medalphabetМедицинский алфавитMedical alphabet2078-56312949-2807ООО «Альфмед»10.33667/2078-5631-2020-21-58-68medalphabet-1665Research ArticleСтатьиЛекарственные поражения печени в практике врача первичного звена (обзор клинических рекомендаций)Drug-induced liver injuries in practice of primary care physician (review of clinical recommendations)ОстроумоваО. Д.OstroumovaO. D.

д.м.н., проф., зав. кафедрой терапии и полиморбидной патологии; проф. кафедры клинической фармакологии и пропедевтики внутренних болезней

г. Москва

Moscow

БорисоваЕ. В.BorisovaE. V.

к.м.н., врач-кардиолог кардиологического отделения № 13

г. Москва

Moscow

ПиксинаГ. Ф.PiksinaG. F.

к.м.н., зав. кардиологическим отделением № 13

г. Москва

Moscow

ПавлееваЕ. Е.PavleevaE. Е.

к.м.н., ассистент кафедры пропедевтики внутренних болезнейи гастроэнтерологии

г. Москва

Moscow

ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России; ФГАОУ ВО «Первый Московский государственный медицинский университет имени И.М. Сеченова (Сеченовский университет)» Минздрава РоссииРоссияRussian Medical Academy for Continuing Professional Education; First Moscow State Medical University n.a. I.M. SechenovRussian FederationГБУЗ г. Москвы «Городская клиническая больница имени Е.О. Мухина» Департамента здравоохранения города г. МосквыРоссияClinical Hospital n.a. E.O. MukhinaRussian FederationФГБОУ ВО «Московский государственный медико-стоматологический университет имени А.И. Евдокимова» Минздрава РоссииРоссияMoscow State University of Medicine and Dentistry n.a. A.I. EvdokimovRussian Federation202014102020021Современная поликлиника (2)5869Copyright © Остроумова О.Д., Борисова Е.В., Пиксина Г.Ф., Павлеева Е.Е., 20202020Остроумова О.Д., Борисова Е.В., Пиксина Г.Ф., Павлеева Е.Е.Ostroumova O.D., Borisova E.V., Piksina G.F., Pavleeva E.Е.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-alphabet.com/jour/article/view/1665

В настоящее время в связи с высокой доступностью лекарственных препаратов и растущим объемом фармацевтического рынка наблюдается четкая тенденция к росту числа лекарственных поражений печени (ЛПП), которые могут быть ассоциированы с приемом практически всех классов лекарственных средств (ЛС), отпускаемых по рецепту или без рецепта, включая фитопрепараты, диетические добавки и биологические добавки к пище и т.п. В связи с высокой актуальностью данной проблемы статья посвящена эпидемиологии и классификации ЛПП, принципам ведения пациентов с ЛПП, прогнозу и профилактике ЛПП с учетом европейских и российских клинических рекомендации по ведению больных с ЛПП – Европейской ассоциации по изучению болезней печени (European Association for the Study of the Liver, EASL; 2019), Российской гастроэнтерологической ассоциации (РГА) (2019), Научного общества гастроэнтерологов России / Российского научного медицинского общества терапевтов (НОГР/РНМОТ) (2020). Подробно описаны критерии диагноза ЛПП, приведены ряд классификаций ЛПП (по степени тяжести, патогенетическая, клинико-лабораторная, по фенотипам и клинико-морфологическим формам). К факторам риска ЛПП относят возраст, пол, расу, генетические факторы, определенные сопутствующие заболевания и состояния, полипрагмазию, межлекарственные взаимодействия, особенности ЛС (доза, длительность приема, липофильность и др.). В диагностике ЛПП центральным звеном является оценка причинно-следственных связей между приемом препарата-индуктора и развитием симптомов поражения печени, для этой цели рекомендуется использовать шкалу CIOMS-RUCAM, определены показания для биопсии печени. Диагноз исключения ЛПП и его постановка требуют проведения исследований, направленных на дифференциацию с острым вирусным гепатитом, аутоиммунным гепатитом, болезнью Вильсона, синдромом Бада-Киари, первичным билиарным холангитом, первичным склерозирующим холангитом, желчекаменной болезнью, онкологическими заболеваниями. Рассмотрены варианты течения ЛПП с выделением благоприятных и неблагоприятных прогностических признаков. Обсужден выбор гепатопротективной терапии. Приведены данные о возможностях препарата Гептронг в лечении ЛПП. Особое внимание уделено профилактическим мерам, препятствующим развитию ЛПП.

Currently, due to the high availability of drugs and the growing volume of the pharmaceutical market, there is a clear trend towards an increase in the number of drug-induced liver injuries (DILI), which can be associated with the use of almost all classes of prescription or non-prescription drugs including herbal remedies, dietary supplements and biological food supplements, etc. Due to the high relevance of this problem, the article is devoted to the epidemiology and classification of DILI, the principles of management of patients with DILI, prognosis and prevention of DILI, taking into account European and Russian clinical recommendations for the management of patients with DILI – European Association for the Study of the Liver (EASL; 2019), Russian Gastroenterological Association (2019), Scientific Society of Gastroenterologists of Russia / Russian Scientific Medical Society of Therapists (NOGR / RNMOT) (2020). The criteria for the diagnosis of DILI are described in detail, a number of classifications of DILI are given (by severity, pathogenetic, clinical and laboratory, by phenotypes and clinical and morphological forms). Risk factors for DILI include age, gender, race, genetic factors, certain concomitant diseases and conditions, polypharmacy, drug-drug interactions, and drug characteristics (dose, duration of administration, lipophilicity, etc.). In the diagnosis of DILI, the central link is the assessment of cause-effect relationships between taking the inducer drug and the development of symptoms of liver damage, for this purpose it is recommended to use the CIOMS-RUCAM scale, and indications for liver biopsy are determined. The diagnosis of exclusion of DILI and its formulation require studies aimed at differentiation with acute viral hepatitis, autoimmune hepatitis, Wilson’s disease, Bad Chiari syndrome, primary biliary cholangitis, primary sclerosing cholangitis, cholelithiasis, and oncological diseases. Variants of the course of DILI with the selection of favorable and unfavorable prognostic signs are considered. The choice of hepatoprotective therapy has been discussed. The data on the possibilities of the drug Heptrong in the treatment of DILI are given. Particular attention is paid to preventive measures that impede the development of DILI.

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The authors declare that there are no conflicts of interest present.