Frühe oder kurzzeitige Insulintherapie bei Typ-2-Diabetes: Stellenwert und Risiko-Nutzen-Bilanz im Rahmen individualisierter Therapiekonzepte

Despite major advances in the quality of diabetes therapy, the contribution of diabetes to total mortality in Germany is estimated about 20 %. Diabetes-related complications have again become the fate of many (especially elderly) patients with long-term diabetes. Prevention of these complications requires early diagnosis, and a rapid, near to normal glycemic control for the remission and maintenance of residual B-cell function, as well as for the protection of the endothelium from gluco- and lipotoxicity. The glycemic load is in principle equally valid for macroangiopathy and microangiopathy. With the ground-breaking results of the outcome studies with SGLT2 inhibitors and GLP1 analogues, movement has now come into the ranking of antidiabetics in guidelines and daily clinical practice as well. In this eventful, very positive development, the postulate of early insulin therapy must undoubtedly be re-examined as part of an individualized, risk-adjusted treatment. This paper shows with well documented controlled trials that an initial, intensified insulin therapy is indicated already at the onset of diabetes in clinically ill patients. Insulin therapy shows the fastest effect on target attainment and on glucolipotoxicity compared to other antidiabetic treatment strategies. In view of the predominant multimorbidity of patients and long-lasting remissions-up to 50 % after 2 years - this is also cost-effective. Certainly, the benefits of early insulin therapy are not directly transferable to longterm diabetes. However, the situation changes when, once the therapy options with oral therapy and GLP1 analogues have been exhausted, diabetes worsens again or diabetes-related complications occur. In these cases, all the positive effects of early insulinization can be taken into account.