W przypadku wskazań do farmakoterapii, tj. niepowodzenia zmiany trybu życia, jedynym lekiem pozostaje metformina. W celu potwierdzenia insulinooporności w historii choroby wskazane wydaje się zapisanie jej pośrednich markerów: wysoki TG, niski HDL, rozpoznania nadciśnienia, wartość WC czy BMI. Jedynie u młodych osób, u których nie stwierdzono powyższych zaburzeń, należy wyliczyć HOMA-IR, jeśli stężenie glukozy na czczo nie wskazuje na nieprawidłową glikemię na czczo (IFG – impaired fasting glycaemia). Jeżeli potwierdzono jakiekolwiek zaburzenia gospodarki cukrowej, oznaczenie stężenia insuliny dla potwierdzenia IR nie jest według mnie potrzebne.
Nie udowodniono korzyści ze stosowania metforminy czy tiazolidynodionów na zmniejszenie ryzyka sercowo-naczyniowego u osób zdrowych. Uwzględniając mechanizmy powstawania insulinooporności oraz wpływ zbilansowanej diety o niskim IG (najchętniej śródziemnomorskiej) i wysiłku fizycznego na nadciśnienie, profil lipidowy czy wrażliwość mięśni na insulinę, zalecenia te nie powinny budzić wątpliwości. Muszą być podstawą konsultacji medycznej u każdego pacjenta niezależnie od wyników badań w kierunku insulinooporności.
Appropriate diagnostic work-up for insulin resistance – to treat or not to treat, and how?
Abstract
The main targets for insulin are muscles, adipose tissue and liver; therefore, obesity associated with an unhealthy diet, liver steatosis and a sedentary lifestyle is often considered synonymous with insulin resistance. In the presence of excess adipose tissue, cells mute insulin signals and interfere with physiological functioning of the hormone. This disturbed signaling results in a rise in lipid and glucose levels while increased concentration of insulin additionally leads to increases in blood pressure and uric acid concentration. As a result of our lack of ability to directly measure insulin sensitivity in everyday medical practice, as well as the lack of standardized criteria for insulin resistance assessment using insulin concentration values, the use of indirect diagnostic methods appears appropriate. Bearing in mind the pathophysiology of the most common type of hyperinsulinism, the markers of this disorder seem to be as follows: high (at least 130 mg%), triglyceride concentration, increased TG/HDL ( >3) ratio and at least overweight and/or increased waist circumference. Additional value is provided by confirmation of increased blood pressure as well as increased concentration of uric acid. In normostenic patients with waist circumference in the normal range, besides the above biochemical markers, the concentration of fasting glucose and insulin levels can be additionally assessed for the purpose of calculating the HOMA-IR index.
Because of confirmed benefits of behavioral intervention, every patient should be educated about healthy lifestyle, regardless of whether any traits of hyperinsulinism are present. This decreases the future risk of developing diabetes and cardiovascular disease. If behavioral treatment (exercise, diet) is ineffective, metformin therapy can be introduced when there is a high probability of insulin resistance. The treatment of insulin resistance includes the correction of each confirmed disturbance (obesity, hypertension, lipid disorders). In cases of excessive body mass, it is important to consider increasingly popular modern treatment methods, such as metabolic surgery.
Piśmiennictwo
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