervention studies (ACCORD, ADVANCE, V-ADT) have failed to show a close connection for reducing clinical endpoints. The data from STENO-2 and the UKPDS have led to the idea that in the long run the positive effects of antidiabetic strategies will be better revealed. The primarily disappointing data from the intervention studies challenged the diabetes treatment. It seems clear that there is no magic optimum of a target HBA1c which fits for all patients. Instead of this approach we will need an individualised therapy taking into account age, comorbidity, duration of diabetes and side effects of drugs. Besides the early start of an optimised diabetes therapy, the additional treatment of the metabolic syndrome is essential for the best care. This has best been shown by studies which have shown the positive effects of life-style modifications and blood pressure treatment in diabetic patients.

Schlüsselwörter

Schlaganfall - Diabetes mellitus - Hyperglykämie

Keywords

stroke - diabetes - hyperglycaemia

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