Antihyperglykämische Mittel zur Behandlung von Typ-2-Diabetes

Siehe auch das separate Management von Typ-2-Diabetes article.

Oral hypoglycaemic agents are the group of drugs that may be taken singly or in combination to lower the blood glucose in type 2 diabetes. Type 2 diabetes can be due to increased peripheral resistance to insulin or to reduced secretion of insulin. They should be used together with changes in diet and lifestyle to achieve good glycaemic control and it is customary to monitor such changes for three months before considering medication. Oral hypoglycaemic agents are not usually used in type 1 diabetes but metformin may be of use in combination with insulin for overweight people with type 1 diabetes.¹

Blood glucose-lowering therapy²

HbA1c measurement

In adults with type 2 diabetes, measure HbA1c levels at:

• 3- to 6-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy

• 6-monatige Intervalle, sobald der HbA1c-Wert und die blutzuckersenkende Therapie stabil sind.

Wenn die HbA1c-Überwachung aufgrund von gestörtem Erythrozytenumsatz oder abnormalem Hämoglobin-Typ ungültig ist, schätzen Sie die Trends in der Blutzuckerkontrolle mit einer der folgenden Methoden:

• Quality-controlled plasma glucose profiles.

• Gesamtschätzung des glykosylierten Hämoglobins (bei abnormalen Hämoglobinen).

• Fructosamin-Schätzung.

HbA1c targets

For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: reinforce advice about diet, lifestyle and adherence to drug treatment, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment.

Erwägen Sie, den Ziel-HbA1c-Wert individuell anzupassen, insbesondere bei älteren oder gebrechlichen Menschen, für Erwachsene mit Typ-2-Diabetes:

• Who are unlikely to achieve longer-term risk-reduction benefits - for example, people with a reduced life expectancy.

• For whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia - for example:

  • People who are at risk of falling.

  • People who have impaired awareness of hypoglycaemia.

  • People who drive or operate machinery as part of their job.

• For whom intensive management would not necessarily be appropriate - for example, people with significant comorbidities.

Wenn Erwachsene mit Typ-2-Diabetes einen HbA1c-Wert erreichen, der unter ihrem Zielwert liegt und sie keine Hypoglykämie erleben, ermutigen Sie sie, diesen Wert beizubehalten. Seien Sie sich bewusst, dass es andere mögliche Gründe für einen niedrigen HbA1c-Wert gibt - zum Beispiel eine sich verschlechternde Nierenfunktion oder plötzlicher Gewichtsverlust.

Rettungstherapie in jeder Behandlungsphase

If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin or a sulfonylurea and review treatment when blood glucose control has been achieved.

First-line drug treatment

Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes. Gradually increase the dose over several weeks to minimise the risk of gastrointestinal side-effects. If an adult with type 2 diabetes experiences gastrointestinal side-effects with standard-release metformin, consider a trial of modified-release metformin.

In adults with type 2 diabetes, review the dose of metformin if the eGFR is below 45 ml/minute/1.73 m². Stop metformin if the eGFR is below 30 ml/minute/1.73 m². Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73 m².

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, assess the cardiovascular risk using a recognised risk scoring system such as QRISK®3.

Basierend auf der kardiovaskulären Risikobewertung für die Person mit Typ-2-Diabetes:

• If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, introduce the drugs sequentially, starting with metformin and checking tolerability. Start the SGLT2 inhibitor as soon as metformin tolerability is confirmed.

• For first-line drug treatment in adults with type 2 diabetes, if metformin is contra-indicated or not tolerated and if they do not have chronic heart failure, or established atherosclerotic cardiovascular disease or are at high risk for developing cardiovascular disease, consider:

  • A DPP‑4 inhibitor; oder

  • Pioglitazone; oder

  • A sulfonylurea; oder

  • An SGLT2 inhibitor for people who meet the criteria in the National Institute for Health and Care Excellence (NICE's) technology appraisal guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies or ertugliflozin as monotherapy or with metformin for treating type 2 diabetes.³

• Before starting an SGLT2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA) - for example if:

  • Sie hatten bereits eine frühere Episode von DKA.

  • Sie sind unwohl aufgrund einer gleichzeitig auftretenden Krankheit.

  • Sie folgen einer sehr kohlenhydratarmen oder ketogenen Diät.

Weitere Maßnahmen

Führen Sie Medikamente, die in der Kombinationstherapie verwendet werden, schrittweise ein und überprüfen Sie die Verträglichkeit und Wirksamkeit jedes einzelnen Medikaments.

For adults with type 2 diabetes, if monotherapy has not continued to control HbA1c to below the person's individually agreed threshold for further intervention, consider adding:

• A DPP‑4 inhibitor; oder

• Pioglitazone; oder

• A sulfonylurea; oder

• Ein SGLT2-Inhibitor für Personen, die die Kriterien in der Technologie-Bewertung von NICE zu Canagliflozin in Kombinationstherapie, Ertugliflozin als Monotherapie oder mit Metformin, oder Dapagliflozin oder Empagliflozin in Kombinationstherapie erfüllen.³

Für Erwachsene mit Typ-2-Diabetes, wenn die duale Therapie mit Metformin und einem anderen oralen Medikament den HbA1c-Wert nicht unter die individuell vereinbarte Schwelle für weitere Interventionen gesenkt hat, ziehen Sie entweder in Betracht:

• Dreifachtherapie durch Hinzufügen eines DPP-4-Inhibitors, Pioglitazon oder eines Sulfonylharnstoffs oder eines SGLT2-Inhibitors für Personen, die die Kriterien in der Technologie-Bewertung von NICE zu Canagliflozin in Kombinationstherapie, Dapagliflozin in Dreifachtherapie, Empagliflozin in Kombinationstherapie oder Ertugliflozin mit Metformin und einem Dipeptidylpeptidase-4-Inhibitor erfüllen;³ oder

• Beginn der insulinbasierten Behandlung (siehe Abschnitt über insulinbasierte Behandlungen).

See the separate article on Insulintherapien for further information.

If triple therapy with metformin and two other oral drugs is not effective, is not tolerated or is contra-indicated, consider triple therapy by switching one drug for a GLP‑1 mimetic for adults with type 2 diabetes who:

• Have a body mass index (BMI) of 35 kg/m² or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) und specific psychological or other medical problems associated with obesity; oder

• Einen BMI unter 35 kg/m haben²; und:

  • For whom insulin therapy would have significant occupational implications; oder

  • Gewichtsverlust würde anderen bedeutenden, mit Fettleibigkeit verbundenen Begleiterkrankungen zugutekommen.

• Only continue GLP‑1 mimetic therapy if the adult with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in sixmonths).

• For adults with type 2 diabetes, only offer combination therapy with a GLP‑1 mimetic and insulin along with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

• Dipeptidylpeptidase-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin and vildagliptin)