Интерферон-индуцированная депрессия

ЛЕКЦИЯ Интерферон-индуцированная депрессия П.П.Огурцов, Н.В.Мазурчик Кафедра факультетской терапии Российского университета дружбы народов, Национальный научный центр наркологии Росздрава Российской Федерации Д ÂÔÂÒÒËfl, ‚ÓÁÌËÍ‡˛˘‡fl ‚ ıÓ‰Â ËÌÚÂÙÂÓÌÓÚÂ‡ÔËË ıÓÌË˜ÂÒÍËı ‚ËÛÒÌ˚ı „ÂÔ‡ÚËÚÓ‚, ‚ ÚÓÏ ˜ËÒÎÂ ıÓÌË˜ÂÒÍÓ„Ó „ÂÔ‡ÚËÚ‡ ë (ïÉë), fl‚ÎflÂÚÒfl Ó‰ÌÓÈ ËÁ ‚‡ÊÌÂÈ¯Ëı ÍÎËÌË˜ÂÒÍËı ÔÓ·ÎÂÏ ÔÓÚË‚Ó‚ËÛÒÌÓÈ ÚÂ‡ÔËË (èÇí), ÍÓÚÓ‡fl ÓÔÂ‰ÂÎflÂÚ ÒÚÂÔÂÌ¸ ÔË‚ÂÊÂÌÌÓÒÚË ·ÓÎ¸Ì˚ı Í ÎÂ˜ÂÌË˛, Â„Ó ÔÓÎÌÓˆÂÌÌÓÒÚ¸ Ë Á‡‚Â¯ÂÌÌÓÒÚ¸ [1,2]. ÑÂÔÂÒÒËfl ‚ Ó·˘ÂÔËÌflÚÓÏ ÔÓÌËÏ‡ÌËË – ÒÓÒÚÓflÌËÂ, ı‡‡ÍÚÂËÁÛ˛˘ÂÂÒfl ÒÚÓÈÍÓ ÔÓÌËÊÂÌÌ˚Ï Ì‡ÒÚÓÂÌËÂÏ, ËÌÚÂÎÎÂÍÚÛ‡Î¸ÌÓÈ (·‡‰ËÙÂÌËfl) Ë ÏÓÚÓÌÓÈ (·‡‰ËÍËÌÂÁËfl) Á‡ÚÓÏÓÊÂÌÌÓÒÚ¸˛, Ì‡Û¯ÂÌËÂÏ ÒÌ‡ Ë ÒÔÂˆËÙË˜ÂÒÍËÏË ‚Â„ÂÚ‡ÚË‚Ì˚ÏË ‡ÒÒÚÓÈÒÚ‚‡ÏË: ÛÂÊÂÌËÂÏ ÔÛÎ¸Ò‡, ÒÌËÊÂÌËÂÏ ÄÑ, ÛÏÂÌ¸¯ÂÌËÂÏ ÍË¯Â˜ÌÓÈ ÔÂËÒÚ‡Î¸ÚËÍË, ÒÛıÓÒÚ¸˛ ÍÓÊË, ËÁÏÂÌÂÌËÂÏ ‡ÔÔÂÚËÚ‡ Ë Ï‡ÒÒ˚ ÚÂÎ‡ [3]. Место интерферон-индуцированного снижения настроения среди депрессивных расстройств. ÑÂÔÂÒÒËË – ÒÓ‚ÓÍÛÔÌÓÒÚ¸ „ÂÚÂÓ„ÂÌÌ˚ı ÒÓÒÚÓflÌËÈ, ÍÓÚÓ˚Â ‰ÂÎflÚÒfl Ì‡ ‰‚Â ÓÒÌÓ‚Ì˚Â „ÛÔÔ˚. èÂ‚‡fl – ˝Ì‰Ó„ÂÌÌ˚Â ‰ÂÔÂÒÒËË ÌÂflÒÌÓÈ ˝ÚËÓÎÓ„ËË, ı‡‡ÍÚÂËÁÛ˛˘ËÂÒfl Ì‡Û¯ÂÌËÂÏ ÌÂÈÓÚ‡ÌÒÏËÚÚÂÌÓ„Ó Ó·ÏÂÌ‡. ÇÚÓ‡fl „ÛÔÔ‡ – Â‡ÍÚË‚Ì˚Â ‰ÂÔÂÒÒËË Í‡Í ÂÒÚÂÒÚ‚ÂÌÌ˚È ˝ÏÓˆËÓÌ‡Î¸Ì˚È ÓÚ‚ÂÚ Ì‡ ÊËÁÌÂÌÌ˚Â ËÒÔ˚Ú‡ÌËfl. Ç ÓÚÎË˜ËÂ ÓÚ ÔÂıÓ‰fl˘Ëı ˝ÔËÁÓ‰Ó‚ ÒÌËÊÂÌËfl Ì‡ÒÚÓÂÌËfl, ‰ÂÔÂÒÒËË ‰ÎflÚÒfl, Í‡Í Ô‡‚ËÎÓ, Ò‚˚¯Â ‰‚Ûı ÌÂ‰ÂÎ¸. ëÛ˘ÂÒÚ‚ÛÂÚ Ú‡ÍÊÂ ÔÓÏÂÊÛÚÓ˜Ì‡fl „ÛÔÔ‡ ‰ÂÔÂÒÒËÈ, ˝ÚËÓÎÓ„Ëfl ÍÓÚÓ˚ı Ò‚flÁ‡Ì‡ Ò ËÌÚÓÍÒËÍ‡ˆËÓÌÌ˚Ï Ù‡ÍÚÓÓÏ: ‡ÎÍÓ„ÓÎ¸Ì˚Ï, ÓÔË‡ÚÌ˚Ï, ÎÂÍ‡ÒÚ‚ÂÌÌ˚Ï (ÏÂÚËÎ‰ÓÙ‡, ÎÂ‚Ó‰ÓÔ‡, ÂÁÂÔËÌ, „Î˛ÍÓÍÓÚËÍÓÒÚÂÓË‰˚, ÌÂÈÓÎÂÔÚËÍË Ë ‰.) [4,5]. ÑÂÔÂÒÒË˛, Ì‡·Î˛‰‡ÂÏÛ˛ Û ·ÓÎ¸Ì˚ı ÔË ËÌÚÂÙÂÓÌÓÚÂ‡ÔËË ıÓÌË˜ÂÒÍËı ‚ËÛÒÌ˚ı „ÂÔ‡ÚËÚÓ‚, ÒÍÓÂÂ ‚ÒÂ„Ó, ÒÎÂ‰Ó‚‡ÎÓ ·˚ ÓÚÌÂÒÚË Í Í‡ÚÂ„ÓËË ÔÓÏÂÊÛÚÓ˜Ì˚ı (ÎÂÍ‡ÒÚ‚ÂÌÌ˚ı). é‰Ì‡ÍÓ Û ·ÓÎ¸Ì˚ı ïÉë ÓÌ‡ Á‡˜‡ÒÚÛ˛ ÌÓÒËÚ ÏÌÓ„ÓÙ‡ÍÚÓÌ˚È ı‡‡ÍÚÂ Â˘Â ‰Ó Ì‡˜‡Î‡ èÇí. èÓÁËÚË‚Ì˚Â ÚÂÒÚ˚ Ì‡ Ï‡ÍÂ˚ ïÉë ˜‡ÒÚ¸˛ ÎËˆ ÔÂÂÊË‚‡˛ÚÒfl Í‡Í ÒËÎ¸Ì˚È ÒÚÂÒÒ, ˜ÚÓ ÔË‚ÌÓÒËÚ ‰Ó·‡‚Ó˜Ì˚È Â‡ÍÚË‚Ì˚È ÍÓÏÔÓÌÂÌÚ ‚ ÒÌËÊÂÌËÂ Ì‡ÒÚÓÂÌËfl. çÂÂ‰Í‡fl ÔË ïÉë ‰ËÒÙÛÌÍˆËfl ˘ËÚÓ‚Ë‰ÌÓÈ ÊÂÎÂÁ˚ ÏÓÊÂÚ ÒÓÔÓ‚ÓÊ‰‡Ú¸Òfl ‰ÂÔÂÒÒË‚ÌÓÈ ÒËÏÔÚÓÏ‡ÚËÍÓÈ [5]. ëÂ‰Ë Í‡Ì‰Ë‰‡ÚÓ‚ Ì‡ èÇí ïÉë ‚˚ÒÓÍ‡ ‰ÓÎfl ÎËˆ Ò ‡ÎÍÓ„ÓÎ¸ÌÓÈ Ë Ì‡ÍÓÚË˜ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ‚ ÒÓÒÚÓflÌËË ÂÏËÒÒËË Ò ÍÎËÌË˜ÂÒÍËÏË ÔËÁÌ‡Í‡ÏË ‰ÂÔÂÒÒËË. ì ÏÌÓ„Ëı ËÁ ÌËı ‰ÂÔÂÒÒËfl fl‚ÎflÎ‡Ò¸ ÔÂÏÓ·Ë‰Ì˚Ï ÙÓÌÓÏ ÁÎÓÛÔÓÚÂ·ÎÂÌËfl ÔÒËıÓ‡ÍÚË‚Ì˚ÏË ‚Â˘ÂÒÚ‚‡ÏË [6]. Ñ‡ÊÂ ÂÒÎË ·ÓÎ¸ÌÓÈ ÌÂ ÁÌ‡ÂÚ, ˜ÚÓ ÓÌ ËÌÙËˆËÓ‚‡Ì HCV, Ò‡ÏÓ ÒÓÒÚÓflÌËÂ ËÌÙËˆËÓ‚‡ÌÌÓÒÚË, ÒÓÔÓ‚ÓÊ‰‡˛˘ÂÂÒfl ‡ÍÚË‚‡ˆËÂÈ ËÌÚÂÙÂÓÌÓ‚Ó„Ó ÏÂı‡ÌËÁÏ‡ Ë ˆËÚÓÍËÌÓ‚ÓÈ ÒËÒÚÂÏ˚, fl‚ÎflÂÚÒfl Ù‡ÍÚÓÓÏ ËÒÍ‡ ‡Á‚ËÚËfl ‰ÂÔÂÒÒËË. é‰Ì‡ ËÁ „ËÔÓÚÂÁ ‚ÓÁÌËÍÌÓ‚ÂÌËfl ˝Ì‰Ó„ÂÌÌÓÈ ‰ÂÔÂÒÒËË, Ì‡fl‰Û Ò „ËÔÂ‡ÍÚË‚ÌÓÒÚ¸˛ 26 „ËÔÓÚ‡Î‡ÏÓ-„ËÔÓÙËÁ‡ÌÓ-Ì‡‰ÔÓ˜Â˜ÌËÍÓ‚ÓÈ Ë ÒËÏÔ‡ÚÓ-‡‰ÂÌ‡ÎÓ‚ÓÈ ÒËÒÚÂÏ, ÔÂ‰ÔÓÎ‡„‡ÂÚ Ì‡ÎË˜ËÂ ËÏÏÛÌÌÓ„Ó ÔÓ‰‡‚ÎÂÌËfl ‡ÍÚË‚ÌÓÒÚË ÒÂÓÚÓÌËÌ˝„Ë˜ÂÒÍÓÈ ÒËÒÚÂÏ˚ [7]. Ç ˜‡ÒÚÌÓÒÚË ËÏÏÛÌÌ˚Â ÏÂı‡ÌËÁÏ˚ Ú‡ÍÊÂ Ó·ÒÛÊ‰‡˛ÚÒfl ÔË ‰ÂÔÂÒÒËflı, ‚ÓÁÌËÍ‡˛˘Ëı Ì‡ ÙÓÌÂ ‰ËÙÙÛÁÌ˚ı Á‡·ÓÎÂ‚‡ÌËÈ ÒÓÂ‰ËÌËÚÂÎ¸ÌÓÈ ÚÍ‡ÌË [5]. Ç ËÚÓ„Â 24% ·ÓÎ¸Ì˚ı ïÉë ËÏÂ˛Ú ÔËÁÌ‡ÍË ‰ÂÔÂÒÒËË ‰Ó Ì‡˜‡Î‡ èÇí [8], ˜ÚÓ Ì‡ 50% ·ÓÎ¸¯Â, ˜ÂÏ ‚ ÔÓÔÛÎflˆËË [9]. Патогенез интерфероновой депрессии. ì 33-37% ·ÓÎ¸Ì˚ı ïÉë ‚ ÓÚ‚ÂÚ Ì‡ ÚÂ‡ÔË˛ ËÌÚÂÙÂÓÌÓÏ-α (àîç-α) Ë Ë·‡‚ËËÌÓÏ ‡Á‚Ë‚‡ÂÚÒfl ‰ÂÔÂÒÒËfl [1012]. ëÔÂˆË‡Î¸ÌÓ ÔÓ‚Â‰ÂÌÌÓÂ ËÒÒÎÂ‰Ó‚‡ÌËÂ ÔÓÍ‡Á‡ÎÓ, ˜ÚÓ ÏÂı‡ÌËÁÏ ‰ÂÔÂÒÒËË, ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ àîç-α, ÒÍÓÂÂ ‚ÒÂ„Ó, Á‡ÍÎ˛˜‡ÂÚÒfl ‚ ÍÓÌÍÛÂÌÚÌÓÏ ÏÂÚ‡·ÓÎËÁÏÂ ÌÂÁ‡ÏÂÌËÏÓÈ ‡ÏËÌÓÍËÒÎÓÚ˚ ÚËÔÚÓÙ‡Ì‡ ËÌ‰ÓÎ‡ÏËÌ-2,3-‰ËÓÍÒË„ÂÌ‡ÁÓÈ Ë ÚËÔÚÓÙ‡Ì-‰ËÓÍÒË„ÂÌ‡ÁÓÈ ‚ ıËÌÓÎËÌÓ‚˚Â ÍËÒÎÓÚ˚. èÓ‚˚¯ÂÌËÂ ‡ÍÚË‚ÌÓÒÚË ˝ÚËı ÙÂÏÂÌÚÓ‚ ÔÓÚÂÌˆËÛÂÚÒfl ˝ÍÁÓ„ÂÌÌ˚Ï àîç-α. èË ˝ÚÓÏ ÔÓÒÚÂÔÂÌÌÓ ‚ÓÁÌËÍ‡ÂÚ ‰ÂÙËˆËÚ ÚËÔÚÓÙ‡Ì‡ Ë „Ë‰ÓÍÒËÚËÔÚÓÙ‡Ì‡ – ÔÂ‰¯ÂÒÚ‚ÂÌÌËÍ‡ ÌÂÈÓÏÂ‰Ë‡ÚÓ‡ ÒÂÓÚÓÌËÌ‡, ÓÚ‚Â˜‡˛˘Â„Ó Á‡ ÒÓÒÚÓflÌËÂ Ì‡ÒÚÓÂÌËfl, Ò ÔÓÒÎÂ‰Û˛˘ËÏ ËÒÚÓ˘ÂÌËÂÏ ÒÂÓÚÓÌËÌÓ‚ÓÈ ÒËÒÚÂÏ˚ ‚ ÎËÏ·Ë˜ÂÒÍËı ÒÚÛÍÚÛ‡ı „ÓÎÓ‚ÌÓ„Ó ÏÓÁ„‡ Ë ‡Á‚ËÚËÂÏ ÎÂÍ‡ÒÚ‚ÂÌÌÓÈ ‰ÂÔÂÒÒËË, ÚÂ‚ÓÊÌÓÒÚË, Ì‡Û¯ÂÌËfl Ô‡ÏflÚË Ë ‚ÌËÏ‡ÌËfl [13]. èÂ„ËÎËÓ‚‡ÌËÂ àîç-α ÌÂ ÔË‚ÂÎÓ Í ÓÒÚÛ ˜‡ÒÚÓÚ˚ ÎÂÍ‡ÒÚ‚ÂÌÌÓÈ ‰ÂÔÂÒÒËË, ˜ÚÓ ÔÓ‰Ú‚ÂÊ‰‡ÂÚÒfl ÔflÏ˚Ï Ò‡‚ÌÂÌËÂÏ ˝ÙÙÂÍÚÓ‚ ‰‚Ûı ÙÓÏ àîç-α [14]. èËÒÓÂ‰ËÌÂÌËÂ Ë·‡‚ËËÌ‡ Í àîç-α ÌÂÁÌ‡˜ËÚÂÎ¸ÌÓ Û‚ÂÎË˜Ë‚‡ÂÚ ˜‡ÒÚÓÚÛ ‰ÂÔÂÒÒËË ‚ ıÓ‰Â èÇí [15], ‚ÓÁÏÓÊÌÓ Á‡ Ò˜ÂÚ ÒÔÓÒÓ·ÌÓÒÚË Ë·‡‚ËËÌ‡ ËÌ‰ÛˆËÓ‚‡Ú¸ ‡ÌÂÏË˛, ÍÓÚÓ‡fl ÓÚÌÓÒËÚÒfl Í Ù‡ÍÚÓ‡Ï ËÒÍ‡ ‰ÂÔÂÒÒËË ‚ ˆÂÎÓÏ Ë ËÌÚÂÙÂÓÌÓ‚ÓÈ ‚ ˜‡ÒÚÌÓÒÚË [5,16]. Факторы риска развития интерферон-индуцированной депрессии. Ç ÓÚÎË˜ËÂ ÓÚ ˝Ì‰Ó„ÂÌÌÓÈ ‰ÂÔÂÒÒËË, ËÌ‰ÛˆËÛÂÏ‡fl àîç-α ‰ÂÔÂÒÒËfl ÌÂ ËÏÂÂÚ Ú‡ÍËı ÔÂ‰ËÍÚÓÓ‚, Í‡Í ÔÓÊËÎÓÈ ‚ÓÁ‡ÒÚ Ë ÊÂÌÒÍËÈ ÔÓÎ [15]. ÑÂÔÂÒÒËfl ˜‡˘Â ‚ÒÂ„Ó Ì‡˜ËÌ‡ÂÚ ‚ÓÁÌËÍ‡Ú¸ ÔÓÒÎÂ 4 ÌÂ‰ÂÎË èÇí, ‰ÓÒÚË„‡fl Ï‡ÍÒËÏÛÏ‡ ˜‡ÒÚÓÚ˚ Ì‡ 12 ÌÂ‰ÂÎÂ [17]. Ñ‡ÌÌ˚Â ‚ÂÏÂÌÌ˚Â ËÌÚÂ‚‡Î˚ ÍÓÒ‚ÂÌÌÓ ÓÚ‡Ê‡˛Ú Ô‡ÚÓ„ÂÌÂÚË˜ÂÒÍÛ˛ Ò‚flÁ¸ ÔÓ·Ó˜ÌÓ„Ó ‰ÂÈÒÚ‚Ëfl ÔÂÔ‡‡ÚÓ‚ àîç-α Ò ˆÂÎÂ‚ÓÈ ËÌ‰ÛÍˆËÂÈ ÔÓÚË‚Ó‚ËÛÒÌÓ„Ó ËÏÏÛÌËÚÂÚ‡. àÏÂÌÌÓ ‚ ˝ÚË ÒÓÍË ÓÊË‰‡ÂÚÒfl ‡ÌÌËÈ ‚ËÛÒÓÎÓ„Ë˜ÂÒÍËÈ ÓÚ‚ÂÚ Ë ÓÍÓÌ˜‡ÚÂÎ¸ÌÓ Â¯‡ÂÚÒfl ‚ÓÔÓÒ Ó ÚÓÏ, ÓÚ‚Â˜‡ÂÚ ÎË ·ÓÎ¸ÌÓÈ Ì‡ èÇí ËÎË ËÏÂÂÚ ÏÂÒÚÓ ÂÁËÒÚÂÌÚÌÓÒÚ¸ Í ÔÓ‚Ó‰ËÏÓÏÛ ÎÂ˜ÂÌË˛ [18]. 2 Ë 3 „ÂÌÓÚËÔ˚ HCV, ı‡‡ÍÚÂËÁÛ˛˘ËÂÒfl Ò‡Ï˚ÏË ‚˚ÒÓÍËÏË ÂÁÛÎ¸Ú‡Ú‡ÏË ÒÓ‚ÂÏÂÌÌÓÈ èÇí, Ó‰ÌÓ‚ÂÏÂÌÌÓ fl‚Îfl˛ÚÒfl Ù‡ÍÚÓ‡ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2 ЛЕКЦИЯ Таблица 1. Частота депрессии при использовании препаα и эффективность противовирусной ратов интерферона-α терапии èÂÔ‡‡Ú˚ èÂ„-àîç α2b + Ë·‡‚ËËÌ èÂ„-àîç α2a + Ë·‡‚ËËÌ ãÂÈÍÓˆËÚ‡Ì˚È àîç-α+Ë·‡‚ËËÌ ó‡ÒÚÓÚ‡ ‰ÂÔÂÒÒËË, % ëÚÓÈÍËÈ ÓÚ‚ÂÚ ÔË HCV 1, % 30 21 13 49 36 34,5-42 î‡ÍÚÓ‡ÏË ËÒÍ‡ Ú‡ÍÊÂ fl‚Îfl˛ÚÒfl ‰ÓÁ‡ ÔÂÔ‡‡Ú‡, ‰ÎËÚÂÎ¸ÌÓÒÚ¸ ÚÂ‡ÔËË, ‡ÌÂÏËfl, ÓÚÒÛÚÒÚ‚ËÂ ÒÓˆË‡Î¸ÌÓÈ ÔÓ‰‰ÂÊÍË, ‰ËÒÙÛÌÍˆËfl ˘ËÚÓ‚Ë‰ÌÓÈ ÊÂÎÂÁ˚ [5,16]. Скрининг депрессивных расстройств перед началом и в ходе интерферонотерапии. çÂ‡ÒÔÓÁÌ‡ÌÌ‡fl ‚Ó‚ÂÏfl ËÎË ÌÂÒ‚ÓÂ‚ÂÏÂÌÌÓ ÎÂ˜ÂÌÌ‡fl ‰ÂÔÂÒÒËfl ÏÓÊÂÚ ÔÓÚÂ·Ó‚‡Ú¸ ÒÌËÊÂÌËfl ‰ÓÁ ËÎË ÓÚÏÂÌ˚ àîçα, ÚÂÏ Ò‡Ï˚Ï ÒÌËÁË‚ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ èÇí, ËÎË ‚˚Á‚‡Ú¸ Û„ÓÊ‡˛˘Û˛ ÊËÁÌË ÔÒËıË‡ÚË˜ÂÒÍÛ˛ Ô‡ÚÓÎÓ„Ë˛ [1,2]. ÑÎfl ÒÍËÌËÌ„‡ ‰ÂÔÂÒÒËË ÔÂÂ‰ Ì‡˜‡ÎÓÏ Ë ‚ ıÓ‰Â èÇí ˆÂÎÂÒÓÓ·‡ÁÌÓ ËÒÔÓÎ¸ÁÓ‚‡ÌËÂ Ó·˘ÂÔËÌflÚ˚ı ‚ ÔÒËıË‡ÚËË ‡ÌÍÂÚ Ò‡ÏÓÓˆÂÌÍË ÚflÊÂÒÚË ‰ÂÔÂÒÒËË. ç‡Ë·ÓÎÂÂ ÔÓÒÚÓÈ ‰Îfl ‚˚ÔÓÎÌÂÌËfl ·ÓÎ¸Ì˚ÏË Ë ËÌÚÂÔÂÚ‡ˆËË ‚‡˜ÓÏ fl‚ÎflÂÚÒfl ¯Í‡Î‡ Ò‡ÏÓÓˆÂÌÍË ‰ÂÔÂÒÒËË ñÛÌ„‡ (1965 „.) [33]. éÌ‡ ÌÂ ÛÒÚÛÔ‡ÂÚ ÔÓ Ò‚ÓÂÈ ‰Ë‡„ÌÓÒÚË˜ÂÒÍÓÈ ˝ÙÙÂÍÚË‚ÌÓÒÚË ‰Û„ËÏ ËÁ‚ÂÒÚÌ˚Ï ¯Í‡Î‡Ï Ò‡ÏÓÓˆÂÌÍË – ÓÔÓÒÌËÍÛ ‰ÂÔÂÒÒËË ÅÂÍ‡ (BDI) Ë ¯Í‡Î˚ ‰ÂÔÂÒÒËË ñÂÌÚ‡ ˝ÔË‰ÂÏËÓÎÓ„Ë˜ÂÒÍËı ËÒÒÎÂ‰Ó‚‡ÌËÈ (CES-D) [34], ÔË ˝ÚÓÏ ÎÛ˜¯Â ÓÚ‡Ê‡ÂÚ ‰ËÌ‡ÏËÍÛ ‰ÂÔÂÒÒË‚Ì˚ı ÒËÏÔÚÓÏÓ‚ ‚ ıÓ‰Â èÇí Ë ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÌÓÈ ÚÂ‡ÔËË [35]. êÛÒÒÍÓflÁ˚˜Ì˚È ‚‡Ë‡ÌÚ ¯Í‡Î˚ ·˚Î ‡‰‡ÔÚËÓ‚‡Ì ‚ ë‡ÌÍÚ-èÂÚÂ·Û„ÒÍÓÏ Ì‡Û˜ÌÓ-ËÒÒÎÂ‰Ó‚‡ÚÂÎ¸ÒÍÓÏ ÔÒËıÓÌÂ‚ÓÎÓ„Ë˜ÂÒÍÓÏ ËÌÒÚËÚÛÚÂ ËÏ. Ç.å.ÅÂıÚÂÂ‚‡ [36]. Ç ÓÚÎË˜ËÂ ÓÚ ÓÔÓÒÌËÍ‡ É‡ÏËÎ¸ÚÓÌ‡ (1967 „.) ÏË ËÒÍ‡ ‡Á‚ËÚËfl ËÌÚÂÙÂÓÌÓ‚ÓÈ ‰ÂÔÂÒÒËË [19]. ÇÓÁÏÓÊÌÓ, ÌÂ ‚ ÔÓÒÎÂ‰Ì˛˛ Ó˜ÂÂ‰¸, ˝ÚÓ Ó·ÛÒÎÓ‚ÎÂÌÓ ÔËÒÛ˘ÂÈ ËÏ ·ÓÎ¸¯ÂÈ ËÌ‰ÛÍˆËÂÈ ËÏÏÛÌÌÓÈ ÒËÒÚÂÏ˚ c ÔÓ‚˚¯ÂÌÌ˚Ï ‡ÒıÓ‰Ó‚‡ÌËÂÏ ÚËÔÚÓÙ‡Ì‡ Â˘Â ‰Ó Ì‡˜‡Î‡ èÇí ÔÓ Ò‡‚ÌÂÌË˛ Ò 1 „ÂÌÓÚËÔÓÏ HCV [20]. ì˜ËÚ˚‚‡fl ÏÂı‡ÌËÁÏ˚ Ô‡ÚÓ„ÂÌÂÁ‡ ËÌÚÂÙÂÓÌÓ‚ÓÈ ‰ÂÔÂÒÒËË, ÌÂÎ¸Áfl ËÒÍÎ˛˜ËÚ¸ ÒÛ˘ÂÒÚ‚Ó‚‡ÌËÂ ÔflÏÓÈ Ò‚flÁË ÏÂÊ‰Û ˜‡ÒÚÓÚÓÈ ‰ÂÔÂÒÒËË ÔË ÔËÏÂÌÂÌËË ‡ÁÎË˜Ì˚ı ÔÂÔ‡‡ÚÓ‚ àîç-α Ë Ëı ˝ÙÙÂÍÚË‚ÌÓÒÚ¸˛ [21-25] (Ú‡·Î. 1), ˜ÚÓ, Ó˜Â‚Ë‰ÌÓ, ÌÂ ÓÔÂ‰ÂÎflÂÚÒfl Ëı ÒÔÓÒÓ·ÌÓÒÚ¸˛ ÔÓ-‡ÁÌÓÏÛ ÔÓÌËÍ‡Ú¸ ˜ÂÂÁ „ÂÏ‡ÚÓ˝ÌˆÂÙ‡ÎË˜ÂÒÍËÈ ·‡¸Â. ëÛ˘ÂÒÚ‚ÛÂÚ ÏÌÂÌËÂ, ˜ÚÓ ˝ÍÁÓ„ÂÌÌ˚È ÒÚ‡Ì‰‡ÚÌ˚È àîç-α ÌÂ ÒÔÓÒÓ·ÂÌ Â„Ó ÔÂÓ‰ÓÎÂÚ¸ [26]. íÂÏ ·ÓÎÂÂ ˝ÚÓ Í‡Ò‡ÂÚÒfl Â„Ó ·ÓÎÂÂ ÍÛÔÌ˚ı ÏÓÎÂÍÛÎflÌ˚ı ÔÂ„ËÎËÓ‚‡ÌÌ˚ı ÙÓÏ àîç-α (èÂ„-àîç-α). ñÂÌÚ‡Î¸ÌÓÈ ÌÂ‚ÌÓÈ ÒËÒÚÂÏ˚ ‰ÓÒÚË„‡˛Ú ‡ÍÚË‚ËÓ‚‡ÌÌ˚Â àîç-α ˆËÚÓÍËÌ˚, Á‡ÔÛÒÍ‡˛˘ËÂ ÏÂı‡ÌËÁÏ ËÒÚÓ˘ÂÌËfl ÒÂÓÚÓÌËÌ‡. ç‡ ÔÂËÙÂËË ÛÒÍÓÂÌÌ˚È ÏÂÚ‡·Ó- Таблица 2. Шкала Цунга для самооценки депрессии ÎËÁÏ ÚËÔÚÓÙ‡Ì‡ ËÌ‰ÓÎ‡ÏËÌ‰ËÓÍÒËëËÏÔÚÓÏ˚ Ë Ó˘Û˘ÂÌËfl çËÍÓ„‰‡ àÌÓ„‰‡ ó‡ÒÚÓ èÓ˜ÚË „ÂÌ‡ÁÓÈ ÔÓËÒıÓ‰ËÚ ÔË ‡ÍÚË‚‡ˆËË ËÎË Í‡ÈÌÂ ‚ÒÂ„‰‡ ËÎË + àîç-α CD4 -ÎËÏÙÓˆËÚÓ‚ [26]. ÇÂÓÂ‰ÍÓ ÔÓÒÚÓflÌÌÓ flÚÌÓ, ˜‡ÒÚÓÚ‡ ‡Á‚ËÚËfl ËÌÚÂÙÂÓÌ1 ü ˜Û‚ÒÚ‚Û˛ ÔÓ‰‡‚ÎÂÌÌÓÒÚ¸ 1 2 3 4 ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË Ì‡ÔflÏÛ˛ 2 ü ÎÛ˜¯Â ‚ÒÂ„Ó ˜Û‚ÒÚ‚Û˛ ÒÂ·fl ÛÚÓÏ 1 2 3 4 Á‡‚ËÒËÚ ÓÚ ÒÔÓÒÓ·ÌÓÒÚË ‡ÁÎË˜Ì˚ı 3 ü ÏÌÓ„Ó ÔÎ‡˜Û 1 2 3 4 1 2 3 4 ÔÂÔ‡‡ÚÓ‚ àîç-α ËÌ‰ÛˆËÓ‚‡Ú¸ 4 ü ÔÎÓıÓ ÒÔÎ˛ ÌÓ˜¸˛ 1 2 3 4 ÔÓÚË‚Ó‚ËÛÒÌ˚È ËÏÏÛÌËÚÂÚ. ëÚÛÍ- 5 ÄÔÔÂÚËÚ Û ÏÂÌfl ÌÂ ıÛÊÂ Ó·˚˜ÌÓ„Ó 6 åÌÂ ÔËflÚÌÓ Ì‡ıÓ‰ËÚ¸Òfl ÒÂ‰Ë 1 2 3 4 ÚÛ‡ ·ÂÎÍ‡ àîç-α, ÔÓ ‚Ë‰ËÏÓÏÛ, ÔË‚ÎÂÍ‡ÚÂÎ¸Ì˚ı ÏÛÊ˜ËÌ/ÊÂÌ˘ËÌ ‚ÎËflÂÚ Ì‡ ˝ÚË ˝ÙÙÂÍÚ˚. ë‡‚ÌËÚÂÎ¸ËÎË Ó·˘‡Ú¸Òfl Ò ÌËÏË 1 2 3 4 Ì˚Â ËÒÒÎÂ‰Ó‚‡ÌËfl èÂ„-àîç-α2b Ë 7 ü Á‡ÏÂÚÌÓ ÚÂfl˛ ‚ ‚ÂÒÂ 1 2 3 4 èÂ„-àîç-α2a ÔÓÍ‡Á‡ÎË, ˜ÚÓ ÔÂÔ‡‡Ú 8 åÂÌfl ·ÂÒÔÓÍÓflÚ Á‡ÔÓ˚ 9 ëÂ‰ˆÂ ·¸ÂÚÒfl ·˚ÒÚÂÂ, ˜ÂÏ Ó·˚˜ÌÓ 1 2 3 4 Ò ÏÂÌ¸¯ÂÈ ÏÓÎÂÍÛÎflÌÓÈ Ï‡ÒÒÓÈ (èÂ- 10 ü ÛÒÚ‡˛ ·ÂÁ ‚ÒflÍËı ÔË˜ËÌ 1 2 3 4 „àÌÚÓÌ) Ó·Î‡‰‡ÂÚ ·ÓÎ¸¯ÂÈ ÔÓÚË‚Ó- 11 ü Ï˚ÒÎ˛ Ú‡Í ÊÂ ˜ÂÚÍÓ, Í‡Í Ë ‡Ì¸¯Â 1 2 3 4 1 2 3 4 ‚ËÛÒÌÓÈ Ë ‡ÌÚËÔÓÎËÙÂ‡ÚË‚ÌÓÈ 12 åÌÂ ÎÂ„ÍÓ ‚˚ÔÓÎÌflÚ¸ ÔË‚˚˜ÌÛ˛ ‡·ÓÚÛ ‡ÍÚË‚ÌÓÒÚ¸˛ ÔÓ Ò‡‚ÌÂÌË˛ Ò ÔÂÔ‡‡13 óÛ‚ÒÚ‚Û˛ ·ÂÒÔÓÍÓÈÒÚ‚Ó Ë ÌÂ ÏÓ„Û 1 2 3 4 ÚÓÏ Ò ‚˚ÒÓÍÓÈ ÏÓÎÂÍÛÎflÌÓÈ Ï‡ÒÒÓÈ ÛÒË‰ÂÚ¸ Ì‡ ÏÂÒÚÂ (èÂ„‡ÒËÒ) [27,28]. 14 ü ÔÓÎÓÌ Ò‚ÂÚÎ˚ı Ì‡‰ÂÊ‰ Ì‡ ·Û‰Û˘ÂÂ 1 2 3 4 1 2 3 4 ÉÂÌÂÚË˜ÂÒÍËÈ ÔÓÎËÏÓÙËÁÏ ÒÂÓ- 15 ü ·ÓÎÂÂ ‡Á‰‡ÊËÚÂÎÂÌ, ˜ÂÏ ‡Ì¸¯Â 1 2 3 4 ÚÓÌËÌÓ‚ÓÈ Ë ‰ÓÙ‡ÏËÌÓ‚ÓÈ ÌÂÈÓÏÂ- 16 åÌÂ ÎÂ„ÍÓ ÔËÌËÏ‡Ú¸ Â¯ÂÌËfl 17 ü ˜Û‚ÒÚ‚Û˛, ˜ÚÓ ÔÓÎÂÁÂÌ Ë ÌÛÊÂÌ 1 2 3 4 ‰Ë‡ÚÓÌ˚ı ÒËÒÚÂÏ (‚ ˜‡ÒÚÌÓÒÚË, Î˛‰flÏ S-‡ÎÎÂÎ¸ „ÂÌ‡ Ú‡ÌÒÔÓÚÂ‡ ÒÂÓÚÓÌË- 18 ü ÊË‚Û ÔÓÎÌÓÈ Ë ËÌÚÂÂÒÌÓÈ ÊËÁÌ¸˛ 1 2 3 4 1 2 3 4 Ì‡) Ó·ÒÛÊ‰‡ÂÚÒfl ‚ Í‡˜ÂÒÚ‚Â Ù‡ÍÚÓ‡ 19 ü ˜Û‚ÒÚ‚Û˛, ˜ÚÓ ‰Û„ËÏ Î˛‰flÏ ·˚ÎÓ ·˚ ÎÛ˜¯Â, ÂÒÎË fl ÛÏÛ ËÒÍ‡ ‡Á‚ËÚËfl Í‡Í ˝Ì‰Ó„ÂÌÌÓÈ, Ú‡Í Ë 20 åÂÌfl ‰Ó ÒËı ÔÓ ‡‰ÛÂÚ ÚÓ, ˜ÚÓ 1 2 3 4 ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒ‡‰Ó‚‡ÎÓ ‚ÒÂ„‰‡ ÒËË [29,30]. ÄÎÎÂÎ¸Ì˚È ÔÓÎËÏÓÙËÁÏ àÌÒÚÛÍˆËfl: Á‡˜ÂÍÌËÚÂ ÒÓÓÚ‚ÂÚÒÚ‚Û˛˘Û˛ ˆËÙÛ ÒÔ‡‚‡ ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ ÚÓ„Ó, Í‡Í Ç˚ ˝ÚËı ÌÂÈÓÏÂ‰Ë‡ÚÓÌ˚ı ÒËÒÚÂÏ ‚ÎËfl- ÒÂ·fl ˜Û‚ÒÚ‚ÛÂÚÂ ‚ ÔÓÒÎÂ‰ÌÂÂ ‚ÂÏfl. ÂÚ Ì‡ ÙÓÏËÓ‚‡ÌËÂ Á‡‚ËÒËÏÓÒÚË ÓÚ ìÓ‚ÂÌ¸ ‰ÂÔÂÒÒËË ‡ÒÒ˜ËÚ˚‚‡ÂÚÒfl ÔÛÚÂÏ ÒÎÓÊÂÌËfl ÔÓÒÚÓÈ ÒÛÏÏ˚ Á‡˜ÂÍÌÛÚ˚ı ˆËÙ ‚ ÔÒËıÓ‡ÍÚË‚Ì˚ı ‚Â˘ÂÒÚ‚. ÅÓÎ¸Ì˚Â ‡Î- ‚˚ÒÍ‡Á˚‚‡ÌËflı ‹1, 3-4, 7-10, 13, 15, 19 Ò ‰Ó·‡‚ÎÂÌËÂÏ Í ÌÂÈ ÒÛÏÏ˚ ·‡ÎÎÓ‚ ‚ ‚˚ÒÍ‡Á˚ÍÓ„ÓÎËÁÏÓÏ, Ì‡ÍÓÏ‡ÌËÂÈ Ë Ú‡·‡˜ÌÓÈ ‚‡ÌËflı ‹2, 5-6, 11-12, 14, 16-18, 20, ÍÓÚÓ˚Â ‡ÒÒ˜ËÚ˚‚‡˛ÚÒfl ‚ Ó·‡ÚÌÓÏ ÔÓfl‰ÍÂ, Ì‡ÔËÏÂ: ‹2 Á‡˜ÂÍÌÛÚ‡ ˆËÙ‡ 1 = 4 ·‡ÎÎ‡; ‹5 Á‡˜ÂÍÌÛÚ ÓÚ‚ÂÚ 2 = 3 ·‡ÎÎ‡; ‹6 Á‡‚ËÒËÏÓÒÚ¸˛ fl‚Îfl˛ÚÒfl „ÛÔÔÓÈ ËÒ- Á‡˜ÂÍÌÛÚ ÓÚ‚ÂÚ 3 = 2 ·‡ÎÎ‡; ‹11 Á‡˜ÂÍÌÛÚ ÓÚ‚ÂÚ 4 = 1 ·‡ÎÎ Ë Ú.‰. ÖÒÎË ÒÛÏÏ‡ ·‡ÎÎÓ‚ Í‡ ‡Á‚ËÚËfl ‰ÂÔÂÒÒËË ‚ ıÓ‰Â ËÌÚÂ- ÒÓÒÚ‡‚ÎflÂÚ ÏÂÌÂÂ 50, ÚÓ ‰ÂÔÂÒÒËfl ÓÚÒÛÚÒÚ‚ÛÂÚ, 50-59 - ÎÂ„Í‡fl (ÒÎ‡·‡fl) ‰ÂÔÂÒÒËfl, 60-69 - ÒÂ‰Ìflfl (ÛÏÂÂÌÌ‡fl), 70 Ë ·ÓÎÂÂ - ÚflÊÂÎ‡fl ‰ÂÔÂÒÒËfl. ÙÂÓÌÓÚÂ‡ÔËË [31,32]. ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2 27 ЛЕКЦИЯ Таблица 3. Ведение больных на комбинированной терапии ИФН и рибавирином при депресии íflÊÂÒÚ¸ àÁÏÂÌÂÌËÂ ‰ÂÔÂÒÒËË ÔÓ ‰ÓÁËÓ‚ÍË åäÅ-10/DSM-IV ãÂ„Í‡fl ëÂ‰Ìflfl íflÊÂÎ‡fl åÓÌËÚÓËÌ„ ‰ÂÔÂÒÒËË (‚ËÁËÚ˚ Ô‡ˆËÂÌÚ‡) çÂ ÚÂ·ÛÂÚÒfl ê‡Á ‚ ÌÂ‰ÂÎ˛ ËÎË ÔÓ ÚÂÎÂÙÓÌÛ + ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ ëÌËÊÂÌËÂ ‰ÓÁ˚ ÖÊÂÌÂ‰ÂÎ¸ÌÓ + ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ àîç Ì‡ 50% çÂÏÂ‰ÎÂÌÌ‡fl ÔÒËıË‡ÚË˜ÂÒÍ‡fl éÚÏÂÌ‡ èÇí ÔÓÏÓ˘¸ Таблица 4. Симптомы депрессии по МКБ 10 пересмотра éÒÌÓ‚Ì˚Â ÒËÏÔÚÓÏ˚ ÑÓÔÓÎÌËÚÂÎ¸Ì˚Â ÒËÏÔÚÓÏ˚ 1. ëÌËÊÂÌÌÓÂ, ÔÓ‰‡‚ÎÂÌÌÓÂ Ì‡ÒÚÓÂÌËÂ (‚ÌÂ Á‡‚ËÒËÏÓÒÚË ÓÚ ÒËÚÛ‡ˆËË Ë ÌÂ ÏÂÌÂÂ 2 ÌÂ‰ÂÎ¸)* 2. ëÌËÊÂÌËÂ ËÎË ÛÚ‡Ú‡ ËÌÚÂÂÒÓ‚ Ë ÒÔÓÒÓ·ÌÓÒÚË ËÒÔ˚Ú˚‚‡Ú¸ Û‰Ó‚ÓÎ¸ÒÚ‚ËÂ ëÌËÊÂÌËÂ ˝ÌÂ„ËË Ë ÔÓ‚˚¯ÂÌÌ‡fl ÛÚÓÏÎflÂÏÓÒÚ¸ 1. ëÌËÊÂÌÌ‡fl Ò‡ÏÓÓˆÂÌÍ‡ Ë ˜Û‚ÒÚ‚Ó ÌÂÛ‚ÂÂÌÌÓÒÚË ‚ ÒÂ·Â 2. à‰ÂË ‚ËÌÓ‚ÌÓÒÚË Ë Ò‡ÏÓÛÌË˜ËÊÂÌËfl 3. èÓ‚ÚÓfl˛˘ËÂÒfl Ï˚ÒÎË Ó ÒÏÂÚË ËÎË Ò‡ÏÓÛ·ËÈÒÚ‚Â, ÒÛËˆË‰‡Î¸Ì˚Â ‰ÂÈÒÚ‚Ëfl 4. ëÌËÊÂÌËÂ ÍÓÌˆÂÌÚ‡ˆËË ‚ÌËÏ‡ÌËfl, ÌÂÒÔÓÒÓ·ÌÓÒÚ¸ ÒÓÒÂ‰ÓÚÓ˜ËÚ¸Òfl 5. ç‡Û¯ÂÌËÂ ÔÒËıÓÏÓÚÓÌÓÈ ‡ÍÚË‚ÌÓÒÚË Ò ‡ÊËÚ‡ˆËÂÈ ËÎË Á‡ÚÓÏÓÊÂÌÌÓÒÚ¸˛ (ÒÛ·˙ÂÍÚË‚ÌÓ ËÎË Ó·˙ÂÍÚË‚ÌÓ) 6. ç‡Û¯ÂÌËÂ ÒÌ‡ Î˛·Ó„Ó ÚËÔ‡ 7. ç‡Û¯ÂÌËÂ ‡ÔÔÂÚËÚ‡ Ò ËÁÏÂÌÂÌËÂÏ Ï‡ÒÒ˚ ÚÂÎ‡ èËÏÂ˜‡ÌËÂ: * 7 ‰ÌÂÈ ÔË ‚ÓÁÌËÍÌÓ‚ÂÌËË ‰ÂÔÂÒÒËË ‚ ıÓ‰Â ÔÓÚË‚Ó‚ËÛÒÌÓÈ ÚÂ‡ÔËË [16] [37], ÔÓÎÛ˜Ë‚¯Â„Ó ¯ËÓÍÓÂ ÔËÏÂÌÂÌËÂ ‚ ÔÒËıË‡ÚËË, ‰‡ÌÌ˚È ÓÔÓÒÌËÍ ÌÂ ÚÂ·ÛÂÚ ÓÚ ‚‡˜ÂÈ Ó·˘ÂÈ Ô‡ÍÚËÍË ÒÔÂˆË‡Î¸Ì˚ı ÁÌ‡ÌËÈ Ë Ì‡‚˚ÍÓ‚ (Ú‡·Î. 2). íÂÒÚ ñÛÌ„‡ Ó·Î‡‰‡ÂÚ ‚˚ÒÓÍÓÈ ˜Û‚ÒÚ‚ËÚÂÎ¸ÌÓÒÚ¸˛ Ë ÒÔÂˆËÙË˜ÌÓÒÚ¸˛ Ë ÔÓÁ‚ÓÎflÂÚ ËÁ·ÂÊ‡Ú¸ ‰ÓÔÓÎÌËÚÂÎ¸Ì˚ı ˝ÍÓÌÓÏË˜ÂÒÍËı Ë ‚ÂÏÂÌÌ˚ı Á‡Ú‡Ú. äÓÏÂ ÚÓ„Ó, Á‡ÔÓÎÌÂÌËÂ ÚÂÒÚ‡ „Ó‡Á‰Ó ÏÂÌÂÂ Ú‡‚ÏËÛÂÚ ÔÒËıËÍÛ ·ÓÎ¸ÌÓ„Ó, ˜ÂÏ ÌÂÓ·ıÓ‰ËÏÓÒÚ¸ ÔÓ‰ÔËÒ‡ÌËfl ËÌÙÓÏËÓ‚‡ÌÌÓ„Ó ÒÓ„Î‡ÒËfl Ì‡ ÓÒÏÓÚ ÔÒËıË‡Ú‡. Алгоритм ведения больных с депрессией. ÑÂÔÂÒÒËfl ÒÎ‡·ÓÈ ÒÚÂÔÂÌË ÌÂ fl‚ÎflÂÚÒfl ÔÓÚË‚ÓÔÓÍ‡Á‡ÌËÂÏ Í ÚÂ‡ÔËË àîç-α. ãÂ„Í‡fl ‰ÂÔÂÒÒËfl, ‚ÓÁÌËÍ‡˛˘‡fl ‚ ıÓ‰Â èÇí, ÌÂ ÚÂ·ÛÂÚ ÍÓÂÍˆËË ‰ÓÁ˚ àîç-α. Ç Ó·ÓËı ÒÎÛ˜‡flı Ì‡ÁÌ‡˜‡ÂÚÒfl ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÌ‡fl ÚÂ‡ÔËfl Ë ÔÓ‚Ó‰ËÚÒfl ÏÓÌËÚÓËÌ„ ÒÚÂÔÂÌË ÚflÊÂÒÚË ‰ÂÔÂÒÒËË Ò ÔÓÏÓ˘¸˛ Ó‰ÌÓÈ ËÁ Ó·˘ÂÔËÌflÚ˚ı ¯Í‡Î (Ì‡ÔËÏÂ, ñÛÌ„‡) ÔË ÔÎ‡ÌÓ‚˚ı ÔÓÒÂ˘ÂÌËflı ‚‡˜‡, ÊÂÎ‡ÚÂÎ¸ÌÓ ÂÊÂÌÂ‰ÂÎ¸Ì˚ı. ÑÓÔÛÒÍ‡ÂÚÒfl ˜ÂÂ‰Ó‚‡ÌËÂ ‚ËÁËÚÓ‚ Í ÎÂ˜‡˘ÂÏÛ ‚‡˜Û Ë ÚÂÎÂÙÓÌÌ˚ı ÍÓÌÚ‡ÍÚÓ‚. èË Ì‡ÎË˜ËË ÔËÁÌ‡ÍÓ‚ ‰ÂÔÂÒÒËË ÌÂÓ·ıÓ‰ËÏÓ ÓÒÛ˘ÂÒÚ‚ÎflÚ¸ ÓÒÏÓÚ ·ÓÎ¸ÌÓ„Ó ÂÊÂÌÂ‰ÂÎ¸ÌÓ [38]. ÑÂÔÂÒÒËfl ÒÂ‰ÌÂÈ Ë ÚflÊÂÎÓÈ ÒÚÂÔÂÌÂÈ fl‚ÎflÂÚÒfl ÔÓÚË‚ÓÔÓÍ‡Á‡ÌËÂÏ Í Ì‡˜‡ÎÛ èÇí, ÌÂÓ·ıÓ‰ËÏ‡ ÍÓÌÒÛÎ¸Ú‡ˆËfl ÔÒËıË‡Ú‡. Ç ˝ÚÓÈ ÒËÚÛ‡ˆËË èÇí, ÚÂÏ ÌÂ ÏÂÌÂÂ, ÏÓÊÂÚ ·˚Ú¸ Ì‡˜‡Ú‡, ÌÓ ÔÓÒÎÂ ‰ÓÒÚËÊÂÌËË ÍÓÌÚÓÎfl Ì‡‰ ‰ÂÔÂÒÒËÂÈ – ÔÓÌËÊÂÌËË ÂÂ ÒÚÂÔÂÌË ÚflÊÂÒÚË ‰Ó ÒÎ‡·ÓÈ Ë, ÚÂÏ ·ÓÎÂÂ, ÔË ÛÏÂÌ¸¯ÂÌËË ÒÔÂÍÚ‡ Ë ‚˚‡ÊÂÌÌÓÒÚË ÂÂ ÒËÏÔÚÓÏÓ‚ ÌËÊÂ ‰Ë‡„ÌÓÒÚË˜ÂÒÍÓ„Ó ÔÓÓ„‡ (ÒÛÏÏ‡ ·‡ÎÎÓ‚ ÔÓ ¯Í‡ÎÂ ñÛÌ„‡ <50) [16]. çÂÍÓÌÚÓÎËÛÂÏ‡fl ‰ÂÔÂÒÒËfl ÒÂ‰ÌÂÈ ÒÚÂÔÂÌË, ‚ÓÁÌËÍ¯‡fl Ì‡ ÙÓÌÂ èÇí, ÚÂ·ÛÂÚ ÛÏÂÌ¸¯ÂÌËfl ‚‰‚ÓÂ ‰ÓÁ˚ àîç-α, ‡ ÚflÊÂÎÓÈ ÒÚÂÔÂÌË – ÔÓÎÌÓÈ ÓÚÏÂÌ˚ èÇí (Ú‡·Î. 3) [38]. Ç Ó·ÓËı ÒÎÛ˜‡flı „Î‡‚Ì‡fl ˆÂÎ¸ èÇí – ˝‡‰ËÍ‡ˆËfl ‚ËÛÒÓ‚ „ÂÔ‡ÚËÚ‡ – ÒÚ‡ÌÓ‚ËÚÒfl ÁÌ‡˜ËÚÂÎ¸ÌÓ ÏÂÌÂÂ ‰ÓÒÚËÊËÏÓÈ, ÓÒÓ·ÂÌÌÓ ÔË ‚ÌÂÒÂÌËË ËÁÏÂÌÂÌËÈ ‚ ‰ÓÁ˚ ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚ Ì‡ Ì‡˜‡Î¸Ì˚ı ˝Ú‡Ô‡ı èÇí. ÑÎfl ÔËÌflÚËfl Â¯ÂÌËfl Ó ÍÓÂÍˆËË ‰ÓÁ˚ ËÎË ÓÚÏÂÌ˚ àîç-α ‚ ıÓ‰Â èÇí, ÒÎÂ‰ÛÂÚ ËÒÔÓÎ¸ÁÓ‚‡Ú¸ ÌÂ ÚÓÎ¸ÍÓ ÒÍËÌËÌ„Ó‚˚Â (¯Í‡Î‡ ñÛÌ„‡), ÌÓ Ë ‰Ë‡„ÌÓÒÚË˜ÂÒÍËÂ ÍËÚÂËË ‰ÂÔÂÒÒËË Ë ÒÚÂÔÂÌË ÂÂ ÚflÊÂÒÚË ÒÓ„Î‡ÒÌÓ ÏÂÊ‰ÛÌ‡Ó‰ÌÓÈ ÍÎ‡ÒÒËÙËÍ‡ˆËË ·ÓÎÂÁÌÂÈ 10 ÔÂÂÒÏÓÚ‡ (Ú‡·Î. 4, 5) [39]. í‡ÍÊÂ fl‚ÎflÂÚÒfl Ó·flÁ‡ÚÂÎ¸ÌÓÈ ÍÓÌÒÛÎ¸Ú‡ˆËfl ÔÒËıË‡Ú‡. èË ÌÂÎÂÍ‡ÒÚ‚ÂÌÌÓÈ ‰ÂÔÂÒÒËË ‰Îfl ÛÒÚ‡ÌÓ‚ÍË ‰Ë‡„ÌÓÁ‡ ÚÂ·ÛÂÚÒfl, ˜ÚÓ·˚ ÒËÏÔÚÓÏ˚ Á‡·ÓÎÂ‚‡ÌËfl ÔÓfl‚ÎflÎËÒ¸ Ì‡ ÔÓÚflÊÂÌËË ÌÂ ÏÂÌÂÂ ‰‚Ûı ÌÂ‰ÂÎ¸ [5]. ÑÎfl ‰Ë‡„ÌÓÒÚËÍË ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË, ÍÓ„‰‡ ‰ÂÔÂÒÒÓ„ÂÌÌ˚È Ù‡ÍÚÓ ËÁ‚ÂÒÚÂÌ, ÔÂ‰ÎÓÊÂÌÓ Ò˜ËÚ‡Ú¸ ‰ÓÒÚ‡ÚÓ˜Ì˚Ï ·ÓÎÂÂ ÍÓÓÚÍËÈ ÒÓÍ ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl ÒËÏÔÚÓÏÓ‚ (ÓÚ 7 ‰ÌÂÈ) Ë ÏÂÌ¸¯ÂÂ ˜ËÒÎÓ ‡Á‚Ë‚‡˛˘ËıÒfl ÒËÏÔÚÓÏÓ‚ (ÓÚ 2-ı) [16]. ùÚÓ Ò‚flÁ‡ÌÓ Ò ÚÂÏ, ˜ÚÓ ÎÂÍ‡ÒÚ‚ÂÌÌÓÂ ÒÌËÊÂÌËÂ Ì‡ÒÚÓÂÌËfl ÏÓÊÂÚ ÔÓ„ÂÒÒËÓ‚‡Ú¸ ‰ÓÒÚ‡ÚÓ˜ÌÓ ·˚ÒÚÓ, ‡ ‰ÂÈÒÚ‚ËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚, Í‡Í Ô‡‚ËÎÓ, ‚ÓÁÌËÍ‡ÂÚ ÓÚÒÓ˜ÂÌÓ (˜ÂÂÁ 1-2 ÌÂ‰ÂÎË). Ç ˝ÚËı ÛÒÎÓ‚Ëflı ‚‡˜ ÎË¯ÂÌ ‚ÓÁÏÓÊÌÓÒÚË ËÒÔÓÎ¸ÁÓ‚‡Ú¸ ‚˚ÊË‰‡ÚÂÎ¸ÌÛ˛ Ú‡ÍÚËÍÛ Ë Â¯ÂÌËÂ Ó ÏÂ‰ËÍ‡ÏÂÌÚÓÁÌÓÈ ‡ÌÚË‰ÂÔÂÒÒË‚ÌÓÈ ÔÓ‰‰ÂÊÍÂ ‰ÓÎÊÌÓ ·˚Ú¸ ÔËÌflÚÓ Ï‡ÍÒËÏ‡Î¸ÌÓ ·˚ÒÚÓ. ç‡ÎË˜ËÂ ‚ ‡Ì‡ÏÌÂÁÂ ‰ÂÔÂÒÒËË, ‡Á‚Ë‚¯ÂÈÒfl ÔË ÎÂ˜ÂÌËË àîç-α, ÔÓ‰‡ÁÛÏÂ‚‡ÂÚ Ì‡ÁÌ‡˜ÂÌËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚ Ó‰ÌÓ‚ÂÏÂÌÌÓ Ò Ì‡˜‡ÎÓÏ ÔÓ‚ÚÓÌÓ„Ó ÍÛÒ‡ èÇí Û ·ÓÎ¸Ì˚ı ·ÂÁ ÓÚ‚ÂÚ‡ Ì‡ ÔÂ‰¯ÂÒÚ‚Û˛˘ËÈ ÍÛÒ èÇí ËÎË Ò ÂˆË‰Ë‚ÓÏ ïÉë ÔÓÒÎÂ ÌÂ„Ó. ê‡Á‚Ë‚‡˛˘‡flÒfl ‚ ıÓ‰Â èÇí ‰ÂÔÂÒÒËfl ÏÓÊÂÚ ÍÓË„ËÓ‚‡Ú¸Òfl ÌÂ ÚÓÎ¸ÍÓ Ò ÔÓÏÓ˘¸˛ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚. äÓÌÚÓÎ¸ Á‡ ‰ÂÔÂÒÒËÂÈ ÏÓÊÌÓ ÓÒÛ˘ÂÒÚ‚ÎflÚ¸, ‚ ÚÓÏ ˜ËÒÎÂ, ‚ÂÏÂÌÌ˚Ï ÒÌËÊÂÌËÂÏ ‰ÓÁ˚ Ë·‡‚ËËÌ‡ ÔË Ì‡ÎË˜ËË ‡ÌÂÏËË, ÍÓÂÍˆËÂÈ ÙÛÌÍˆËË ˘ËÚÓ‚Ë‰ÌÓÈ ÊÂÎÂÁ˚ ÔË ÂÂ ‰ËÒÙÛÌÍˆËË, Ò ÔÓÏÓ˘¸˛ ‡ˆËÓÌ‡Î¸ÌÓÈ ÔÒËıÓÚÂ‡ÔËË ÔË ‚˚‡ÊÂÌÌÓÏ ÒËÚÛ‡ˆËÓÌÌÓÏ ÍÓÏÔÓÌÂÌÚÂ (ÔË ‚ÓÁÌËÍ‡˛˘Ëı ÊËÁÌÂÌÌ˚ı ÚÛ‰ÌÓÒÚflı, ÔË “ÍÓÒÏÂÚË˜ÂÒÍËı” ÌÂÊÂÎ‡- Таблица 5. Критерии тяжести депрессии по МКБ 10 пересмотра ëÚÂÔÂÌ¸ ÚflÊÂÒÚË òËÙ ëËÏÔÚÓÏ˚ ãÂ„Í‡fl ìÏÂÂÌÌ‡fl (ÒÂ‰Ìflfl) F32.0 F32.1 íflÊÂÎ‡fl ·ÂÁ ÔÒËıÓÚË˜ÂÒÍËı ÒËÏÔÚÓÏÓ‚ íflÊÂÎ‡fl Ò ÔÒËıÓÚË˜ÂÒÍËÏË ÒËÏÔÚÓÏ‡ÏË F32.2 28 F32.3 ç‡ÎË˜ËÂ ÌÂ ÏÂÌÂÂ 2 ÓÒÌÓ‚Ì˚ı Ë ‰ÓÔÓÎÌËÚÂÎ¸Ì˚ı ÒËÏÔÚÓÏÓ‚ (Ó·˘ÂÂ ÍÓÎË˜ÂÒÚ‚Ó ÌÂ ÏÂÌÂÂ 4) ç‡ÎË˜ËÂ ÌÂ ÏÂÌÂÂ 2 ÓÒÌÓ‚Ì˚ı Ë ‰ÓÔÓÎÌËÚÂÎ¸Ì˚ı ÒËÏÔÚÓÏÓ‚ ‰Ó Ó·˘Â„Ó ÍÓÎË˜ÂÒÚ‚‡ ÌÂ ÏÂÌÂÂ 6. á‡ÚÛ‰ÌÂÌ‡ ÔË‚˚˜Ì‡fl ‰ÂflÚÂÎ¸ÌÓÒÚ¸ ëÓ˜ÂÚ‡ÌËÂ ‚ÒÂı 3 ÓÒÌÓ‚Ì˚ı Ë ‰ÓÔÓÎÌËÚÂÎ¸Ì˚ı ÒËÏÔÚÓÏÓ‚ ‰Ó ÒÛÏÏ‡ÌÓ„Ó ÍÓÎË˜ÂÒÚ‚‡ ÌÂ ÏÂÌÂÂ 8. ëÛËˆË‰‡Î¸Ì˚Â Ï˚ÒÎË Ë ÔÓÔ˚ÚÍË. èÓ˜ÚË ËÎË ÔÓÎÌÓÂ ÔÂÍ‡˘ÂÌËÂ ÔË‚˚˜ÌÓÈ ‰ÂflÚÂÎ¸ÌÓÒÚË äËÚÂËË F32.2 + „‡ÎÎ˛ˆËÌ‡ˆËË, ·Â‰, ÔÒËıÓÏÓÚÓÌ‡fl Á‡ÚÓÏÓÊÂÌÌÓÒÚ¸, ÒÚÛÔÓ, „ÓÎÓ‰‡ÌËÂ, Ó·ÂÁ‚ÓÊË‚‡ÌËÂ (ÍËÚÂËË ¯ËÁÓÙÂÌËË ÓÚÒÛÚÒÚ‚Û˛Ú) ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2 ЛЕКЦИЯ Таблица 6. Классификация и нежелательные эффекты антидепрессантов ÉÛÔÔ˚ èÂÔ‡‡Ú˚ çÂÊÂÎ‡ÚÂÎ¸Ì˚Â fl‚ÎÂÌËfl Ë ÚÛ‰ÌÓÒÚË ‚Â‰ÂÌËfl ·ÓÎ¸Ì˚ı íËˆËÍËÎ˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚ ÄÏËÚËÔÚËÎËÌ, ÌÓÚËÔÚËÎËÌ, ‰ÂÁËÔ‡ÏËÌ, ËÏËÔ‡ÏËÌ çË‡Î‡ÏË‰, ÙÂÌËÎÁËÌ, Ú‡ÌËÎˆËÔÓÏËÌ, ËÁÓÍ‡·ÓÍÒ‡ÁË‰ ä‡‰ËÓÚÓÍÒË˜ÌÓÒÚ¸, ÓÚÓÒÚ‡Á, ıÓÎËÌÓÎËÚË˜ÂÒÍÓÂ ‰ÂÈÒÚ‚ËÂ, Ì‡Û¯ÂÌËÂ Û„ÎÂ‚Ó‰ÌÓ„Ó Ó·ÏÂÌ‡ ÑËÂÚ‡ Ò ËÒÍÎ˛˜ÂÌËÂÏ ÔÓ‰ÛÍÚÓ‚ Ì‡ÚÛ‡Î¸ÌÓ„Ó ·ÓÊÂÌËfl, „ÂÔ‡ÚÓÚÓÍÒË˜ÌÓÒÚ¸, ÒÎÓÊÌÓÒÚË ÔÂÂıÓ‰‡ Ì‡ ‰Û„ÓÈ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ, ÚÓÎ¸ÍÓ ÏÓÌÓÚÂ‡ÔËfl ëÓÌÎË‚ÓÒÚ¸, Â‰ÍÓ ÎÂÈÍÓÔÂÌËfl, ‡„‡ÌÛÎÓˆËÚÓÁ, ÒÌËÊÂÌËÂ ÄÑ, Û‚ÂÎË˜ÂÌËÂ Ï‡ÒÒ˚ ÚÂÎ‡ àÌ„Ë·ËÚÓ˚ ÏÓÌÓ‡ÏËÌÓÍÒË‰‡Á˚ ëÂÎÂÍÚË‚Ì˚Â ËÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÌÓ‡‰ÂÌ‡ÎËÌ‡/‡ÌÚ‡„ÓÌËÒÚ˚ ÌÓ‡‰ÂÌ‡ÎËÌ‡ ëÂÎÂÍÚË‚Ì˚Â ÒÚËÏÛÎflÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ ëÂÎÂÍÚË‚Ì˚Â ËÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ àÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ Ë ÌÓ‡‰ÂÌ‡ÎËÌ‡ åË‡ÌÒÂËÌ, Ï‡ÔÓÚËÎËÌ íË‡ÌÂÔÚËÌ ëÂÚ‡ÎËÌ, ÙÎÛÓÍÒÂÚËÌ, ÙÎÛ‚ÓÍÒ‡ÏËÌ, Ô‡ÓÍÒÂÚËÌ, ˆËÚ‡ÎÓÔ‡Ï ÇÂÌÎ‡Ù‡ÍÒËÌ, ‰ÛÎÓÍÒÂÚËÌ, ÏËÎÌ‡ˆËÔ‡Ì çÓ‡‰ÂÌÂ„Ë˜ÂÒÍËÂ Ë ÒÂÎÂÍÚË‚Ì˚Â åËÚ‡Á‡ÔËÌ ÒÂÓÚÓÌËÌÂ„Ë˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚ àÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ í‡ÁÓ‰ÓÌ, ÌÂÙ‡ÁÓ‰ÓÌ ÒÂÓÚÓÌËÌ‡/‡ÌÚ‡„ÓÌËÒÚ˚ ÒÂÓÚÓÌËÌ‡ ÚÂÎ¸Ì˚ı fl‚ÎÂÌËÈ (çü) èÇí, Ì‡ÔËÏÂ, ÔË ÔÓ‚˚¯ÂÌÌÓÏ ‚˚Ô‡‰ÂÌËË ‚ÓÎÓÒ, ÔÓıÛ‰‡ÌËË) [15,16]. Выбор антидепрессанта. Ç Ì‡ÒÚÓfl˘ÂÂ ‚ÂÏfl ËÁ‚ÂÒÚÌÓ ÌÂÒÍÓÎ¸ÍÓ ÍÎ‡ÒÒÓ‚ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚ Ò ‡ÁÎË˜‡˛˘ËÏÒfl ÏÂı‡ÌËÁÏÓÏ ‰ÂÈÒÚ‚Ëfl (Ú‡·Î. 6,7). ëÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, ÓÌË ‡ÁÎË˜‡˛ÚÒfl ÒÔÂÍÚÓÏ çü, ÍÓÚÓ˚Â ‚ ÁÌ‡˜ËÚÂÎ¸ÌÓÈ ÏÂÂ ‚ÎËfl˛Ú Ì‡ ‚˚·Ó ÔÂÔ‡‡Ú‡ ‰Îfl ÎÂ˜ÂÌËfl ‰ÂÔÂÒÒËË Û ·ÓÎ¸Ì˚ı Ò ıÓÌË˜ÂÒÍËÏË Á‡·ÓÎÂ‚‡ÌËflÏË ÔÂ˜ÂÌË. íËˆËÍÎË˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚ Ó·Î‡‰‡˛Ú Ó·˘ËÏË çü: ÒÂ‰‡ÚË‚Ì˚Ï, å-ıÓÎËÌÓ·ÎÓÍËÛ˛˘ËÏ Ë ÒÂ‰Â˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ÏË. èÓÒÎÂ‰ÌËÂ ‚ÍÎ˛˜‡˛Ú ‚ ÒÂ·fl ÓÚÓÒÚ‡ÚË˜ÂÒÍÛ˛ „ËÔÓÚÓÌË˛, Ú‡ıËÍ‡‰Ë˛ Ë Ì‡Û¯ÂÌËfl ËÚÏ‡ ÒÂ‰ˆ‡ ËÁ-Á‡ ıËÌË‰ËÌÓÔÓ‰Ó·ÌÓ„Ó ‰ÂÈÒÚ‚Ëfl (Û‰ÎËÌÂÌËÂ ËÌÚÂ‚‡ÎÓ‚ PQ, QRS, QT, Á‡ÏÂ‰ÎÂÌËÂ ‡ÚËÓ‚ÂÌÚËÍÛÎflÌÓÈ ÔÓ‚Ó‰ËÏÓÒÚË ‚ÔÎÓÚ¸ ‰Ó ÔÓÎÌÓÈ ‡ÚËÓ‚ÂÌÚËÍÛÎflÌÓÈ ·ÎÓÍ‡‰˚). å-ıÓÎËÌÓ·ÎÓÍËÛ˛˘ÂÂ ‰ÂÈÒÚ‚ËÂ ÏÓÊÂÚ ÔÓfl‚ÎflÚ¸Òfl ‚ Á‡ÔÓ‡ı, Á‡‰ÂÊÍÂ ÏÓ˜ÂËÒÔÛÒÍ‡ÌËfl, ÒÛıÓÒÚË ‚Ó ÚÛ, ÌÂ˜ÂÚÍÓÒÚË ÁÂÌËfl. ì‚ÂÎË˜ÂÌËÂ ‚ÂÒ‡ Ò‚flÁ˚‚‡˛Ú ÒÓ ÒÓ‰ÒÚ‚ÓÏ Í „ËÒÚ‡ÏËÌÓ‚˚Ï ç1-ÂˆÂÔÚÓ‡Ï [41]. ç‡Û¯ÂÌËÂ ÒÂÍÒÛ‡Î¸ÌÓÈ ÙÛÌÍˆËË (Á‡ÚÛ‰ÌÂÌÌ‡fl ˝flÍÛÎflˆËfl, ËÏÔÓÚÂÌˆËfl Ë ‡ÌÓ„‡ÁÏËfl), Ì‡·Î˛‰‡ÂÏÓÂ Û 2-5% ·ÓÎ¸Ì˚ı, ÎÂ˜ÂÌÌ˚ı ‡ÏËÚËÔÚËÎËÌÓÏ, Ò‚flÁ‡Ì˚, „Î‡‚Ì˚Ï Ó·‡ÁÓÏ, Ò ÒÂÓÚÓÌËÌ˝„Ë˜ÂÒÍËÏË ˝ÙÙÂÍÚ‡ÏË ÔÂÔ‡‡Ú‡. ëÂ‰Ë ‰Û„Ëı ÔÓ·Ó˜Ì˚ı fl‚ÎÂÌËÈ – Ì‡Û¯ÂÌËÂ Û„ÎÂ‚Ó‰ÌÓ„Ó Ó·ÏÂÌ‡, ÚÂÏÓ, ÔÓÚÎË‚ÓÒÚ¸. àÌ„Ë·ËÚÓ˚ ÏÓÌÓ‡ÏËÌÓÍÒË‰‡Á˚ ÚÂ·Û˛Ú ÒÚÓ„ÓÈ ‰ËÂÚ˚ Ò ËÒÍÎ˛˜ÂÌËÂÏ ÔÓ‰ÛÍÚÓ‚ Ì‡ÚÛ‡Î¸ÌÓ„Ó ·ÓÊÂÌËfl, ‚ ÒÓ˜ÂÚ‡ÌËË Ò ÍÓÚÓ˚ÏË ÓÌË ÏÓ„ÛÚ ‚˚Á˚‚‡Ú¸ “ÚË‡ÏËÌÓ‚˚Â ÍËÁ˚” – ÂÁÍËÂ ÔÓ‰˙ÂÏ˚ ÄÑ Ò ËÒÍÓÏ ‡Á‚ËÚËfl ËÌÒÛÎ¸Ú‡ ËÎË ËÌÙ‡ÍÚ‡ ÏËÓÍ‡‰‡. èÓ‰Ó·Ì˚Â ÍËÁ˚ ÓÔËÒ‡Ì˚ Ë ÚÓ„‰‡, ÍÓ„‰‡ ˜ÂÚÍÓÈ Ò‚flÁË Ò ÔÓ„Â¯ÌÓÒÚflÏË ‚ ‰ËÂÚÂ ‚˚fl‚ËÚ¸ ÌÂ Û‰‡ÂÚÒfl [41]. èËÂÏ ËÌ„Ë·ËÚÓÓ‚ ÏÓÌÓ‡ÏËÌÓÍÒË‰‡Á˚ ÏÓÊÂÚ ÒÓÔÓ‚ÓÊ‰‡Ú¸Òfl ·ÂÒÒÓÌÌËˆÂÈ, ÓÚÓÒÚ‡ÚË˜ÂÒÍÓÈ „ËÔÓÚÂÌÁËÂÈ, Û‚ÂÎË˜ÂÌËÂÏ ‚ÂÒ‡, Ì‡Û¯ÂÌËÂÏ ÔÓÎÓ‚ÓÈ ÙÛÌÍˆËË, ÒÛıÓÒÚ¸˛ ‚Ó ÚÛ, Á‡ÔÓ‡ÏË, Á‡‰ÂÊÍÓÈ ÏÓ˜Ë, ÚÓ¯ÌÓÚÓÈ. ùÚÓÚ ÍÎ‡ÒÒ ÔÂÔ‡‡ÚÓ‚ ÔËÌflÚÓ Ò˜ËÚ‡Ú¸ Ì‡Ë·ÓÎÂÂ „ÂÔ‡ÚÓÚÓÍÒË˜Ì˚Ï. äÓÏÂ ÚÓ„Ó, ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2 çÂ‚ÓÁÌÓÒÚ¸, Ì‡Û¯ÂÌËfl ÒÌ‡, ÒÛıÓÒÚ¸ ‚Ó ÚÛ, ıËÏË˜ÂÒÍ‡fl Á‡‚ËÒËÏÓÒÚ¸ íÓ¯ÌÓÚ‡, ‰Ë‡Âfl, „ÓÎÓ‚Ì‡fl ·ÓÎ¸, Ì‡Û¯ÂÌËÂ ÒÌ‡, ÒÂÍÒÛ‡Î¸Ì˚Â ‡ÒÒÚÓÈÒÚ‚‡, ÚÂ‚ÓÊÌÓÒÚ¸, ÔË·‡‚Í‡ ‚ÂÒ‡ íÓ¯ÌÓÚ‡, ‰Ë‡Âfl, „ÓÎÓ‚Ì‡fl ·ÓÎ¸, Ì‡Û¯ÂÌËÂ ÒÌ‡, ÒÂÍÒÛ‡Î¸Ì˚Â ‡ÒÒÚÓÈÒÚ‚‡, ÚÂ‚ÓÊÌÓÒÚ¸, ÔË·‡‚Í‡ ‚ÂÒ‡, ‡ÚÂË‡Î¸Ì‡fl „ËÔÂÚÓÌËfl (‚ÂÌÎ‡Ù‡ÍÒËÌ) ì‚ÂÎË˜ÂÌËÂ Ï‡ÒÒ˚ ÚÂÎ‡, ÒÓÌÎË‚ÓÒÚ¸, Â‰ÍÓ - ‡„‡ÌÛÎÓˆËÚÓÁ ëÓÌÎË‚ÓÒÚ¸, ‰ËÒÔÂÔÒËfl, „ÓÎÓ‚ÓÍÛÊÂÌËÂ, „ÓÎÓ‚Ì‡fl ·ÓÎ¸, Â‰ÍÓ - ÔË·‡‚Í‡ ‚ ‚ÂÒÂ, Â‰ÍÓ - ÒÂÍÒÛ‡Î¸Ì˚Â ‰ËÒÙÛÌÍˆËË (ÔË‡ÔËÁÏ, ‡ÌÓ„‡ÁÏËfl); ÙÛÎ¸ÏËÌ‡ÌÚÌ‡fl ÔÂ˜ÂÌÓ˜Ì‡fl ÌÂ‰ÓÒÚ‡ÚÓ˜ÌÓÒÚ¸ (1:300 000) ËÌ„Ë·ËÚÓ˚ ÏÓÌÓ‡ÏËÌÓÍÒË‰‡Á˚ ÌÂ ÚÓÎ¸ÍÓ Ô‡ÍÚË˜ÂÒÍË ÌÂ ÒÓ˜ÂÚ‡˛ÚÒfl Ò ‰Û„ËÏË ÍÎ‡ÒÒ‡ÏË ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚, ÌÓ Ë ÚÂ·Û˛Ú ÓÒÓ·˚ı ÁÌ‡ÌËÈ Ë ÓÔ˚Ú‡ ÔË ÒÏÂÌÂ ÔÂÔ‡‡Ú‡. í‡ÍËÏ Ó·‡ÁÓÏ, ¯ËÓÍËÈ ÒÔÂÍÚ ÓÒÎÓÊÌÂÌËÈ ÚÂ‡ÔËË ÚËˆËÍÎË˜ÂÒÍËÏË ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡ÏË Ë ËÌ„Ë·ËÚÓ‡ÏË ÏÓÌÓ‡ÏËÌÓÍÒË‰‡Á˚ ‰ÂÎ‡ÂÚ Ëı ÔËÏÂÌÂÌËÂ Û ·ÓÎ¸Ì˚ı Ò ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËÂÈ ÌÂ‡ˆËÓÌ‡Î¸Ì˚Ï. òËÓÚ‡ ÌÂÓ·ıÓ‰ËÏÓÒÚË ÔËÏÂÌÂÌËfl ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚ ‚ÌÂ ÍÎËÌËÍË ÔÒËıË‡ÚËË Ë ÌÂÛ‰Ó‚ÎÂÚ‚ÓÂÌÌÓÒÚ¸ ‚‡˜ÂÈ ‰ÂÈÒÚ‚ËÂÏ “ÍÎ‡ÒÒË˜ÂÒÍËı” ÔÂÔ‡‡ÚÓ‚ ÔË‚ÂÎË Í ‡Á‡·ÓÚÍÂ ÌÓ‚˚ı ÍÎ‡ÒÒÓ‚ ÎÂÍ‡ÒÚ‚ÂÌÌ˚ı ÒÂ‰ÒÚ‚ [7] (Ú‡·Î. 6). èË‚Â‰ÂÌÌ‡fl ÍÎ‡ÒÒËÙËÍ‡ˆËfl ÌÂ fl‚ÎflÂÚÒfl, Ó˜Â‚Ë‰ÌÓ, ÛÒÚÓfl‚¯ÂÈÒfl, ÔÓÒÍÓÎ¸ÍÛ Ë‰ÂÚ ÔÓÒÚÓflÌÌÓÂ ÛÚÓ˜ÌÂÌËÂ ÏÂı‡ÌËÁÏ‡ ‰ÂÈÒÚ‚Ëfl ˝ÚËı ÔÂÔ‡‡ÚÓ‚. ëÛ˘ÂÒÚ‚Û˛Ú Ë ‰Û„ËÂ ÍÎ‡ÒÒËÙËÍ‡ˆËË, ÓÒÌÓ‚‡ÌÌ˚Â ·ÓÎÂÂ Ì‡ ıËÏË˜ÂÒÍÓÈ ÒÚÛÍÚÛÂ ÔÂÔ‡‡ÚÓ‚, ÌÂÊÂÎË ˜ÂÏ Ì‡ ÏÂı‡ÌËÁÏÂ ‰ÂÈÒÚ‚Ëfl. Ç˚·Ó ÔÂÔ‡‡ÚÓ‚ ‰Îfl ‡ÌÚË‰ÂÔÂÒÒË‚ÌÓÈ ÚÂ‡ÔËË ‰ËÍÚÛÂÚÒfl ‚ ÁÌ‡˜ËÚÂÎ¸ÌÓÈ ÏÂÂ Ô‡ÚÓ„ÂÌÂÚË˜ÂÒÍËÏ ÏÂı‡ÌËÁÏÓÏ ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË – Ì‡Û¯ÂÌËÂÏ ÒÂÓÚÓÌËÌÓ‚Ó„Ó Ó·ÏÂÌ‡. Ç ˝ÚÓÈ Ò‚flÁË Ì‡Ë·ÓÎÂÂ Ô‡ÚÓ„ÂÌÂÚË˜ÂÒÍË Ó·ÓÒÌÓ‚‡ÌÌ˚Ï fl‚ÎflÂÚÒfl Ì‡ÁÌ‡˜ÂÌËÂ ÒÂÎÂÍÚË‚Ì˚ı ËÌ„Ë·ËÚÓÓ‚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ (ëàéáë) [9,13,14,16,17,38,40]. èÂÔ‡‡Ú˚ ˝ÚÓÈ „ÛÔÔ˚ ÁÌ‡˜ËÚÂÎ¸ÌÓ ÏÂÌÂÂ ÚÓÍÒË˜Ì˚ (‚ ÚÓÏ ˜ËÒÎÂ Ë ÔË ÔÂÂ‰ÓÁËÓ‚ÍÂ), ˜ÂÏ ÚËˆËÍÎË˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚. ü‚ÎflflÒ¸ ÔÓÚÂÌˆË‡Î¸Ì˚ÏË ËÌ„Ë·ËÚÓ‡ÏË ÒËÒÚÂÏ˚ ˆËÚÓıÓÏÓ‚, ÓÌË ÏÓ„ÛÚ ÓÍ‡Á˚‚‡Ú¸ ‚ÎËflÌËÂ Ì‡ ÏÂÚ‡·ÓÎËÁÏ ‰Û„Ëı ÎÂÍ‡ÒÚ‚. ÉÛÔÔÓ‚˚Â çü ‚ÍÎ˛˜‡˛Ú: „ÓÎÓ‚ÌÛ˛ ·ÓÎ¸, Ì‡Û¯ÂÌËfl ÒÚÛÎ‡, ÒÂÍÒÛ‡Î¸Ì˚Â ‡ÒÒÚÓÈÒÚ‚‡, ÚÂÏÓ, ÔÓÚÎË‚ÓÒÚ¸, ÚÂ‚ÓÊÌÓÒÚ¸, ·ÂÒÒÓÌÌËˆÛ, ÔË·‡‚ÍÛ ‚ ‚ÂÒÂ. ëàéáë ‚˚ÒÓÍÓ˝ÙÙÂÍÚË‚Ì˚ ‚ ÓÚÌÓ¯ÂÌËË Ú‡ÍËı ÒÔÂˆËÙË˜Ì˚ı ‰Îfl ‰ÂÔÂÒÒËË ÒËÏÔÚÓÏÓ‚, Í‡Í ÒÌËÊÂÌËÂ Ì‡ÒÚÓÂÌËfl, ÍÓ„ÌËÚË‚Ì˚Â ‡ÒÒÚÓÈÒÚ‚‡. ë‡‚ÌËÚÂÎ¸Ì˚ı ËÒÒÎÂ‰Ó‚‡ÌËÈ ÔË ËÌÚÂÙÂÓÌËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË ‚ÌÛÚË ‰‡ÌÌÓÈ „ÛÔÔ˚ ÔÂÔ‡‡ÚÓ‚ ÌÂ ÔÓ‚Ó‰ËÎÓÒ¸. Ç ÎËÚÂ‡ÚÛÂ Ì‡Ë·ÓÎÂÂ 29 ЛЕКЦИЯ Таблица 7. Наиболее широко используемые антидепрессанты ÉÛÔÔ˚ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚ èÂÔ‡‡Ú˚ äÓÏÏÂ˜ÂÒÍÓÂ Ì‡Á‚‡ÌËÂ ç‡˜‡Î¸Ì‡fl ‰ÓÁ‡, Ï„/ÒÛÚ íÂ. ‰ÓÁ‡, Ï„/ÒÛÚ ëÂÎÂÍÚË‚Ì˚Â ËÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ ÒÂÚ‡ÎËÌ ÙÎÛÓÍÒÂÚËÌ 25-50 10-20 50-200 20-80 Ô‡ÓÍÒÂÚËÌ ˆËÚ‡ÎÓÔ‡Ï S-ˆËÚ‡ÎÓÔ‡Ï ÙÎÛ‚ÓÍÒ‡ÏËÌ ‚ÂÌÎ‡Ù‡ÍÒËÌ ‰ÛÎÓÍÒÂÚËÌ ÏËÚ‡Á‡ÔËÌ ëÚËÏÛÎÓÚÓÌ, áÓÎÓÙÚ èÓ‰ÂÔ, î‡ÏÂÍÒ, îÎÓÍÒ˝Ú, èÓÙÎÛÁ‡Í, ÑÂÔÂÌÓÌ è‡ÍÒËÎ, êÂÍÒÂÚËÌ, ñËÔ‡ÏËÎ ñËÔ‡ÎÂÍÒ îÂ‚‡ËÌ ÇÂÎ‡ÍÒËÌ, ùÙÂÍÚËÌ àÌÚË‚, ëËÏ·‡ÎÚ‡ êÂÏÂÓÌ 10-20 20 10 50-100 37,5 30-60 15-30 20-80 20-60 10-30 150-300 75-450 60 15-60 ÏË‡ÌÒÂËÌ ãÂË‚ÓÌ 30-40 30-90 ëÂÎÂÍÚË‚Ì˚Â ËÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡ Ë ÌÓ‡‰ÂÌ‡ÎËÌ‡ çÓ‡‰ÂÌÂ„Ë˜ÂÒÍËÂ Ë ÒÂÎÂÍÚË‚Ì˚Â ÒÂÓÚÓÌËÌÂ„Ë˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚ àÌ„Ë·ËÚÓ˚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÌÓ‡‰ÂÌ‡ÎËÌ‡/‡ÌÚ‡„ÓÌËÒÚ˚ ÌÓ‡‰ÂÌ‡ÎËÌ‡ ˜‡ÒÚÓ ÛÔÓÏËÌ‡ÂÚÒfl ˆËÚ‡ÎÓÔ‡Ï, ÓÒÓ·ÂÌÌÓ S-ˆËÚ‡ÎÓÔ‡Ï (S-ËÁÓÏÂ ˆËÚ‡ÎÓÔ‡Ï‡), ËÏÂ˛˘ËÈ ·ÓÎ¸¯Û˛ ·ËÓÎÓ„Ë˜ÂÒÍÛ˛ ‡ÍÚË‚ÌÓÒÚ¸, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ Ì‡ÁÌ‡˜‡Ú¸ Â„Ó ‚ ‚‰‚ÓÂ ÏÂÌ¸¯ÂÈ ‰ÓÁËÓ‚ÍÂ Ë, ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, ÓÊË‰‡Ú¸ ÏÂÌ¸¯ÂÈ ÚÓÍÒË˜ÌÓÒÚË, ˜ÚÓ ‚‡ÊÌÓ ÔË Á‡·ÓÎÂ‚‡ÌËflı ÔÂ˜ÂÌË [9]. äÓÏÂ ÚÓ„Ó, ˆËÚ‡ÎÓÔ‡Ï – Â‰ËÌÒÚ‚ÂÌÌ˚È ÔÂÔ‡‡Ú ËÁ „ÛÔÔ˚ ëàéáë, ÌÂ ÓÍ‡Á˚‚‡˛˘ËÈ ‚ÎËflÌËÂ Ì‡ ÒËÒÚÂÏÛ ˆËÚÓıÓÏÓ‚ [16]. êfl‰ ËÒÒÎÂ‰Ó‚‡ÌËÈ ÔÓÒ‚fl˘ÂÌ Ô‡ÓÍÒÂÚËÌÛ, ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ Ë ÓÚÌÓÒËÚÂÎ¸Ì‡fl ·ÂÁÓÔ‡ÒÌÓÒÚ¸ ÍÓÚÓÓ„Ó ‰ÓÍ‡Á‡Ì‡ Û ·ÓÎ¸Ì˚ı ïÉë Ì‡ ÙÓÌÂ èÇí, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ‡‚ÚÓÓÏ Ò˜ËÚ‡Ú¸ Â„Ó ÔÂÔ‡‡ÚÓÏ ÔÂ‚Ó„Ó fl‰‡ [13,14,42]. é‰Ì‡ÍÓ, ÔË ÎÂ˜ÂÌËË ‰ÂÔÂÒÒËË, ÌÂ Ò‚flÁ‡ÌÌÓÈ Ò àîç-α, Ô‡ÓÍÒÂÚËÌ ÌÂ ‰ÂÏÓÌÒÚËÛÂÚ Ó˜Â‚Ë‰ÌÓ„Ó ÔÂ‚ÓÒıÓ‰ÒÚ‚‡. éÌ ˜‡˘Â, ˜ÂÏ ‰Û„ËÂ ëàéáë, ‚˚Á˚‚‡ÂÚ ÒÛıÓÒÚ¸ ‚Ó ÚÛ Ë Á‡ÔÓ˚, ÛÒÚÛÔ‡ÂÚ ÙÎÛÓÍÒÂÚËÌÛ ÔÓ Ú‡ÍÓÏÛ çü Ô‡ÍÚË˜ÂÒÍË ‚ÒÂı ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚, Í‡Í ÔË·‡‚Í‡ Ï‡ÒÒ˚ ÚÂÎ‡. îÎÛÓÍÒÂÚËÌ Ó·Î‡‰‡ÂÚ ‰ÎËÚÂÎ¸Ì˚Ï ÔÂËÓ‰ÓÏ ÔÓÎÛ‡ÒÔ‡‰‡, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ËÌÓ„‰‡ Ì‡ÁÌ‡˜‡Ú¸ Â„Ó 1 ‡Á ‚ 2-3 ÒÛÚÓÍ. ë ‰Û„ÓÈ ÒÚÓÓÌ˚, ÒÂÚ‡ÎËÌ Ë Ô‡ÓÍÒÂÚËÌ ÂÊÂ, ˜ÂÏ ÙÎÛÓÍÒÂÚËÌ, ‚˚Á˚‚‡˛Ú ÔÒËıÓÏÓÚÓÌÓÂ ‚ÓÁ·ÛÊ‰ÂÌËÂ [41]. èÓÒÍÓÎ¸ÍÛ ëàéáë ÏÓ„ÛÚ ‚˚Á˚‚‡Ú¸ ·ÂÒÒÓÌÌËˆÛ, ÓÒÓ·ÂÌÌÓ ‚ Ì‡˜‡ÎÂ ÎÂ˜ÂÌËfl, ÙÎÛÓÍÒÂÚËÌ Ë Ô‡ÓÍÒÂÚËÌ Ì‡ÁÌ‡˜‡˛Ú Ó·˚˜ÌÓ 1 ‡Á ‚ ÒÛÚÍË ÛÚÓÏ. ëÂÚ‡ÎËÌ ÏÓÊÌÓ Ì‡ÁÌ‡˜‡Ú¸ Í‡Í ÛÚÓÏ, Ú‡Í Ë ‚Â˜ÂÓÏ. ç‡ ‚˚·Ó ÔÂÔ‡‡Ú‡ Û ÍÓÌÍÂÚÌÓ„Ó ·ÓÎ¸ÌÓ„Ó ÏÓ„ÛÚ ‚ÎËflÚ¸ Í‡Í ÓÒÓ·ÂÌÌÓÒÚË ÍÎËÌË˜ÂÒÍÓ„Ó ÚÂ˜ÂÌËfl ÒÓ·ÒÚ‚ÂÌÌÓ Á‡·ÓÎÂ‚‡ÌËfl ÔÂ˜ÂÌË, Ú‡Í Ë fl‰ ÒÓÔÛÚÒÚ‚Û˛˘Ëı Á‡·ÓÎÂ‚‡ÌËÈ Ë ËÌ‰Ë‚Ë‰Û‡Î¸Ì˚Â ÔÓfl‚ÎÂÌËfl çü èÇí (Ì‡ÔËÏÂ, „ÓÎÓ‚Ì‡fl ·ÓÎ¸, ÁÌ‡˜ËÚÂÎ¸ÌÓÂ ÔÓıÛ‰‡ÌËÂ, ÚÂ‚ÓÊÌÓÒÚ¸ Ë ‰.). èË ‰ÓÏËÌËÓ‚‡ÌËË ÌÂÈÓ‚Â„ÂÚ‡ÚË‚Ì˚ı ‡ÒÒÚÓÈÒÚ‚ (ÒÎ‡·ÓÒÚ¸, ‡ÌÓÂÍÒËfl, ·ÓÎË, ÔÒËıÓÏÓÚÓÌ‡fl Á‡ÚÓÏÓÊÂÌÌÓÒÚ¸) ÒÎÂ‰ÛÂÚ ÓÚ‰‡‚‡Ú¸ ÔÂ‰ÔÓ˜ÚÂÌËÂ ÍÓÏ·ËÌËÓ‚‡ÌÌ˚Ï ÒÂÓÚÓÌËÌ-ÌÓ‡‰ÂÌ‡ÎËÌÓ‚˚Ï ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡Ï (‚ÂÌÎ‡Ù‡ÍÒËÌ) Ë, ‚ÓÁÏÓÊÌÓ, ÔÒËıÓÒÚËÏÛÎflÚÓ‡Ï. èË ÔÂÓ·Î‡‰‡ÌËË ·ÂÒÒÓÌÌËˆ˚ Ï‡ÍÒËÏ‡Î¸ÌÓ ˝ÙÙÂÍÚË‚Ì˚ ÚÂÚ‡ˆËÍÎË˜ÂÒÍËÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ˚ [16], Í ÍÓÚÓ˚Ï ÓÚÌÓÒflÚ ÏË‡ÌÒÂËÌ Ë ÏËÚ‡Á‡ÔËÌ. ä Ëı Ó˜Â‚Ë‰Ì˚Ï ÔÎ˛Ò‡Ï ÓÚÌÓÒËÚÒfl Ô‡ÍÚË˜ÂÒÍÓÂ ÓÚÒÛÚÒÚ‚ËÂ ÒÂÍÒÛ‡Î¸Ì˚ı ‡ÒÒÚÓÈÒÚ‚, ‚˚ÒÓÍ‡fl ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÔË ÚÂ‚ÓÊÌ˚ı ‡ÒÒÚÓÈÒÚ‚‡ı Ë ÒÓˆËÓÙÓ·Ëflı, Í ÏËÌÛÒ‡Ï – ‡Á‚ËÚËÂ (Ó˜ÂÌ¸ Â‰ÍÓ) Ô‡ÌˆËÚÓÔÂÌËË. ùÚË ÔÂÔ‡‡Ú˚ Ì‡ÁÌ‡˜‡˛ÚÒfl 1 ‡Á ‚ ÒÛÚÍË ÔÂÂ‰ ÒÌÓÏ. 30 èÓ ‰‡ÌÌ˚Ï ç‡ˆËÓÌ‡Î¸ÌÓ„Ó ËÌÒÚËÚÛÚ‡ Á‰ÓÓ‚¸fl ëòÄ Ë Ö‚ÓÔÂÈÒÍÓÈ ‡ÒÒÓˆË‡ˆËË ÔÓ ËÁÛ˜ÂÌË˛ ÔÂ˜ÂÌË (2002) 60% ·ÓÎ¸Ì˚ı ïÉë ËÏÂ˛Ú ÓÔ˚Ú ÛÔÓÚÂ·ÎÂÌËfl Ì‡ÍÓÚËÍÓ‚ ‚ ‡Ì‡ÏÌÂÁÂ [43]. Ç ˝ÚÓÈ Ò‚flÁË Ì‡ÁÌ‡˜ÂÌËÂ Ì‡ ‰ÎËÚÂÎ¸Ì˚È ÒÓÍ ÒÂÎÂÍÚË‚Ì˚ı ÒÚËÏÛÎflÚÓÓ‚ Ó·‡ÚÌÓ„Ó Á‡ı‚‡Ú‡ ÒÂÓÚÓÌËÌ‡, ‚ ˜‡ÒÚÌÓÒÚË ÚË‡ÌÂÔÚËÌ‡, ‰Îfl ÍÓÂÍˆËË ËÌÚÂÙÂÓÌÓ‚ÓÈ ‰ÂÔÂÒÒËË Û ·ÓÎ¸Ì˚ı ïÉë ÏÓÊÂÚ ÒÓÔÓ‚ÓÊ‰‡Ú¸Òfl ËÒÍÓÏ ÁÎÓÛÔÓÚÂ·ÎÂÌËfl ‰‡ÌÌ˚Ï ÔÂÔ‡‡ÚÓÏ ‚ ·ÓÎ¸¯Ëı ‰ÓÁ‡ı, ÔÓÒÍÓÎ¸ÍÛ Ì‡Í‡ÔÎË‚‡ÂÚÒfl ‚ÒÂ ·ÓÎ¸¯Â ‰‡ÌÌ˚ı Ó ÒÔÓÒÓ·ÌÓÒÚË ÚË‡ÌÂÔÚËÌ‡ ‚˚Á˚‚‡Ú¸ ıËÏË˜ÂÒÍÛ˛ Á‡‚ËÒËÏÓÒÚ¸ [44,45]. à‰Â‡Î¸ÌÓ„Ó ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡, ÎË¯ÂÌÌÓ„Ó Í‡ÍËıÎË·Ó çü, ÌÂ ÒÛ˘ÂÒÚ‚ÛÂÚ. Ç Í‡˜ÂÒÚ‚Â ÔËÏÂ‡ ÏÓÊÌÓ ÔË‚ÂÒÚË ·ÛÔÓÔËÓÌ, ÍÓÚÓ˚È ‚˚„Ó‰ÌÓ ÓÚÎË˜‡ÎÒfl ÓÚ ÓÒÌÓ‚Ì˚ı ÍÓÌÍÛÂÌÚÓ‚ ÓÚÒÛÚÒÚ‚ËÂÏ ÒÂÍÒÛ‡Î¸Ì˚ı ‡ÒÒÚÓÈÒÚ‚ Ë ÔË·‡‚ÍË Ï‡ÒÒ˚ ÚÂÎ‡. é‰Ì‡ÍÓ ÓÍ‡Á‡ÎÓÒ¸, ˜ÚÓ Â„Ó ÒÓ˜ÂÚ‡ÌËÂ Ò àîç-α ÒÛ˘ÂÒÚ‚ÂÌÌÓ Û‚ÂÎË˜Ë‚‡ÂÚ ËÒÍ ‡Á‚ËÚËfl ‚ÒÂı ‰Û„Ëı çü ‰‡ÌÌÓ„Ó ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡ [16]. åÂı‡ÌËÁÏ ˝ÚÓ„Ó ‚Á‡ËÏÓ‰ÂÈÒÚ‚Ëfl ÓÒÚ‡ÂÚÒfl ÌÂflÒÌ˚Ï. ç‡ ‚˚·Ó ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡ ÔË ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË ‰ÓÎÊÌ‡ ‚ÎËflÚ¸ ÍÓÌÍÂÚÌ‡fl ÒËÏÔÚÓÏ‡ÚËÍ‡ ‰ÂÔÂÒÒËË, ÍÓÚÓ‡fl ÏÓÊÂÚ ·˚Ú¸ ‰ÓÒÚ‡ÚÓ˜ÌÓ ÔÓÎËÏÓÙÌÓÈ. èË Ô‡‚ËÎ¸ÌÓÏ Ë Ò‚ÓÂ‚ÂÏÂÌÌÓÏ ÔÓ‰·ÓÂ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚ‡ Ò ‡Á‚Ë‚¯ÂÈÒfl ‰ÂÔÂÒÒËÂÈ Û‰‡ÂÚÒfl ÒÔ‡‚ËÚ¸Òfl ‚ ·ÓÎ¸¯ËÌÒÚ‚Â ÒÎÛ˜‡Â‚. ëÓ‚ÂÏÂÌÌ˚Â ÔÂÔ‡‡Ú˚ Ó·Î‡‰‡˛Ú ÏÓ˘ÌÓÈ ‡ÌÚË‰ÂÔÂÒÒË‚ÌÓÈ ‡ÍÚË‚ÌÓÒÚ¸˛, ÔÓÁ‚ÓÎfl˛˘ÂÈ Ó·ıÓ‰ËÚÒfl ÏËÌËÏ‡Î¸Ì˚ÏË Ë Ï‡Î˚ÏË ‰ÓÁ‡ÏË Û ·ÓÎ¸Ì˚ı ‚ ıÓ‰Â èÇí, ¯ËÓÍËÏ ÍÓË‰ÓÓÏ ·ÂÁÓÔ‡ÒÌÓÒÚË, ‚ÓÁÏÓÊÌÓÒÚ¸˛ ÍÓÏ·ËÌ‡ˆËË ‡ÁÎË˜Ì˚ı ÍÎ‡ÒÒÓ‚ ‰Îfl ‰ÓÒÚËÊÂÌËfl ÓÔÚËÏ‡Î¸ÌÓ„Ó ˝ÙÙÂÍÚ‡. Ç‡ÊÌÓ ÔÓÏÌËÚ¸, ˜ÚÓ ÓÔËÒ‡ÌÌ˚Â çü ‰ÓÁÓÁ‡‚ËÒËÏ˚ Ë Ì‡·Î˛‰‡˛ÚÒfl, Í‡Í Ô‡‚ËÎÓ, ‚ ‚ÂıÌÂÈ ˜‡ÒÚË “ÍÓË‰Ó‡ ·ÂÁÓÔ‡ÒÌÓÒÚË” – Ï‡ÍÒËÏ‡Î¸ÌÓ ‡ÁÂ¯ÂÌÌ˚ı ‰ÓÁ‡ı. àÌÚÂÙÂÓÌÓ‚‡fl ‰ÂÔÂÒÒËfl ÚÂ·ÛÂÚ Ú‡ÍËı ‰ÓÁ Í‡ÈÌÂ Â‰ÍÓ. Ç ÔÓ‰‡‚Îfl˛˘ÂÏ ·ÓÎ¸¯ËÌÒÚ‚Â ÒÎÛ˜‡Â‚ ‰Îfl ÍÓÌÚÓÎfl Ì‡‰ ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËÂÈ ‰ÓÒÚ‡ÚÓ˜ÌÓ Ì‡˜‡Î¸Ì˚ı ‰ÓÁ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚. í‡Í, Ì‡ÏË ‚ÏÂÒÚÂ Ò Ì‡Û˜Ì˚Ï ÒÓÚÛ‰ÌËÍÓÏ à.ë.åËÍ‡‰ÁÂ Ó·ÒÎÂ‰Ó‚‡ÌÓ 18 ·ÓÎ¸Ì˚ı Ò HCV/HIV-ÍÓËÌÙÂÍˆËÂÈ (Í‡Í ËÁ‚ÂÒÚÌÓ, HIV-ËÌÙÂÍˆËfl fl‚ÎflÂÚÒfl ‰ÓÔÓÎÌËÚÂÎ¸Ì˚Ï Ù‡ÍÚÓÓÏ ËÒÍ‡ ‡Á‚ËÚËfl ‰ÂÔÂÒÒËË), ÓÔË‡ÚÌÓÈ Ì‡ÍÓÏ‡ÌËÂÈ ‚ ‡Ì‡ÏÌÂÁÂ Ë ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËÂÈ. Ç ıÓ‰Â èÇí ïÉë ËÏ ÔÓ‚Ó‰ËÎÓÒ¸ Ì‡ÁÌ‡˜ÂÌËÂ ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2 ЛЕКЦИЯ ëàéáë. ì 12 ·ÓÎ¸Ì˚ı ÚÂ‡ÔËfl ·˚Î‡ ÛÒÔÂ¯ÌÓÈ ÛÊÂ ÔË ËÒÔÓÎ¸ÁÓ‚‡ÌËË Ì‡˜‡Î¸Ì˚ı ‰ÓÁ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚. ÉÎ‡‚Ì˚Ï ÔÂ‰ËÍÚÓÓÏ ÌÂÓ·ıÓ‰ËÏÓÒÚË ÔÓ‚˚¯ÂÌËfl ‰ÓÁ˚ fl‚ÎflÎÒfl ÍÓÓÚÍËÈ ÒÓÍ (ÏÂÌÂÂ ÔÓÎÛ„Ó‰‡) ÓÔË‡ÚÌÓÈ ‡·ÒÚËÌÂÌˆËË. Ç‡ÊÌÓ ÓÚÏÂÚËÚ¸, ˜ÚÓ ÔÓÚÂ·ÌÓÒÚ¸ ‚ ÔÓ‚˚¯ÂÌËË ‰ÓÁ˚ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚ ËÌÓ„‰‡ Ò‚flÁ‡Ì‡ Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ ÚÂÎ‡. ë‡‚ÌËÚÂÎ¸Ì˚Â ËÒÒÎÂ‰Ó‚‡ÌËfl èÂ„-àîç-α2‡ Ë èÂ„-àîç-α2b ‰ÂÏÓÌÒÚËÛ˛Ú ‡ÁÌËˆÛ ‚ ˜‡ÒÚÓÚÂ ‡Á‚ËÚËfl Ú‡ÍËı çü èÇí, Í‡Í ˆËÚÓÔÂÌËfl Ë ‰ÂÔÂÒÒËfl. èÂ„-àîç-α2‡ Ò ·ÓÎ¸¯ÓÈ ÏÓÎÂÍÛÎflÌÓÈ Ï‡ÒÒÓÈ (èÂ„‡ÒËÒ) ˜‡˘Â ‚˚Á˚‚‡ÂÚ ˆËÚÓÔÂÌË˜ÂÒÍËÂ ÓÒÎÓÊÌÂÌËfl, ‚ ÚÓ ‚ÂÏfl Í‡Í ÔÂ„ËÎËÓ‚‡ÌÌ˚È àîç-α2b Ò ÏÂÌ¸¯ÂÈ Ï‡ÒÒÓÈ (èÂ„àÌÚÓÌ) ˜‡˘Â ‰ÂÏÓÌÒÚËÛÂÚ ‡Á‚ËÚËÂ ‰ÂÔÂÒÒËË [11,15,24]. èË ˝ÚÓÏ ˝ÍÓÌÓÏË˜ÂÒÍËÂ Á‡Ú‡Ú˚ ‰Îfl ÍÓÌÚÓÎfl Ì‡‰ ‰ÂÔÂÒÒËÂÈ ÌÂÒÓÔÓÒÚ‡‚ËÏÓ ÏÂÌ¸¯Â, ˜ÂÏ Á‡ ÌÂÈÚÓÔÂÌËÂÈ, ÚÂ·Û˛˘ÂÈ Ì‡ÁÌ‡˜ÂÌËfl „‡ÌÛÎÓˆËÚ‡ÌÓ„Ó ÍÓÎÓÌËÂÒÚËÏÛÎËÛ˛˘Â„Ó Ù‡ÍÚÓ‡ ‰Îfl ÒÓı‡ÌÂÌËfl ÂÊËÏ‡ ÓÔÚËÏ‡Î¸ÌÓ„Ó ‰ÓÁËÓ‚‡ÌËfl ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚. í‡ÍËÏ Ó·‡ÁÓÏ, ‚ÓÓÛÊÂÌÌÓÒÚ¸ ‚‡˜‡ ÁÌ‡ÌËflÏË Ó ÒÛ˘ÂÒÚ‚Â Ë ÔÓfl‚ÎÂÌËflı ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË ÔË èÇí ıÓÌË˜ÂÒÍËı ‚ËÛÒÌ˚ı „ÂÔ‡ÚËÚÓ‚ ÔÓÁ‚ÓÎflÂÚ Û‚ÂÎË˜ËÚ¸ ÔË‚ÂÊÂÌÌÓÒÚ¸ Í ÎÂ˜ÂÌË˛ ·ÓÎ¸Ì˚ı ‚ ÂÁÛÎ¸Ú‡ÚÂ ‡ÌÌÂÈ ‰Ë‡„ÌÓÒÚËÍË Ë ‡‰ÂÍ‚‡ÚÌÓÈ ÍÓÂÍˆËË Ò ÔÓÏÓ˘¸˛ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚, ˜ÚÓ Ó·ÂÒÔÂ˜Ë‚‡ÂÚ Ï‡ÍÒËÏ‡Î¸ÌÛ˛ ‚ÂÓflÚÌÓÒÚ¸ ÒÚÓÈÍÓ„Ó ‚ËÛÒÓÎÓ„Ë˜ÂÒÍÓ„Ó ÓÚ‚ÂÚ‡. èÓ ÏÂÊ‰ÛÌ‡Ó‰Ì˚Ï ‰‡ÌÌ˚Ï, Û 85% ·ÓÎ¸Ì˚ı Ò ‡Á‚ËÚËÂÏ ‰ÂÔÂÒÒËË Ì‡ ÙÓÌÂ èÇí ÓÌ‡ ÍÓÌÚÓÎËÛÂÏ‡, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ÒÓı‡ÌËÚ¸ ËÒıÓ‰Ì˚Â ‰ÓÁ˚ ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚ [10,16]. 1. 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Комментарий главного редактора Ç Ì‡ÒÚÓfl˘ÂÂ ‚ÂÏfl ËÏÂÂÚÒfl ÏÌÓÊÂÒÚ‚Ó ‚ÓÁÏÓÊÌÓÒÚÂÈ ÍÓÂÍˆËË ‡Á‚Ë‚‡˛˘ËıÒfl ‚ ıÓ‰Â ÔÓÚË‚Ó‚ËÛÒÌÓÈ ÚÂ‡ÔËË (èÇí) ÌÂÊÂÎ‡ÚÂÎ¸Ì˚ı fl‚ÎÂÌËÈ (çü). ùÚÓ, ‚ ÔÂ‚Û˛ Ó˜ÂÂ‰¸ Í‡Ò‡ÂÚÒfl „ÂÏ‡ÚÓÎÓ„Ë˜ÂÒÍËı çü, ÓÒ‚Â˘ÂÌÌ˚ı ‚ ÒÚ‡Ú¸Â ù.á.ÅÛÌÂ‚Ë˜‡. àÒÔÓÎ¸ÁÓ‚‡ÌËÂ ˜ÂÎÓ‚Â˜ÂÒÍÓ„Ó ÂÍÓÏ·ËÌ‡ÌÚÌÓ„Ó ˝ËÚÓÔÓ˝ÚËÌ‡ ÔË ‡ÌÂÏËË ‚ ıÓ‰Â èÇí ÔÓÁ‚ÓÎflÂÚ ‚ÓÒÒÚ‡Ì‡‚ÎË‚‡Ú¸ ÛÓ‚ÂÌ¸ „ÂÏÓ„ÎÓ·ËÌ‡ Ë ÚÂÏ Ò‡Ï˚Ï ÌÂ ÚÓÎ¸ÍÓ ÔÓ‚˚ÒËÚ¸ Í‡˜ÂÒÚ‚Ó ÊËÁÌË ·ÓÎ¸Ì˚ı ïÉë ‚Ó ‚ÂÏfl ÎÂ˜ÂÌËfl, ÌÓ, ˜ÚÓ ÓÒÓ·ÂÌÌÓ ‚‡ÊÌÓ, ÒÓı‡ÌËÚ¸ ÓÔÚËÏ‡Î¸ÌÛ˛ ‰ÓÁÛ Ë·‡‚ËËÌ‡, ˜ÚÓ ÓÔÂ‰ÂÎflÂÚ ‚ ÍÓÌÂ˜ÌÓÏ ËÚÓ„Â ‚˚ÒÓÍËÂ ÂÁÛÎ¸Ú‡Ú˚ èÇí. èË ˝ÚÓÏ Ì‡ÁÌ‡˜ÂÌËÂ ÔÂÔ‡‡ÚÓ‚ ˜ÂÎÓ‚Â˜ÂÒÍÓ„Ó ÂÍÓÏ·ËÌ‡ÌÚÌÓ„Ó ˝ËÚÓÔÓ˝ÚËÌ‡ Ó·ÓÒÌÓ‚‡ÌÓ ÌÂ ÚÓÎ¸ÍÓ ÔË ‡Á‚ËÚËË ‡ÌÂÏËË, ÌÓ Ë ÔË ·˚ÒÚÓÈ ÓÚËˆ‡ÚÂÎ¸ÌÓÈ ‰ËÌ‡ÏËÍÂ Â„Ó ÛÓ‚Ìfl ‚Ó ‚ÂÏfl èÇí. èÓÙËÎ‡ÍÚË˜ÂÒÍÓÂ Ì‡ÁÌ‡˜ÂÌËÂ ˜ÂÎÓ‚Â˜ÂÒÍÓ„Ó ÂÍÓÏ·ËÌ‡ÌÚÌÓ„Ó ˝ËÚÓÔÓ˝ÚËÌ‡ ˆÂÎÂÒÓÓ·‡ÁÌÓ ÚÓÎ¸ÍÓ ‚ ÒÎÛ˜‡Â ËÒÔÓÎ¸ÁÓ‚‡ÌËfl ‚˚ÒÓÍËı ‰ÓÁ Ë·‡‚ËËÌ‡ (Ì‡ÔËÏÂ, 15,2 Ï„/Í„/ÒÛÚ) ‚ ÎÂ˜ÂÌËË “ÚÛ‰Ì˚ı” ·ÓÎ¸Ì˚ı ïÉë (1 „ÂÌÓÚËÔ HCV ‚ ÒÓ˜ÂÚ‡ÌËË Ò ‚˚ÒÓÍÓÈ ‚ËÛÒÌÓÈ Ì‡„ÛÁÍÓÈ). èË ÌÂÈÚÓÔÂÌËË, ÌÂÂ‰ÍÓ ÓÚÏÂ˜‡˛˘ÂÈÒfl ÔË èÇí, Û˜ËÚ˚‚‡fl ÓÚÒÛÚÒÚ‚ËÂ ÔflÏÓÈ ÍÓÂÎflˆËË ÏÂÊ‰Û ÌÂÈÚÓÔÂÌËÂÈ Ë ËÌÙÂÍˆËÓÌÌ˚ÏË ÓÒÎÓÊÌÂÌËfl, ¯ËÓÍÓÂ ËÒÔÓÎ¸ÁÓ‚‡ÌËÂ „‡ÌÛÎÓˆËÚ‡ÌÓ„Ó ÍÓÎÓÌËÂÒÚËÏÛÎËÛ˛˘Â„Ó Ù‡ÍÚÓ‡ ‚ ÍÎËÌË˜ÂÒÍÓÈ Ô‡ÍÚËÍÂ 32 ÒÍÓÂÂ ÌÂ ˆÂÎÂÒÓÓ·‡ÁÌÓ, ˜ÂÏ ÓÔ‡‚‰‡ÌÓ. çÂÓ·ıÓ‰ËÏÓ ÔÓ‚Â‰ÂÌËÂ ÍÓÌÚÓÎËÛÂÏ˚ı ÍÎËÌË˜ÂÒÍËı ËÒÒÎÂ‰Ó‚‡ÌËÈ ‰Îfl ÓÔÂ‰ÂÎÂÌËfl ÔÓÍ‡Á‡ÌËÈ Í Ì‡ÁÌ‡˜ÂÌË˛ ÙËÎ„‡ÒÚËÏ‡ ÔË àîç-α-‡ÒÒÓˆËËÓ‚‡ÌÌÓÈ ÌÂÈÚÓÔÂÌËË. èÓÒÍÓÎ¸ÍÛ ‚ÓÁÏÓÊÌÓÒÚË Ù‡Ï‡ÍÓÎÓ„Ë˜ÂÒÍÓÈ ÍÓÂÍˆËË ÚÓÏ·ÓˆËÚÓÔÂÌËË ÎËÏËÚËÓ‚‡Ì˚ ·ÓÎ¸¯ËÏ ˜ËÒÎÓÏ çü (ËÌÚÂÎÂÈÍËÌ-11) ËÎË ÌÂ‰ÓÒÚ‡ÚÓ˜ÌÓ ËÁÛ˜ÂÌ˚ (˝Î¸ÚÓÏ·ÓÔ‡Í), ÔË ÂÂ ‚ÓÁÌËÍÌÓ‚ÂÌËË Ì‡Ë·ÓÎÂÂ ÓÔ‡‚‰‡ÌÌÓÈ fl‚ÎflÂÚÒfl ÍÓÂÍˆËfl ‰ÓÁ ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚. ÅÂÁÛÒÎÓ‚ÌÓ, ‚‡ÊÌ˚Ï ‡ÒÔÂÍÚÓÏ èÇí fl‚ÎflÂÚÒfl ÓˆÂÌÍ‡ ÙÛÌÍˆËÓÌ‡Î¸ÌÓ„Ó ÒÓÒÚÓflÌËfl ˘ËÚÓ‚Ë‰ÌÓÈ ÊÂÎÂÁ˚ ‰Ó Ì‡˜‡Î‡ ÎÂ˜ÂÌËfl Ë ‰ËÌ‡ÏË˜ÂÒÍ‡fl ÓˆÂÌÍ‡ ‚ ıÓ‰Â èÇí, ÔÓÁ‚ÓÎfl˛˘‡fl Ì‡ ‡ÌÌËı ÒÚ‡‰Ëflı ‚˚fl‚ÎflÚ¸ „ËÔÂ- ËÎË „ËÔÓÚËÂÓÁ Ò Ú‡‰ËˆËÓÌÌ˚Ï ÔÓ‰ıÓ‰ÓÏ Í ÍÓÂÍˆËË ‚ÓÁÌËÍ‡˛˘Ëı ËÁÏÂÌÂÌËÈ „ÓÏÓÌ‡Î¸ÌÓ„Ó ÔÓÙËÎfl. ÇÓÁÏÓÊÌ˚Â ‚‡Ë‡ÌÚ˚ ÔÓ‡ÊÂÌËfl ˘ËÚÓ‚Ë‰ÌÓÈ ÊÂÎÂÁ˚ ‚ ıÓ‰Â èÇí Ë Ëı ÍÓÂÍˆËfl ÔÂ‰ÒÚ‡‚ÎÂÌ˚ ‚ ÒÚ‡Ú¸Â à.É.çËÍËÚËÌ‡. é‰ÌÛ ËÁ ÒÂ¸ÂÁÌÂÈ¯Ëı ÔÓ·ÎÂÏ èÇí ÔÂ‰ÒÚ‡‚ÎflÂÚ ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌ‡fl ‰ÂÔÂÒÒËfl, ÍÓÚÓ‡fl, ÁÌ‡˜ËÚÂÎ¸ÌÓ ÛıÛ‰¯‡fl Í‡˜ÂÒÚ‚Ó ÊËÁÌË ·ÓÎ¸Ì˚ı, ÔË‚Ó‰ËÚ Í ÒÌËÊÂÌË˛ ÔË‚ÂÊÂÌÌÓÒÚË Í ÎÂ˜ÂÌË˛, Ë, Ú‡ÍËÏ Ó·‡ÁÓÏ, Í ÛÏÂÌ¸¯ÂÌË˛ ¯‡ÌÒ‡ Ì‡ ‚˚Á‰ÓÓ‚ÎÂÌËÂ. ëÓ‚ÂÏÂÌÌ‡fl ÍÎËÌË˜ÂÒÍ‡fl Ù‡Ï‡ÍÓÎÓ„Ëfl ‡ÒÔÓÎ‡„‡ÂÚ ¯ËÓÍËÏ ÒÔÂÍÚÓÏ ‡ÌÚË‰ÂÔÂÒÒ‡ÌÚÓ‚, ÔÓÁ‚ÓÎfl˛˘Ëı ·˚ÒÚÓ ÛÒÚ‡ÌflÚ¸ ÔÒËıË˜ÂÒÍËÂ ‡ÒÒÚÓÈÒÚ‚‡. èÓ‰ıÓ‰˚ Í ÍÓÂÍˆËË ËÌÚÂÙÂÓÌ-ËÌ‰ÛˆËÓ‚‡ÌÌÓÈ ‰ÂÔÂÒÒËË ‰ÂÚ‡Î¸ÌÓ ‡ÁÓ·‡Ì˚ ‚ ÒÚ‡Ú¸Â è.è.é„ÛˆÓ‚‡ Ë ç.Ç.å‡ÁÛ˜ËÍ. é‰ÌËÏ ËÁ ‚‡ÊÌ˚ı ÔÓ‰ıÓ‰Ó‚ ‚ Â¯ÂÌËË ‡ÒÒÏ‡ÚË‚‡ÂÏÓÈ ÔÓ·ÎÂÏ˚ fl‚ÎflÂÚÒfl ÔÂ‰ÛÔÂÊ‰ÂÌËÂ çü, ‚ÓÁÌËÍ‡˛˘Ëı ÔË èÇí, ˜ÚÓ, ÔÂÊ‰Â ‚ÒÂ„Ó, ‚ÓÁÏÓÊÌÓ Ò ÔÓÏÓ˘¸˛ ÛÍÓÓ˜ÂÌËfl ÒÓÍÓ‚ ÎÂ˜ÂÌËfl. Ç Ì‡ÒÚÓfl˘ÂÂ ‚ÂÏfl Ö‚ÓÔÂÈÒÍËÏ ‡„ÂÌÚÒÚ‚ÓÏ ÔÓ ÏÂ‰ËˆËÌÒÍËÏ ÔÂÔ‡‡Ú‡Ï (ÖåÖÄ) Á‡Â„ËÒÚËÓ‚‡Ì 24-ÌÂ‰ÂÎ¸Ì˚È ÍÛÒ èÇí èÂ„-àîç-α2b 1,5 Ï„Í/Í„/ÒÛÚ Ë Ë·‡‚ËËÌÓÏ 800-1400 Ï„/ÒÛÚ Û ·ÓÎ¸Ì˚ı ïÉë, ËÌÙËˆËÓ‚‡ÌÌ˚ı HCV 1 „ÂÌÓÚËÔ‡, ËÏÂ˛˘Ëı ÌËÁÍÛ˛ ‚ËÛÒÌÛ˛ Ì‡„ÛÁÍÛ ‰Ó Ì‡˜‡Î‡ ÎÂ˜ÂÌËfl (<600000 åÖ/ÏÎ) Ë ÔÓ‰ÂÏÓÌÒÚËÓ‚‡‚¯Ëı ÙÓÏËÓ‚‡ÌËÂ ‡ÌÌÂ„Ó ‚ËÛÒÓÎÓ„Ë˜ÂÒÍÓ„Ó ÓÚ‚ÂÚ‡ ‚ ‚Ë‰Â ‡‚ËÂÏËË ˜ÂÂÁ 4 ÌÂ‰ÂÎË ÎÂ˜ÂÌËfl. éÒÌÓ‚‡ÌËÂÏ Â„ËÒÚ‡ˆËË ÍÓÓÚÍÓÈ ÒıÂÏ˚ èÇí ÔË ËÌÙËˆËÓ‚‡ÌËË HCV 1 „ÂÌÓÚËÔ‡ fl‚ËÎ‡Ò¸ Ó‰ËÌ‡ÍÓ‚‡fl ÂÁÛÎ¸Ú‡ÚË‚ÌÓÒÚ¸ 24- Ë 48-ÌÂ‰ÂÎ¸ÌÓÈ ÚÂ‡ÔËË èùÉ-àîç-α2b Ë Ë·‡‚ËËÌÓÏ (89% Ë 85% ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ) ·ÓÎ¸Ì˚ı ïÉë ÔË ÒÓ·Î˛‰ÂÌËË ‚˚¯ÂÛÍ‡Á‡ÌÌ˚ı ÍËÚÂËÂ‚. èË ËÌÙËˆËÓ‚‡ÌËË HCV 2 ËÎË 3 „ÂÌÓÚËÔ‡ Ë Â„ËÒÚ‡ˆËÂÈ ‡‚ËÂÏËË ÛÊÂ ˜ÂÂÁ 4 ÌÂ‰ÂÎË èÇí ˜‡ÒÚÓÚ‡ ëÇé ÔË ÔËÏÂÌÂÌËË èùÉ-àîç-α2b 1,0-1,5 ÏÍ„/Í„/ÌÂ‰ Ë Ë·‡‚ËËÌ‡ (800-1200 Ï„/ÒÛÚ) ‰ÓÒÚË„‡ÂÚ 82% ‚ ÔÓÚË‚Ó‚ÂÒ 67% (<0,0001) ÔË ÒÓı‡ÌÂÌËË HCV RNA ‚ Ò˚‚ÓÓÚÍÂ ÍÓ‚Ë Ì‡ ˝ÚÓÏ ÒÓÍÂ. í‡ÍËÏ Ó·‡ÁÓÏ, ‚ fl‰Â ÍÎËÌË˜ÂÒÍËı ÒËÚÛ‡ˆËÈ ‚ÓÁÏÓÊÌÓ ÛÍÓÓ˜ÂÌËÂ ÒÓÍ‡ ÎÂ˜ÂÌËfl ·ÓÎ¸Ì˚ı ïÉë, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ‡ÒÒ˜ËÚ˚‚‡Ú¸ Ì‡ ÛÏÂÌ¸¯ÂÌËÂ ˜‡ÒÚÓÚ˚ çü. çÓ, ÂÒÚÂÒÚ‚ÂÌÌÓ, ÓÒÚ‡ÂÚÒfl ÌÂÓ·ıÓ‰ËÏÓÒÚ¸ Ú˘‡ÚÂÎ¸ÌÓ„Ó ÍÓÌÚÓÎfl Á‡ ÔÓ‚Ó‰ËÏÓÈ èÇí ‚Ó ‚ÒÂı ÒÎÛ˜‡flı Ò ˆÂÎ¸˛ ·ÓÎÂÂ ‡ÌÌÂ„Ó ‚˚fl‚ÎÂÌËfl ËÁ‚ÂÒÚÌ˚ı çü Ò ËÒÔÓÎ¸ÁÓ‚‡ÌËÂÏ ‡Á‡·ÓÚ‡ÌÌ˚ı ÏÂÚÓ‰Ó‚ ÂÂ ÍÓÂÍˆËË. ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 2

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