Dislipidemia en diabetes

25.10.2017
Diabetologia – postępy 2016/2017
Jacek Sieradzki

La prevalencia de la diabetes sigue aumentando y según los pronósticos en 2040 en el mundo habrá más de 640 millones de diabéticos. Esto se debe a la creciente epidemia de obesidad que conlleva una resistencia a la insulina y, en consecuencia, el desarrollo de la diabetes tipo 2. Aunque se han descrito más de 150 genes que posiblemente pueden causar su desarrollo, no se ha conseguido frenar su prevalencia epidémica.1 La epidemia se observa sobre todo en los países en vías de desarrollo de América Latina y Asia.2,3 El problema que se presenta en el tratamiento de la diabetes es el de centrarse en el control glucémico en ayunas y entre comidas, mientras que se omite la cuestión de la glucemia después de la comida y es este el criterio que con más probabilidad será el próximo objetivo en el tratamiento diabético.4 Un problema importante que se plantea en la actualidad es la evaluación de la seguridad cardiovascular de los fármacos antidiabéticos. La Administración de Alimentos y Medicamentos (FDA, Food and Drug Administration) dedicó a este asunto una directiva publicada por primera vez en 2008 y actualizada en 2016.5,6 En ella se basan los estudios prospectivos sobre fármacos hipoglucemiantes realizados en los últimos años, incluidos los estudios que se terminaron en 2016.

Dislipidemia en diabetes

Respecto a las nuevas recomendaciones detalladas por la Asociación Polaca de Diabetes (PTD) acerca de los objetivos del tratamiento de la dislipidemia en la diabetes47, convendría mencionar algunas de las nuevas publicaciones que tratan del metabolismo lipídico. En un estudio prospectivo con un período de observación de 13,5 años (mediana) se analizó la relación entre la concentración de apolipoproteínas en plasma y el riesgo de desarrollo de diabetes tipo 2. Se demostró que la concentración de la apolipoproteína C-III, así como la proporción entre la ApoCIII y la apolipoproteína A-I eran predictores relevantes para la aparición de diabetes tipo 2 en una población examinada de 971 personas.48 En un estudio observacional acerca de la prevención primaria de las enfermedades cardiovasculares mediante el uso de tratamiento hipolipemiante, sobre todo estatinas, en pacientes con diabetes tipo 1 diagnosticada antes de los 30 años de edad, y en el que se incluyeron 24 000 pacientes, se demostró que la aplicación de este tratamiento disminuía el riesgo de desarrollo de enfermedades cardiovasculares. El tratamiento hipolipemiante en personas con diabetes tipo 1 sin enfermedades cardiovasculares en esta población sueca reducía el riesgo de estas enfermedades y de muerte en un 22-44 %.49 En el estudio VADT se demostró que el control glucémico intensivo pero en combinación con un mejor perfil lipídico, especialmente con una concentración mayor de C-HDL, era eficaz en la prevención de la retinopatía relacionada con la diabetes tipo 2.50 La importancia del aumento de la concentración de triglicéridos y de la disminución de la concentración de colesterol C-HDL para el desarrollo de la enfermedad renal diabética se mencionó ya anteriormente (véase Nefropatía diabética).25 Los biomarcadores lipídicos, tales como los triglicéridos, fosfatidilcolina y otros fosfolípidos plasmáticos, medidos al principio del 2.o trimestre del embarazo eran predictores de aparición de diabetes gestacional (diagnosticada luego mediante una prueba oral de tolerancia a la glucosa), independientes de los factores de riesgo ya conocidos, como la edad y el índice de la masa corporal de la madre.51

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