Лечение хронического гепатита С у лиц с наркотической зависимостью
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ЛЕКЦИЯ Лечение хронического гепатита С у лиц с наркотической зависимостью П.П.Огурцов, Н.В.Мазурчик Кафедра факультетской терапии и центр изучения печени Российского Университета дружбы народов ÂÒÏÓÚfl ̇ ÚÓ, ˜ÚÓ Á‡·Ó΂‡ÂÏÓÒÚ¸ ̇ÍÓχÌËÂÈ Á‡ ÔÓÒΉÌË 5 ÎÂÚ ‚ êÓÒÒËË ÒÌËÁË·Ҹ ‚ 3 ‡Á‡, ÓÚϘÂÌÓ ÙÓÏËÓ‚‡ÌË Á̇˜ËÚÂθÌÓ„Ó ÍÓÌÚËÌ„ÂÌÚ‡ ·ÓθÌ˚ı Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛. èÓ ‰‡ÌÌ˚Ï ÓÙˈˇθÌÓÈ ÒÚ‡ÚËÒÚËÍË ÓÌ ÓˆÂÌË‚‡ÂÚÒfl ‚ 360000 ˜ÂÎÓ‚ÂÍ, ÒÓÒÚÓfl˘Ëı ̇ ‰ËÒÔ‡ÌÒÂÌÓÏ Û˜ÂÚÂ. èÓ ÂÁÛÎ¸Ú‡Ú‡Ï ÒÔˆˇθÌ˚ı ˝ÔˉÂÏËÓÎӄ˘ÂÒÍËı ËÒÒΉӂ‡ÌËÈ Ó·˘Â ˜ËÒÎÓ ÔÓÚ·ËÚÂÎÂÈ Ì‡ÍÓÚ˘ÂÒÍËı ‚¢ÂÒÚ‚, ‚Íβ˜‡fl “ÒÍ˚Ú˚ı” ̇ÍÓχÌÓ‚, ÏÓÊÂÚ ‚ÚÓ Ô‚˚¯‡Ú¸ ÍÓ΢ÂÒÚ‚Ó ÒÓÒÚÓfl˘Ëı ̇ ÓÙˈˇθÌÓÏ Û˜ÂÚ [1]. 85% ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ÛÔÓÚ·Îfl˛Ú „ÂÓËÌ Ë ‰Û„Ë ÔÓËÁ‚Ó‰Ì˚ ÓÔˇÚÓ‚, ÔË ˝ÚÓÏ ÚË ˜ÂÚ‚ÂÚË ÛÔÓÚ·Îfl˛Ú ̇ÍÓÚËÍË ‚ÌÛÚË‚ÂÌÌÓ. ÑÎfl Îˈ Ò ÓÔˇÚÌÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ı‡‡ÍÚÂ̇ ‚˚ÒÓ͇fl ËÌÙˈËÓ‚‡ÌÌÓÒÚ¸ ‚ËÛÒ‡ÏË Ò Ô‡ÂÌÚ‡θÌ˚Ï ÔÛÚÂÏ Ô‰‡˜Ë, ‚ ˜‡ÒÚÌÓÒÚË ‚ËÛÒ‡ÏË „ÂÔ‡ÚËÚ‡ ë (HCV) Ë Ç (HBV). 30-50% ·ÓθÌ˚ı ËÌÙˈËÛ˛ÚÒfl ̇ 1 „Ó‰Û Ì‡ÍÓÚËÁ‡ˆËË Ë ‰Îfl ÌËı ı‡‡ÍÚÂ̇ ËÒıӉ̇fl ‡ÒÒӈˇˆËfl „ÂÔ‡ÚÓÚÓÔÌ˚ı ‚ËÛÒÓ‚ [2]. éÍÓÎÓ 10% ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ Ú‡ÍÊ ËÌÙˈËÓ‚‡Ì˚ Çàó. èÓ ÂÁÛÎ¸Ú‡Ú‡Ï ˝ÔˉÂÏËÓÎӄ˘ÂÒÍËı ËÒÒΉӂ‡ÌËÈ ÍÓÌÚËÌ„ÂÌÚ‡ ‡ÍÚË‚Ì˚ı ÔÓÚ·ËÚÂÎÂÈ ËÌ˙Â͈ËÓÌÌ˚ı ̇ÍÓÚËÍÓ‚ ‚ åÓÒÍ‚Â, ÇÓ΄ӄ‡‰Â Ë Å‡Ì‡ÛΠÔÓ͇Á‡ÌÓ, ˜ÚÓ 60-70% ËÁ ÌËı ËÌÙˈËÓ‚‡Ì˚ HCV [3]. í‡ÍËÏ Ó·‡ÁÓÏ, ‚ ̇ÒÚÓfl˘Â ‚ÂÏfl ÓÚϘ‡ÂÚÒfl ‚˚ÒÓ͇fl ‰ÓÎfl Îˈ Ò ÓÔ˚ÚÓÏ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚ ËÎË ÔÓ‰ÓÎʇ˛˘ËÏÒfl Ëı ËÒÔÓθÁÓ‚‡ÌËÂÏ, ÒÚ‡‰‡˛˘Ëı ıÓÌ˘ÂÒÍËÏË ‚ËÛÒÌ˚ÏË „ÂÔ‡ÚËÚ‡ÏË Ë Ëı ÔÓÒΉÒÚ‚ËflÏË Ë ÌÛʉ‡˛˘ËıÒfl ‚ èÇí. ì‰ÂθÌ˚È ‚ÂÒ ·ÓθÌ˚ı Ò ıÓÌ˘ÂÒÍËÏ „ÂÔ‡ÚËÚÓÏ ë (ïÉë), ËÌÙˈËÓ‚‡ÌÌ˚ı ‚ ÂÁÛθڇÚ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚, ÒÓÒÚ‡‚ÎflÂÚ ÓÒÌÓ‚ÌÛ˛ ˜‡ÒÚ¸ ·ÓθÌ˚ı ïÉë (‰Ó 60%) [4,5]. ã˜ÂÌË ·ÓθÌ˚ı ‚ËÛÒÌ˚ÏË „ÂÔ‡ÚËÚ‡ÏË Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ fl‚ÎflÂÚÒfl ÒÎÓÊÌÓÈ Á‡‰‡˜ÂÈ. ä‡Í Ë ‚ ÒÎÛ˜‡Â β·ÓÈ ‰Û„ÓÈ ÒÓ˜ÂÚ‡ÌÌÓÈ Ô‡ÚÓÎÓ„ËË, ‚ ÔÂ‚Û˛ Ә‰¸, ÌÂÓ·ıÓ‰ËÏÓ Â¯ËÚ¸ ‚ÓÔÓÒ Ó ‚ÓÁÏÓÊÌÓÒÚË ÎË·Ó Ó‰ÌÓ‚ÂÏÂÌÌÓÈ Ú‡ÔËË ˝ÚËı Á‡·Ó΂‡ÌËÈ, ÎË·Ó Ó ÔÓÒΉӂ‡ÚÂθÌÓÏ Î˜ÂÌËË Í‡Ê‰Ó„Ó ËÁ ÌËı. Ç ÔÓÒΉÌÂÏ ÒÎÛ˜‡Â ÌÂÓ·ıÓ‰ËÏÓ ‚˚‰ÂÎËÚ¸ ÔËÓËÚÂÚÌÓ Á‡·Ó΂‡ÌËÂ, ‚ ÓÔ‰ÂÎÂÌËË ÍÓÚÓÓ„Ó „·‚Ì˚Ï Ù‡ÍÚÓÓÏ fl‚ÎflÂÚÒfl ÔÓ„ÌÓÒÚ˘ÂÒ͇fl Á̇˜ËÏÓÒÚ¸. éÔˇÚ̇fl ̇ÍÓχÌËfl – ÚflÊ·fl ıÓÌ˘ÂÒ͇fl ·ÓÎÂÁ̸. ë‰Ìflfl ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË ·ÓθÌÓ„Ó Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ÒÓÒÚ‡‚ÎflÂÚ 6-10 ÎÂÚ, Ô˘ÂÏ ÓÒÌÓ‚Ì˚ Ô˘ËÌ˚ ÒÏÂÚË Ì‡ÍÓχÌÓ‚ ÓÔ‰ÂÎfl˛ÚÒfl Ëı Ó·‡ÁÓÏ ÊËÁÌË Ë ‚Íβ˜‡˛Ú ̇ÒËθÒÚ‚ÂÌÌÛ˛ ÒÏÂÚ¸ Ë „Ë·Âθ ÓÚ Ô‰ÓÁËÓ‚ÍË Ì‡ÍÓÚË͇. èÓ˝ÚÓÏÛ Ì‡ÍÓχÌËfl ·ÓΠڇ̇ÚÓ„ÂÌ̇, ˜ÂÏ ïÉë. Н 16 äÓÏ ÚÓ„Ó, ̇ÍÓÚ˘ÂÒ͇fl Á‡‚ËÒËÏÓÒÚ¸ ÏÂÌ ÍÛ‡·Âθ̇. í‡Í, ‰ÓÒÚË„ÌÛÚ¸ ‰ÎËÚÂθÌÓÈ (·ÓΠ1 „Ó‰‡) ÂÏËÒÒËË Û‰‡ÂÚÒfl, ‚ ÎÛ˜¯ÂÏ ÒÎÛ˜‡Â, ÚÓθÍÓ Û 1/3 ·ÓθÌ˚ı. ç‡ÔËÏÂ, ÒÂ‰Ë ·ÓθÌ˚ı „ÂÓËÌÓ‚ÓÈ Ì‡ÍÓχÌËÂÈ, „ÓÒÔËÚ‡ÎËÁËÓ‚‡ÌÌ˚ı ‚ ççñ ̇ÍÓÎÓ„ËË, ÚÓθÍÓ 8% ÔÂÓ‰ÓÎÂÎË ÒÓÍ Ó‰ÌӄӉ˘ÌÓÈ ÂÏËÒÒËË. èË ˝ÚÓÏ ‚ÂÓflÚÌÓÒÚ¸ ˆˉ˂‡ χÍÒËχθ̇ ÔË Ï‡Î˚ı ÒÓ͇ı ‚ÓÁ‰ÂʇÌËfl Ë ÂÁÍÓ ÛÏÂ̸¯‡ÂÚÒfl ÔÓÒΠ1 „Ó‰‡ ÔË ÛÒÎÓ‚ËË Ì‡ıÓʉÂÌËfl ‚ ‡·ËÎËÚ‡ˆËÓÌÌ˚ı ÔÓ„‡Ïχı (ËÒ. 1) [6]. ÑÎËÚÂθÌÓ ÔÓ‰‰ÂÊË‚‡˛˘Â Î˜ÂÌË ‚ÎËflÂÚ Ì‡ ‚ΘÂÌËÂ Í Ì‡ÍÓÚËÍÛ Ë ˝ÚËÏ ÓÔ‰ÂÎflÂÚ ‰Ë̇ÏËÍÛ ·ÓÎÂÁÌË, ËÁÏÂÌflfl ı‡‡ÍÚ Ú˜ÂÌËfl Á‡·Ó΂‡ÌËfl: ÒÌËʇÂÚÒfl ÚflÊÂÒÚ¸ ÔÓfl‚ÎÂÌËÈ ÔÒËıÓÔ‡ÚÓÎӄ˘ÂÒÍÓÈ ÒËÏÔÚÓχÚËÍË ÂˆË‰Ë‚Ó‚, ÓÌË Î„˜Â Ë ·ÓΠ·˚ÒÚÓ ÍÛÔËÛ˛ÚÒfl, ˜ÚÓ, ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, ÔË‚Ó‰ËÚ Í ÙÓÏËÓ‚‡Ì˲ ·ÓΠ͇˜ÂÒÚ‚ÂÌÌ˚ı Ë ‰ÎËÚÂθÌ˚ı ÂÏËÒÒËÈ [6]. é‰Ì‡ÍÓ ‰‡Ê ‰Ó·Ó‚ÓθÌÓ Ô·˚‚‡ÌË ‚ “Ú‡Ô‚Ú˘ÂÒÍÓÈ ÍÓÏÏÛÌ” ÔÓÁ‚ÓÎflÂÚ ‰ÓÒÚË„‡Ú¸ Ó‰ÌӄӉ˘ÌÓÈ ÂÏËÒÒËË ÚÓθÍÓ Û 15% ·ÓθÌ˚ı [7]. ì˜ËÚ˚‚‡fl ‡ÁÌ˚È ÔÓ„ÌÓÁ ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ ÛÓ‚Ìfl ̇ÍÓÎӄ˘ÂÒÍÓ„Ó Â‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓÚÂ̈ˇ·, ·ÓθÌ˚ı ïÉë Ò ÓÔ˚ÚÓÏ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚ ÏÓÊÌÓ ÛÒÎÓ‚ÌÓ ‡Á‰ÂÎËÚ¸ ̇ ÚË „ÛÔÔ˚: ·ÓθÌ˚Â, ÔÓ‰ÓÎʇ˛˘Ë ̇ÍÓÚËÁ‡ˆË˛ (‰ÂÈÒÚ‚Û˛˘Ë ̇ÍÓχÌ˚), ·ÓθÌ˚Â, Ëϲ˘Ë ÒÓÍ ÂÏËÒÒËË ‰Ó 1 „Ó‰‡ Ë Îˈ‡, Ëϲ˘Ë ‰ÎËÚÂθÌÛ˛ ÂÏËÒÒ˲. Противовирусная терапия в условиях продолжающейся наркотизации ïÓÚfl Ó·‡Á ÊËÁÌË ·ÓθÌÓ„Ó Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ fl‚ÎflÂÚÒfl „·‚Ì˚Ï Ó„‡Ì˘ËÚÂÎÂÏ Â ÔÓ‰ÓÎÊËÚÂθÌÓÒÚË, Û ‡ÍÚË‚Ì˚ı ̇ÍÓχÌÓ‚ ÇàóËÌÙÂ͈Ëfl Ë ˆËÓÁ Ô˜ÂÌË ‚ ËÒıӉ ïÉë ÒÚÓflÚ ‚ fl‰Û Ô˘ËÌ ÒÏÂÚË ‚ÒΉ Á‡ Ô‰ÓÁËÓ‚ÍÓÈ Ì‡ÍÓÚËÍÓ‚ Ë Ì‡ÒËθÒÚ‚ÂÌÌÓÈ ÒÏÂÚ¸˛. ë Òӂ¯ÂÌÒÚ‚Ó‚‡ÌËÂÏ ‚˚ÒÓÍÓ‡ÍÚË‚ÌÓÈ ‡ÌÚËÂÚÓ‚ËÛÒÌÓÈ Ú‡ÔËË ËÏÂÌÌÓ ÔÓ‡ÊÂÌË Ô˜ÂÌË ‚ ‡Ï͇ı HCV-ËÌÙÂ͈ËË ‚˚‰‚ËÌÛÎÓÒ¸ ̇ 1 ÏÂÒÚÓ ÒÂ‰Ë ÒÓχÚ˘ÂÒÍËı Ô˘ËÌ ÎÂڇθÌÓÒÚË ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ [8-10]. Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl ïÉë fl‚ÎflÂÚÒfl ÔÓ„ÌÓÒÚ˘ÂÒÍË Á̇˜ËÏ˚Ï ‰Îfl ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ Ë, Ú‡ÍËÏ Ó·‡ÁÓÏ, ÌÛʉ‡ÂÚÒfl ‚ ΘÂÌËË. äÓÏ ÚÓ„Ó, ÔÓÚ·ËÚÂÎË ÔÒËıÓ‡ÍÚË‚Ì˚ı ‚¢ÂÒÚ‚, fl‚ÎflflÒ¸ ËÒÚÓ˜ÌËÍÓÏ HCV-ËÌÙÂ͈ËË, Ô‰ÒÚ‡‚Îfl˛Ú ˝ÔˉÂÏËÓÎӄ˘ÂÒÍÛ˛ ÓÔ‡ÒÌÓÒÚ¸ ‰Îfl Ó·˘ÂÒÚ‚‡. Ç ÚÓÊ ‚ÂÏfl ÒÛ˘ÂÒÚ‚ÛÂÚ fl‰ ÚÛ‰ÌÓÒÚÂÈ Î˜ÂÌËfl ïÉë Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛, ˜ÚÓ ÓÔ‰ÂÎflÂÚ Á‡ÚÛ‰ÌÂÌË ‚ ÔËÌflÚËË Â¯ÂÌËfl Ó èÇí, „·‚Ì˚ÏË ËÁ ÍÓÚÓ˚ı fl‚Îfl˛ÚÒfl ÓÚÒÛÚÒÚ‚Ë ÏÓÚË‚‡ˆËË Í Î˜ÂÌ˲ Ë Ì‰ÓÒÚ‡ÚӘ̇fl ÔË‚ÂÊÂÌÌÓÒÚ¸ Í ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2007, 3 ЛЕКЦИЯ Ú‡ÔËË Ò ÌÂÒӷβ‰ÂÌËÂÏ Ô‡‚Ë· “ÏËÌËχθÌÓÈ ‰ÓÒÚ‡ÚÓ˜ÌÓÒÚË” (80/80/80). ëÓ‚ÓÍÛÔÌÓÒÚ¸ ˝ÚËı ÔÓ·ÎÂÏ ÔË‚Ó‰ËÚ Í ÒÚÓÈÍÓÏÛ Û·ÂʉÂÌ˲ ‚‡˜ÂÈ, Á‡ÌËχ˛˘ËıÒfl ΘÂÌËÂÏ ïÉë, ˜ÚÓ Î˜ËÚ¸ ‡ÍÚË‚Ì˚ı ̇ÍÓχÌÓ‚ ̈ÂÎÂÒÓÓ·‡ÁÌÓ. çÂÒӷβ‰ÂÌË ڇÍËÏË ·ÓθÌ˚ÏË ÂÊËχ ‰ÓÁËÓ‚‡ÌËfl ÒÎÛÊËÚ Ó·ÓÒÌÓ‚‡ÌËÂÏ ‰Îfl ÓÚ͇Á‡ Ôӂ‰ÂÌËfl èÇí ËÎË Â ‚ÓÁÓ·ÌÓ‚ÎÂÌËfl ‚ ÒÎÛ˜‡Â ÔÂ˚‚‡ÌËfl, ‡ Ú‡ÍÊ ‚ Ôӂ‰ÂÌËË ÔÓ‚ÚÓÌ˚ı ÍÛÒÓ‚ ΘÂÌËfl. ê‡Ò˜ÂÚ Ù‡Ï‡ÍÓ˝ÍÓÌÓÏ˘ÂÒÍÓÈ ˝ÙÙÂÍÚË‚ÌÓÒÚË Î˜ÂÌËfl ïÉë Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ÔÓ͇Á‡Î ÓÚÒÛÚÒÚ‚Ë Á‡Ú‡ÚÌÓÈ ˝ÙÙÂÍÚË‚ÌÓÒÚË ‚ ΘÂÌËË ˝ÚÓÈ Í‡Ú„ÓËË ·ÓθÌ˚ı, ˜ÚÓ ÔË‚ÂÎÓ Í Òӄ·ÒËÚÂθÌÓÏÛ Â¯ÂÌ˲ 燈ËÓ̇θÌÓ„Ó ËÌÒÚËÚÛÚ‡ Á‰ÓÓ‚¸fl ëòÄ (2002), ÄÏÂË͇ÌÒÍÓ„Ó Ó·˘ÂÒÚ‚‡ ÔÓ ËÁÛ˜ÂÌ˲ ·ÓÎÂÁÌÂÈ Ô˜ÂÌË (2004) Ë Ö‚ÓÔÂÈÒÍÓ„Ó Ó·˘ÂÒÚ‚‡ ÔÓ ËÁÛ˜ÂÌ˲ Ô˜ÂÌË (1999) Ó ÌˆÂÎÂÒÓÓ·‡ÁÌÓÒÚË èÇí, ÂÒÎË ÔÂ͇˘ÂÌË ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚ ÒÓ ÒÚÓÓÌ˚ ·ÓθÌÓ„Ó Ì ËÏÂÂÚ ‰Ó΄ӂÂÏÂÌÌÓÈ ÓÒÌÓ‚˚ ËÎË ÂÒÎË ‚‡˜ Ì ۂÂÂÌ ‚ ÔÓÎÌÓÏ ÓÚ͇Á ·ÓθÌÓ„Ó ÓÚ Ì‡ÍÓÚ˘ÂÒÍËı ÔÂÔ‡‡ÚÓ‚ [11-13]. é‰Ì‡ÍÓ ‚Ó ÏÌÓ„Ëı Òڇ̇ı ÔË Î˜ÂÌËË Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ËÒıÓ‰flÚ ËÁ ÚÓ„Ó, ˜ÚÓ ‰Îfl ˜‡ÒÚË ˝ÚËı ·ÓθÌ˚ı Ò ÏÌÓ„ÓÎÂÚÌËÏ ÒÚ‡ÊÂÏ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚË͇, ̽ÙÙÂÍÚË‚Ì˚ÏË ÔÓÔ˚Ú͇ÏË Î˜ÂÌËfl Û Ì‡ÍÓÎÓ„Ó‚, ̇΢ËÂÏ ÒÓχÚ˘ÂÒÍËı ÔÓ·ÎÂÏ ÔÓÒÚ‡Ìӂ͇ ‚ÓÔÓÒ‡ Ó ÔÓÎÌÓÏ ÓÚ͇Á ÓÚ Ì‡ÍÓÚË͇ ÌÂÓ·ÓÒÌÓ‚‡Ì̇, Ì„ÛχÌ̇ Ë Ì‰ÓÒÚËÊËχ. ñÂθ ‚‡˜Â·ÌÓÈ ‡·ÓÚ˚ Ò Ú‡ÍËÏË ·ÓθÌ˚ÏË – ÒÌËÊÂÌË ‚‰‡ ÓÚ Ì‡ÍÓÚËÁ‡ˆËË ‰Îfl ̇ÍÓχ̇ Ë Ó·˘ÂÒÚ‚‡, ‚Íβ˜‡fl ÔÓÙË·ÍÚËÍÛ Ô‰‡˜Ë Ô‡ÂÌÚ‡θÌ˚ı ËÌÙÂ͈ËÈ, ‰ÂÍËÏË̇ÎËÁ‡ˆË˛ Ë ÒӈˇθÌÛ˛ ‡·ËÎËÚ‡ˆË˛ ·ÓθÌ˚ı. ÑÎfl ˝ÚÓ„Ó ÔËÏÂÌflÂÚÒfl ÔÓ„‡Ïχ “ÒÌËÊÂÌËfl ‚‰‡”, ‚Íβ˜‡˛˘‡fl Á‡ÏÂÒÚËÚÂθÌÛ˛ Ú‡Ô˲ ÏÂÚ‡‰ÓÌÓÏ ËÎË ·ÛÔÂÌÓÙËÌÓÏ – ÒËÌÚÂÚ˘ÂÒÍËÏË ÓÔˇڇÏË, ‡ Ú‡ÍÊ ËÌ˙Â͈ËÓÌÌ˚Ï „ÂÓËÌÓÏ. ùÙÙÂÍÚË‚ÌÓÒÚ¸ Ú‡ÍËı ÔÓ„‡ÏÏ ÓˆÂÌË‚‡ÂÚÒfl ÔÓ ÓÚÒÛÚÒڂ˲ ÛÔÓÚ·ÎÂÌËfl “Û΢ÌÓ„Ó” ̇ÍÓÚË͇ Ë ‰ÓÒÚË„‡ÂÚ 50-70%. ÇÍβ˜ÂÌË ·ÓθÌ˚ı ‚ Á‡ÏÂÒÚËÚÂθÌ˚ ÔÓ„‡ÏÏ˚ ÔÓÁ‚ÓÎflÂÚ ‚ ÔÓÒÎÂ‰Û˛˘ÂÏ ‰ÓÒÚË„ÌÛÚ¸ ·Óθ¯ÂÈ Ì‡ÒÚÓÂÌÌÓÒÚË ·ÓθÌÓ„Ó Ì‡ èÇí ïÉë Ë ÔÓ‚˚ÒËÚ¸ ÔË‚ÂÊÂÌÌÓÒÚ¸ Í ÌÂÈ, ÔË‚Ó‰fl, Ú‡ÍËÏ Ó·‡ÁÓÏ, Í ËÁÏÂÌÂÌ˲ ı‡‡ÍÚ‡ هχÍÓ˝ÍÓÏ˘ÂÒÍÓÈ ÒÚÓÓÌ˚ ΘÂÌËfl Ò ‰ÓÒÚËÊÂÌËÂÏ ÍËÚÂË‚ Á‡Ú‡ÚÌÓÈ ˝ÙÙÂÍÚË‚ÌÓÒÚË. Ç ÌÂÍÓÚÓ˚ı Òڇ̇ı ÒÓ·300 250 242 (68%) 200 150 100 50 24 (6,8%) 8 (2,2%) 4 (1%) 0 0 6-12 ÏÂÒ 1-3 „Ó‰‡ 3-5 ÎÂÚ Рис. 1. Частота рецидивов при опиатной зависимости за 5летний период наблюдения (n=354) ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2007, 3 ÒÚ‚ÂÌÌÓ ıÓÌ˘ÂÒÍË „ÂÔ‡ÚËÚ˚ Ç Ë ë, ̇fl‰Û Ò ÇàóËÌÙÂ͈ËÂÈ Ë ·ÂÂÏÂÌÌÓÒÚ¸˛, fl‚Îfl˛ÚÒfl ‰ÓÔÓÎÌËÚÂθÌ˚Ï ÔÓ͇Á‡ÌËÂÏ ‰Îfl ̇Á̇˜ÂÌËfl Á‡ÏÂÒÚËÚÂθÌÓÈ Ú‡ÔËË Ë Ó̇ ÂÍÓÏẨÛÂÚÒfl ÌÂÁ‡‚ËÒËÏÓ ÓÚ ÒÓÍÓ‚ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚË͇, ‚ÓÁ‡ÒÚ‡ ·ÓθÌÓ„Ó Ë Ì‡Î˘Ëfl ÒÔˆËÙ˘ÂÒÍÓ„Ó Ì‡ÍÓÎӄ˘ÂÒÍÓ„Ó Î˜ÂÌËfl [14]. Ç ÔÓÒΉÌË „Ó‰˚ ̇ÍÓÔÎÂÌ ÓÔ‰ÂÎÂÌÌ˚È ÓÔ˚Ú Ì‡·Î˛‰ÂÌËfl Á‡ ·ÓθÌ˚ÏË, ÔÓÎÛ˜‡˛˘Ëı Á‡ÏÂÒÚËÚÂθÌÛ˛ Ú‡Ô˲ ÓÔˇڇÏË Ë èÇí. èË ˝ÚÓÏ Ó·ÒÛʉ‡ÂÚÒfl fl‰ ÓÒÓ·ÂÌÌÓÒÚÂÈ ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛, ‚ÎËfl˛˘Ëı ̇ ËÒıÓ‰˚ èÇí ïÉë. í‡Í, ‰Îfl ·ÓθÌ˚ı ̇ÍÓχÌËÂÈ ı‡‡ÍÚÂÂÌ ıÛ‰¯ËÈ ÒÓχÚ˘ÂÒÍËÈ Ë ËÏÏÛÌÌ˚È ÒÚ‡ÚÛÒ ÔÓ Ò‡‚ÌÂÌ˲ Ò ·ÓθÌ˚ÏË ·ÂÁ ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚË. чÊ ‚ ÓÚÒÛÚÒÚ‚Ë HIV-ËÌÙÂ͈ËË ÏÓÊÂÚ ‚ÒÚ˜‡Ú¸Òfl ÒÓ˜ÂÚ‡Ì̇fl ÂÔÎË͇ˆËfl HCV Ë HBV, HBV Ë HDV, ˜ÚÓ Ú·ÛÂÚ Ì‡Á̇˜ÂÌËfl ÓÚ΢‡˛˘ËıÒfl ÓÚ Òڇ̉‡ÚÌ˚ı ÒıÂÏ èÇí (̇ÔËÏÂ, Ô„ËÎËÓ‚‡ÌÌ˚È ËÌÚÂÙÂÓÌα, Ë·‡‚ËËÌ Ë ‡Ì‡ÎÓ„ ÌÛÍÎÂÓÚ(Á)ˉӂ) [2]. àϲÚÒfl ‰‡ÌÌ˚Â Ó ÚÓÏ, ˜ÚÓ ·ÓθÌ˚Ï Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ Ò‚ÓÈÒÚ‚ÂÌÂÌ ·ÓΠ·˚ÒÚ˚È ÚÂÏÔ ÔÓ„ÂÒÒËÓ‚‡ÌËfl ÙË·ÓÁ‡ ÌÂÁ‡‚ËÒËÏÓ ÓÚ Ì‡Î˘Ëfl ËÎË ÓÚÒÛÚÒÚ‚Ëfl Çàó-ËÌÙÂ͈ËË [15]. éÌË ˜‡˘Â ÒÍÎÓÌÌ˚ Í ‡Á‚ËÚ˲ ‰ÂÔÂÒÒËË ‚ ıӉ èÇí, ˜ÚÓ ÔË‚Ó‰ËÚ Í ÌÂÓ·ıÓ‰ËÏÓÒÚË ‰ÓÒÓ˜ÌÓ„Ó ÔÂ͇˘ÂÌËfl ΘÂÌËfl [16]. ùÚË Ó·ÒÚÓflÚÂθÒÚ‚‡ ÏÓ„ÛÚ ÒÌËʇڸ ÂÁÛθڇÚË‚ÌÓÒÚ¸ èÇí. ÇÏÂÒÚÂ Ò ÚÂÏ, Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ˜‡˘Â ÓÔ‰ÂÎflÂÚÒfl ÎÛ˜¯Â ÔÓ‰‰‡˛˘ËÈÒfl ΘÂÌ˲ 3 „ÂÌÓÚËÔ HCV [17]. Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl ÔÓ͇Á‡ÌÓ, ˜ÚÓ ÔË ‚˚ÒÓÍÓÈ ÔË‚ÂÊÂÌÌÓÒÚË Í èÇí ·ÓθÌÓ„Ó Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ˜‡ÒÚÓÚ‡ ÒÚÓÈÍÓ„Ó ‚ËÛÒÓÎӄ˘ÂÒÍÓ„Ó ÓÚ‚ÂÚ‡ (ëÇé) ÒÛ˘ÂÒÚ‚ÂÌÌÓ Ì ÓÚ΢‡ÂÚÒfl ÓÚ „ÛÔÔ ·ÓθÌ˚ı ïÉë ·ÂÁ ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚË [18-21]. í‡Í, ÔË Ì‡·Î˛‰ÂÌËË Á‡ 406 ·ÓθÌ˚ÏË, ÔÓÎÛ˜‡‚¯Ëı èÇí ‚ Ò‚flÁË Ò ïÉë Ë ˜ÂÚ‚ÂÚ¸ ËÁ ÍÓÚÓ˚ı ÒÓÒÚ‡‚ÎflÎË ÓÔˇÚÌ˚ ̇ÍÓχÌ˚, ÔÓÒΠÒڇ̉‡ÚËÁ‡ˆËË ÔÓ „ÂÌÓÚËÔÛ Ì ‚˚fl‚ÎÂÌÓ ‡ÁÌˈ˚ ‚ ‰ÓÒÚËÊÂÌËË ëÇé Û ÔÓ‰ÓÎʇ˛˘Ëı ÛÔÓÚ·ÎflÚ¸ ̇ÍÓÚËÍË Ë ‚ ÒÓÒÚÓflÌËË Ì‡ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË, ‡ Ú‡Í ÊÂ Û ·ÓθÌ˚ı, ÔÓÎÛ˜‡˛˘Ëı Ë Ì ÔÓÎÛ˜‡˛˘Ëı Á‡ÏÂÒÚËÚÂθÌÛ˛ Ú‡Ô˲ ÏÂÚ‡‰ÓÌÓÏ [22]. Ç ä‡Ì‡‰Â ‚ ÛÒÎÓ‚Ëflı ÔËÌÛ‰ËÚÂθÌÓ„Ó ‚ÓÁ‰ÂʇÌËfl ÓÚ ÛÔÓÚ·ÎÂÌËfl “Û΢Ì˚ı” ̇ÍÓÚËÍÓ‚ ÔË ËÒÔÓθÁÓ‚‡ÌËË Á‡ÏÂÒÚËÚÂθÌ˚ı ÔÓ„‡ÏÏ Ë ‚˚ÒÓÍÓÈ ÔË‚ÂÊÂÌÌÓÒÚË ·ÓθÌ˚ ‰ÂÏÓÌÒÚËÓ‚‡ÎË ÙÓÏËÓ‚‡ÌË ëÇé ‚ 66% ̇·Î˛‰ÂÌËÈ [18]. Ç ‰Û„ÓÏ ËÒÒΉӂ‡ÌËË, „‰Â ËÁ 170 ·ÓθÌ˚ı ̇ Á‡ÏÂÒÚËÚÂθÌÓÈ ÓÔËÓˉÌÓÈ Ú‡ÔËË ·˚ÎË ÓÚÓ·‡Ì˚ 43 ˜ÂÎÓ‚Â͇ Ò ÚflÊÂÎ˚Ï ÙË·ÓÁÓÏ Ô˜ÂÌË, ÔÓÒΠ̇Á̇˜ÂÌËfl èÇí Ô„ËÎËÓ‚‡ÌÌ˚Ï ËÌÚÂÙÂÓÌÓÏ-α ‚ ÒÓ˜ÂÚ‡ÌËË Ò Ë·‡‚ËËÌÓÏ Û 90% ˝ÚËı ·ÓθÌ˚ı ‰ÓÒÚË„ÌÛÚ ÌÂÔÓÒ‰ÒÚ‚ÂÌÌ˚È ‚ËÛÒÓÎӄ˘ÂÒÍËÈ ÓÚ‚ÂÚ, ‡ ëÇé – Û 62% [22]. LJÊÌÓ, ˜ÚÓ ÔË Ôӂ‰ÂÌËË èÇí Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ Ì ÓÚϘ‡ÂÚÒfl ̇‡ÒÚ‡ÌËfl ˜‡ÒÚÓÚ˚ ÌÂÊ·ÚÂθÌ˚ı fl‚ÎÂÌËÈ, Á‡ ËÒÍβ˜ÂÌËÂÏ ‰ÂÔÂÒÒËË, ÍÓÚÓ‡fl, Ӊ̇ÍÓ, fl‚ÎflÂÚÒfl ÍÓÌÚÓÎËÛÂÏÓÈ. éÔ˚Ú Ó‰ÌÓ‚ÂÏÂÌÌÓ„Ó Ì‡Á̇˜ÂÌËfl ÓÔˇÚÓ‚ Ò Á‡ÏÂÒÚËÚÂθÌÓÈ ˆÂθ˛ Ë ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚, ÓÒÓ·ÂÌÌÓ ËÌÚÂÙÂÓ̇-α, ‚ ̇ÒÚÓfl˘Â ‚ÂÏfl ÒΉÛÂÚ ÔËÁ̇ڸ ̉ÓÒÚ‡ÚÓ˜Ì˚Ï ‰Îfl ‚˚‡·ÓÚÍË ÓÔ‰ÂÎÂÌ17 ЛЕКЦИЯ Таблица 1. Критерии высокого уровня реабилитационного потенциала лиц с наркотической зависимостью èÂÏӷˉÌ˚È ÙÓÌ äÎËÌ˘ÂÒ͇fl ͇ÚË̇ ëӈˇθ̇fl ‡·ËÎËÚ‡ˆËfl ã˘ÌÓÒÚÌ˚È Ù‡ÍÚÓ éÚÒÛÚÒÚ‚Ë ÔÒËıÓÔ‡ÚÓÎӄ˘ÂÒÍÓÈ Ì‡ÒΉÒÚ‚ÂÌÌÓÒÚË (ÔÒËı˘ÂÒÍËı Á‡·Ó΂‡ÌËÈ, ‡ÎÍÓ„ÓÎËÁχ, ̇ÍÓχÌËÈ), ÛÒÔ¯̇fl ۘ·‡, ‡·ÓÚ‡ I ÒÚ‡‰Ëfl ̇ÍÓχÌËË (Ì·Óθ¯Ë ÒÓÍË Ë Ì·Óθ¯Ë ‰ÓÁ˚ ̇ÍÓÚËÁ‡ˆËË, ‰ÍÓ ‚ÌÛÚË‚ÂÌÌÓ ‚‚‰ÂÌË ̇ÍÓÚË͇, ÔÂËÏÛ˘ÂÒÚ‚ÂÌÌÓ ËÌڇ̇Á‡Î¸ÌÓ ‚‚‰ÂÌËÂ, ÏÓÌÓ̇ÍÓχÌËfl) ÅÓθÌÓÈ ÏÓÊÂÚ ‡·ÓÚ‡Ú¸, Û˜ËÚ¸Òfl Ñ„‡‰‡ˆËfl ΢ÌÓÒÚË I ÒÚÂÔÂÌË (ÎÊË‚ÓÒÚ¸, ÌÂÓ·flÁ‡ÚÂθÌÓÒÚ¸, ÓÚÒÛÚÒÚ‚Ë ÍËÏË̇θÌÓ„Ó Ôӂ‰ÂÌËfl, Ì„ÎÛ·ÓÍÓ ÏӇθÌÓ-˝Ú˘ÂÒÍÓ ÒÌËÊÂÌËÂ) Ì˚ı ÂÍÓÏẨ‡ˆËÈ, ıÓÚfl ‚ ÔÓÒΉÌÂÏ ÛÍÓ‚Ó‰ÒÚ‚Â ÄÏÂË͇ÌÒÍÓÈ „‡ÒÚÓ˝ÌÚÂÓÎӄ˘ÂÒÍÓÈ ‡ÒÒӈˇˆËË ÔÓ Î˜ÂÌ˲ ïÉë ÔÓ͇Á‡ÌËfl Í èÇí Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ Á̇˜ËÚÂθÌÓ ‡Ò¯ËÂÌ˚ [23]. í·ÛÂÚÒfl Ôӂ‰ÂÌË ‰‡Î¸ÌÂȯËı ËÒÒΉӂ‡ÌËÈ ÔÓ ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË Ë ·ÂÁÓÔ‡ÒÌÓÒÚË ÒÓ˜ÂÚ‡ÌÌÓÈ ÔÓÚË‚Ó‚ËÛÒÌÓÈ Ë Á‡ÏÂÒÚËÚÂθÌÓÈ Ú‡ÔËË. LJÊÌÓ, ˜ÚÓ ÓÔ˚Ú Á‡ÏÂÒÚËÚÂθÌ˚ı ÔÓ„‡ÏÏ ÌÂθÁfl ‡‚ÚÓχÚ˘ÂÒÍË ÔÂÂÌÓÒËÚ¸ ̇ ·ÓθÌ˚ı, ÛÔÓÚ·Îfl˛˘Ëı “Û΢Ì˚” ÓÔˇÚ˚, ÒÓ‰Âʇ˘Ëı ÏÌÓ„Ó˜ËÒÎÂÌÌ˚ ÔËÏÂÒË Ë Í‡˜ÂÒÚ‚ÂÌÌÓ ÏÂÌfl˛˘Ëı Ú˜ÂÌË ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚË. éÚÌÓÒËÚÂθ̇fl ·ÂÁÓÔ‡ÒÌÓÒÚ¸ “ωˈËÌÒÍËı” ÓÔˇÚÓ‚ Ì ‡‚ÌÓÒËθ̇ ·ÂÁÓÔ‡ÒÌÓÒÚË “Û΢ÌÓ„Ó” ̇ÍÓÚË͇, ÔËÂÏ ÍÓÚÓÓ„Ó, ÍÓÏ ‚ÒÂ„Ó ÔӘ„Ó, ‚‰ÂÚ Í Ì‰ÓÒÚËÊËÏÓÒÚË Òӷβ‰ÂÌËfl ÂÊËχ ‰ÓÁËÓ‚‡ÌËfl ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚. èÓ‚ÒÂÏÂÒÚÌÓ„Ó ÔËÏÂÌÂÌËfl ÓÔ˚Ú Á‡ÏÂÒÚËÚÂθÌÓÈ Ú‡ÔËË ÔÓ͇ Ì ̇¯ÂÎ, ‡ ‚ êÓÒÒËË ÔÓÎÌÓÒÚ¸˛ ÓÚÒÛÚÒÚ‚ÛÂÚ. Ç ÓÚ΢ˠÓÚ ‰Û„Ëı ÒÚ‡Ì ‚ êÓÒÒËË ËÒÚÓ˘ÂÒÍË ÒÎÓÊËÎÒfl ËÌÒÚËÚÛÚ ‡Á‚ËÚÓÈ ÏÌÓ„ÓÛÓ‚Ì‚ÓÈ Ì‡ÍÓÎӄ˘ÂÒÍÓÈ ÔÓÏÓ˘Ë (ÓÚ ‰ËÒÔ‡ÌÒÂÓ‚ Ë ÒÚ‡ˆËÓ̇ӂ ‰Ó ‡·ËÎËÚ‡ˆËÓÌÌ˚ı ˆÂÌÚÓ‚) Ò ˝Ú‡Ô‡ÏË Î˜·ÌÓ-‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓˆÂÒÒ‡, ̇ԇ‚ÎÂÌÌÓ„Ó ËÒÍβ˜ËÚÂθÌÓ Ì‡ ÔÓÎÌ˚È ÓÚ͇Á ÓÚ Ì‡ÍÓÚË͇, Ô˘ÂÏ ‚ Ëı Á‡‰‡˜Ë Ì ‚ıÓ‰ËÚ ÒÓχÚ˘ÂÒ͇fl ‡·ËÎËÚ‡ˆËfl ·ÓθÌ˚ı, ‚ ÚÓÏ ˜ËÒΠÔӂ‰ÂÌË èÇí [24,25]. èÓ˝ÚÓÏÛ ‚‡˜, Á‡ÌËχ˛˘ËÈÒfl ΘÂÌËÂÏ ïÉë, ͇ÈÌ ‰ÍÓ ÔËÌËχÂÚ Â¯ÂÌËÂ Ó èÇí Û ‰ÂÈÒÚ‚Û˛˘Â„Ó Ì‡ÍÓχ̇, ÔÓÒÍÓθÍÛ ˝ÚË ·ÓθÌ˚ ̇·Î˛‰‡˛ÚÒfl Û Ì‡ÍÓÎÓ„‡. èÓ‰‡‚Îfl˛˘Â ·Óθ¯ËÌÒÚ‚Ó ˝ÚËı ·ÓθÌ˚ı Ó·‡˘‡ÂÚÒfl Í „ÂÔ‡ÚÓÎÓ„Û ‚ Ò‚flÁË Ò ïÉë ̇ ‡ÁÌ˚ı ÒÓ͇ı ÓÚ͇Á‡ ÓÚ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚. Ç ÚÓÊ ‚ÂÏfl, Ì ÒÛ˘ÂÒÚ‚ÛÂÚ ÌÓχÚË‚Ì˚ı ‰ÓÍÛÏÂÌÚÓ‚ ËÎË ÂÍÓÏẨ‡ˆËÈ ‚ êÓÒÒËÈÒÍÓÈ î‰‡ˆËË, ÍÓÚÓ˚ ӄ‡Ì˘˂‡ÎË ·˚ Ôӂ‰ÂÌË èÇí ̇ β·˚ı ˝Ú‡Ô‡ı Ú˜ÂÌËfl ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚË – ÔÓ‰ÓÎʇ˛˘ÂÈÒfl ̇ÍÓÚËÁ‡ˆËË ËÎË ÂÏËÒÒËË ‡ÁÌ˚ı ÒÓÍÓ‚. Противовирусная терапия в условиях ремиссии до 1 года ì˜ËÚ˚‚‡fl ‚˚ÒÓÍÛ˛ ‚ÂÓflÚÌÓÒÚ¸ Ò˚‚‡ ̇ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË Ì‡ ‰‡ÌÌÓÏ ˝Ú‡Ô ‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓˆÂÒÒ‡, ÔË ÔËÌflÚËË Â¯ÂÌËfl Ó Ì‡˜‡Î èÇí ÒΉÛÂÚ ËÏÂÚ¸ ‚ ‚Ë‰Û ÚÓ, ˜ÚÓ Û„ÓÁ‡ Ò˚‚‡ ̇ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË Ì‡ÔflÏÛ˛ Á‡‚ËÒËÚ ÓÚ Â ÔÓ‰ÓÎÊËÚÂθÌÓÒÚË Ë ËÒıÓ‰ÌÓ„Ó ÛÓ‚Ìfl ‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓÚÂ̈ˇ· [25]. èË Ì‡Î˘ËË ‚˚ÒÓÍÓ„Ó ÛÓ‚Ìfl ‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓÚÂ̈ˇ· (Ú‡·Î. 1) ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ΘÂÌËfl ïÉë ÛÊÂ Ò ‡ÌÌËı ÒÓÍÓ‚ ‚ÓÁ‰ÂʇÌËfl Û ·ÓθÌ˚ı, ‡Ì ÛÔÓÚ·Îfl‚¯Ëı ̇ÍÓÚËÍË, ÒÓÔÓÒÚ‡‚ËÏÓ Ò Ú‡ÍÓ‚˚Ï Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ÒÓ ÒÓÍÓÏ ‚ÓÁ‰ÂʇÌËfl ·ÓΠ„Ó‰‡. èÓÒΠÔÂÓ‰ÓÎÂÌËfl ÓÒÚÓ„Ó ‡·ÒÚËÌÂÌÚÌÓ„Ó ÒÓÒÚÓfl18 ÌËfl „·‚Ì˚Ï ÔË̈ËÔÓÏ ÔÓÒÚÓÂÌËfl ̇ÍÓÎӄ˘ÂÒÍÓÈ Ú‡Ô‚Ú˘ÂÒÍÓÈ ÔÓ„‡ÏÏ˚ fl‚ÎflÂÚÒfl ÔÓ‰‡‚ÎÂÌË ÓÒÚ‡ÚÓ˜ÌÓÈ ÔÒËıÓÔ‡ÚÓÎӄ˘ÂÒÍÓÈ ÒËÏÔÚÓχÚËÍË. Ç ˝ÚËı ˆÂÎflı ËÒÔÓθÁÛ˛ÚÒfl ÌÂÈÓÎÂÔÚËÍË, ‡ÌÚˉÂÔÂÒÒ‡ÌÚ˚, ÌÓÏÓÚËÏËÍË, ·ÎÓ͇ÚÓ˚ ÓÔˇÚÌ˚ı ˆÂÔÚÓÓ‚. èÓ‰‡‚Îfl˛˘Â ·Óθ¯ËÌÒÚ‚Ó ˝ÚËı ÎÂ͇ÒÚ‚ÂÌÌ˚ı ÔÂÔ‡‡ÚÓ‚ „ÂÔ‡ÚÓÚÓÍÒ˘Ì˚, ÌÂÍÓÚÓ˚ ӷ·‰‡˛Ú „ÂχÚÓÎӄ˘ÂÒÍÓÈ ÚÓÍÒ˘ÌÓÒÚ¸˛ [26]. LJÊÌÓ, ˜ÚÓ ·ÂÁÓÔ‡ÒÌÓÒÚ¸ Ó‰ÌÓ‚ÂÏÂÌÌÓ„Ó ÔËÂχ ‰‡ÌÌ˚ı ÔÒËıÓÚÓÔÌ˚ı ÔÂÔ‡‡ÚÓ‚ Ë ÔÓÚË‚Ó‚ËÛÒÌ˚ı Ò‰ÒÚ‚ ‰ÓÒÍÓ̇θÌÓ Ì ËÁÛ˜‡Î‡Ò¸. 燘‡ÎÓ èÇí ̇ ÙÓÌ Ëı ÔËÂχ ÏÓÊÂÚ ·˚Ú¸ ÒÓÔflÊÂÌÓ Ò ‰ÓÔÓÎÌËÚÂθÌ˚ÏË ÚÛ‰ÌÓÒÚflÏË ÔË ÍÓÌÚÓΠ̇‰ ÒÓÒÚÓflÌËÂÏ Ô˜ÂÌË, ÒËÒÚÂÏ˚ ÍÓ‚Ë Ë ÔÒËı˘ÂÒÍÓ„Ó ÒÚ‡ÚÛÒ‡ ·ÓθÌÓ„Ó. LJÊÌÓ Û˜ËÚ˚‚‡Ú¸ ÚÓÚ Ù‡ÍÚ, ˜ÚÓ Ì‡˜‡ÎÓ èÇí ̇ ÒÓ͇ı ÂÏËÒÒËË ‰Ó 1 „Ó‰‡ ÏÓÊÂÚ ·˚Ú¸ Í‡Í ‰ÓÔÓÎÌËÚÂθÌ˚Ï ÏÓÚË‚‡ˆËÓÌÌ˚Ï Ù‡ÍÚÓÓÏ Â ۉÂʇÌËfl, Ú‡Í Ë Ù‡ÍÚÓÓÏ, ÒÔÓÒÓ·ÒÚ‚Û˛˘ËÏ Â Ò˚‚Û ËÁ-Á‡ ‡Á‚ËÚËfl ‰ÂÔÂÒÒËË, Ô˘ÂÏ ÓÚ͇Á ÓÚ ÔÒËıÓ‡ÍÚË‚Ì˚ı ‚¢ÂÒÚ‚ ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸˛ ÏÂÌ ˜ÂÏ 6 ÏÂÒflˆÂ‚, ÔÓ Ì‡¯ËÏ ‰‡ÌÌ˚Ï, fl‚ÎflÂÚÒfl Ù‡ÍÚÓÓÏ ËÒ͇ ‡Á‚ËÚËfl ÌÂÍÓÌÚÓÎËÛÂÏÓ„Ó Ú˜ÂÌËfl ‰ÂÔÂÒÒËË ÔË èÇí Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ [26]. ÑÛ„ËÏ Ù‡ÍÚÓÓÏ ËÒ͇ ‡Á‚ËÚËfl ÌÂÍÓÌÚÓÎËÛÂÏÓÈ ‰ÂÔÂÒÒËË fl‚ÎflÂÚÒfl ÌÂÛÒÚÓȘ˂‡fl ̇ÍÓÎӄ˘ÂÒ͇fl ÂÏËÒÒËfl (‰ËÌ˘Ì˚ Ò˚‚˚, ÒÏÂ̇ ÙÓÏ Ì‡ÍÓÚËÁ‡ˆËË). LJÊÌÓ, ˜ÚÓ ‰ÂÈÒÚ‚Ë ËÌÚÂÙÂÓ̇-α ̇ ñçë ÏÓÊÂÚ ÔÓfl‚ÎflÚ¸Òfl Ì ÚÓθÍÓ ‡Á‚ËÚËÂÏ ‰ÂÔÂÒÒËË, ÌÓ Ë ‡„ÂÒÒË‚Ì˚Ï Ôӂ‰ÂÌËÂÏ, ÒÔÛÚ‡ÌÌÓÒÚ¸˛ ÒÓÁ̇ÌËfl Ë ‰Û„ËÏË ËÁÏÂÌÂÌËflÏË ÔÒËı˘ÂÒÍÓ„Ó ÒÓÒÚÓflÌËfl ÔÒËıÓÚ˘ÂÒÍÓ„Ó ÚËÔ‡. é‰Ì‡ÍÓ ˝ÚË ‡ÚËÔ˘Ì˚ ‡ÒÒÚÓÈÒÚ‚‡ ͇ÈÌ ‰ÍË, Ô‰ÒÚ‡‚ÎÂÌ˚ ‰ËÌ˘Ì˚ÏË ÓÔËÒ‡ÌËflÏË, ̇·Î˛‰‡˛ÚÒfl, ‚ ÓÒÌÓ‚ÌÓÏ, Û ·ÓθÌ˚ı Ò ‰ÎËÚÂθÌ˚Ï ÓÔ˚ÚÓÏ ÛÔÓÚ·ÎÂÌËfl ̇ÍÓÚËÍÓ‚, ˜ÚÓ ‰Â·ÂÚ ‚Í·‰ ËÌÚÂÙÂÓ̇-α ‚ Ëı ‡Á‚ËÚˠ̉ÓÒÚ‡ÚÓ˜ÌÓ Û·Â‰ËÚÂθÌ˚Ï [27]. ïÓÚfl ˝ÚË ËÁÏÂÌÂÌËfl Ó·‡ÚËÏ˚, ÓÌË ‚ÏÂÒÚÂ Ò ‰ÂÔÂÒÒËÂÈ ÏÓ„ÛÚ ÔË‚ÂÒÚË Í Ò˚‚Û Ì‡ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË, ‚ ÚÓÏ ˜ËÒÎÂ Ò Û„ÓÁÓÈ Ô‰ÓÁËÓ‚ÍË Ì‡ÍÓÚË͇ Ò ‚ÓÁÏÓÊÌÓÒÚ¸˛ ÎÂڇθÌÓ„Ó ËÒıÓ‰‡. ë Ó‰ÌÓÈ ÒÚÓÓÌ˚, ̇ÍÓχÌËfl Ì ÔÓÔ‡‰‡ÂÚ ÔÓ‰ ÓÔ‰ÂÎÂÌË “ÚflÊÂÎÓ„Ó ÔÒËı˘ÂÒÍÓ„Ó Á‡·Ó΂‡ÌËfl ËÎË ‚˚‡ÊÂÌÌ˚ı ÔÒËı˘ÂÒÍËı ̇ۯÂÌËÈ ‚ ‡Ì‡ÏÌÂÁ” Ë “̇ۯÂÌËÈ ÙÛÌ͈ËË ñçë”, ‚˚ÒÚÛÔ‡˛˘Ëı ‚ ͇˜ÂÒÚ‚Â ÔÓÚË‚ÓÔÓ͇Á‡ÌËÈ Í èÇí Òӄ·ÒÌÓ ÓÙˈˇθÌÓÈ ËÌÒÚÛ͈ËË Í Ô„ËÎËÓ‚‡ÌÌ˚Ï ËÌÚÂÙÂÓ̇Ï. ë ‰Û„ÓÈ – ‚‡ÊÌ˚Ï Ó·ÒÚÓflÚÂθÒÚ‚ÓÏ èÇí Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ fl‚ÎflÂÚÒfl ‚ÓÁÏÓÊÌÓÒÚ¸ ̇΢Ëfl ˝Ì‰Ó„ÂÌÌÓ„Ó ÔÒËı˘ÂÒÍÓ„Ó Á‡·Ó΂‡ÌËfl, ÔÓÒÍÓθÍÛ Ì‡ÍÓχÌËfl ˜‡ÒÚÓ ‡Á‚Ë‚‡ÂÚÒfl Í‡Í ÍÓÏӷˉ̇fl Ô‡ÚÓÎÓ„Ëfl Û ÔÒËıˇÚ˘ÂÒÍËı ·ÓθÌ˚ı, ÓÒÓ·ÂÌÌÓ ÔË ¯ËÁÓÙÂÌËË, ÍÓÚÓ‡fl ‚ ÛÒÎÓ‚Ëflı ̇ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2007, 3 ЛЕКЦИЯ ÍÓÚËÁ‡ˆËË ËÏÂÂÚ ÒÍ˚ÚÓ Ú˜ÂÌËÂ. í‡ÍËÏ Ó·‡ÁÓÏ, Ô·ÌËÛfl èÇí ·ÓθÌÓÏÛ, ‡Ì ÛÔÓÚ·Îfl‚¯ÂÏÛ Ì‡ÍÓÚËÍË, ÌÂÓ·ıÓ‰ËÏÓ ËÏÂÚ¸ Á‡Íβ˜ÂÌË ÔÒËıˇڇ ËÎË ÔÒËıˇڇ-̇ÍÓÎÓ„‡ Ó ÔÒËı˘ÂÒÍÓÏ ÒÓÒÚÓflÌËË ·ÓθÌÓ„Ó. äÓÏ ÚÓ„Ó, ÔÓÚË‚ÓÔÓ͇Á‡ÌËfl Í Ì‡Á̇˜ÂÌ˲ ËÌÚÂÙÂÓÌÓ‚ ‰‡Ê ÔË “‚˚‡ÊÂÌÌ˚ı ÔÒËı˘ÂÒÍËı ̇ۯÂÌËflı” Ì fl‚Îfl˛ÚÒfl ‡·ÒÓβÚÌ˚ÏË. ÇÓÔÓÒ Ó Ì‡˜‡Î ËÎË ÔÓ‰ÓÎÊÂÌËË èÇí ÏÓÊÂÚ ·˚Ú¸ ¯ÂÌ ÔÓÎÓÊËÚÂθÌÓ ÍÓÌÒËÎËÛÏÓÏ „ÂÔ‡ÚÓÎÓ„‡ Ë ÔÒËıˇڇ. ì˜ËÚ˚‚‡fl ÒÔˆËÙ˘ÂÒÍË ËÁÏÂÌÂÌËfl ΢ÌÓÒÚË Ë Ôӂ‰ÂÌËfl ̇ÍÓχ̇, ÍÓÚÓ˚ ӄ‡Ì˘˂‡˛Ú ÒÔÓÒÓ·ÌÓÒÚ¸ ˝ÚËı ·ÓθÌ˚ı ÓÒÓÁ̇ÌÌÓ ÛÍÓ‚Ó‰ËÚ¸ Ò‚ÓËÏ Ôӂ‰ÂÌËÂÏ, ÔË ÔËÌflÚËË Â¯ÂÌËfl Ó Ï‰ˈËÌÒÍÓÏ ‚ϯ‡ÚÂθÒÚ‚Â, ÌÂÓ·ıÓ‰ËÏÓ ˜ÚÓ·˚ ‰Ó·Ó‚ÓθÌÓ ËÌÙÓÏËÓ‚‡ÌÌÓ Òӄ·ÒË ÔÓ‰ÔËÒ˚‚‡Î Ì ÚÓθÍÓ Ò‡Ï ·ÓθÌÓÈ, ÌÓ Ë Â„Ó ÓÔÂÍÛÌ (̇ÔËÏÂ, ˜ÎÂÌ ÒÂϸË). Противовирусная терапия в условиях ремиссии более 1 года ÅÓθÌ˚Â, ‰ÓÒÚË„¯Ë „Ӊ˘ÌÓÈ Ì‡ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË, ËÏÂ˛Ú ·Óθ¯ÓÈ ¯‡ÌÒ Â ‰ÎËÚÂθÌÓ„Ó Û‰ÂʇÌËfl. èË̈ËÔˇθÌÓ ‚‡ÊÌÓ ‰Îfl ·ÓθÌÓ„Ó Ì‡ ˝ÚÓÏ ˝Ú‡Ô ‡·ËÎËÚ‡ˆËË Ì‡ıÓ‰ËÚÒfl ‚ Ú‡Ô‚Ú˘ÂÒÍËı ÒÓÓ·˘ÂÒÚ‚‡ı, „ÛÔÔ‡ı ÔÒËıÓÚ‡Ô‚Ú˘ÂÒÍÓÈ ÔÓ‰‰ÂÊÍË [6]. Ç ÚÓ ‚ÂÏfl Í‡Í Ì‡ ˝ÚÓÏ ÒÓÍ ÔÒËıÓÔ‡ÚÓÎӄ˘ÂÒ͇fl ÒËÏÔÚÓχÚË͇ ÓÚÒÚÛÔ‡ÂÚ Ì‡ ‚ÚÓÓÈ Ô·Ì, ÓÒÌÓ‚ÌÛ˛ Û„ÓÁÛ ÊËÁÌË Ì‡˜Ë̇˛Ú Ô‰ÒÚ‡‚ÎflÚ¸ ÒÓχÚ˘ÂÒÍË ÔÓÒΉÒÚ‚Ëfl ̇ÍÓχÌËË, ‚ ÔÂ‚Û˛ Ә‰¸, ÔÓ‡ÊÂÌË Ô˜ÂÌË. í‡Í, Û Îˈ, ÔÂ͇ÚË‚¯Ëı ÛÔÓÚ·ÎÂÌË ̇ÍÓÚËÍÓ‚, ˆËÓÁ Ô˜ÂÌË ‚ ËÒıӉ ïÉë ‚˚fl‚ÎflÂÚÒfl ‚ ÚÂÚË Ì‡·Î˛‰ÂÌËÈ, ‡ ÔÓ‡ÊÂÌË Ô˜ÂÌË fl‚ÎflÂÚÒfl ÓÒÌÓ‚ÌÓÈ Ô˘ËÌÓÈ ÒÏÂÚË Í‡Í Û Çàó-Ì„‡ÚË‚Ì˚ı, Ú‡Í Ë Û Çàó-ÔÓÁËÚË‚Ì˚ı ·ÓθÌ˚ı (‚ ÚÓÏ ˜ËÒΠÔË ‡‰ÂÍ‚‡ÚÌÓÈ ‚˚ÒÓÍÓ‡ÍÚË‚ÌÓÈ ‡ÌÚËÂÚÓ‚ËÛÒÌÓÈ Ú‡ÔËË) [28,29]. ÖÒÎË “‡ÎÍÓ„ÓθÌ˚È ÍÓÏÔÓÌÂÌÚ” ÔÓ‡ÊÂÌËfl Ô˜ÂÌË, ̉ÍÓ ÔËÒÛÚÒÚ‚Û˛˘ËÈ Û Ì‡ÍÓχÌÓ‚, „ÂÒÒËÛÂÚ ‚ Ú˜ÂÌË „Ó‰‡ ‚ÓÁ‰ÂʇÌËfl ÓÚ ÔËÂχ ‡ÎÍÓ„ÓÎfl, ÚÓ ËÁÏÂÌÂÌËfl, Ò‚flÁ‡ÌÌ˚Â Ò ıÓÌ˘ÂÒÍÓÈ HCV-ËÌÙÂ͈ËÂÈ, ÔÓ‰ÓÎʇ˛Ú ÔÓ„ÂÒÒËÓ‚‡Ú¸. èË ‰Ë̇Ï˘ÂÒÍÓÏ Ì‡·Î˛‰ÂÌËË Á‡ ÓÔˇÚÌ˚ÏË Ì‡ÍÓχ̇ÏË ‚ ÛÒÎÓ‚Ëflı ‰ÎËÚÂθÌÓ„Ó ‚ÓÁ‰ÂʇÌËfl Ï˚ Ì „ËÒÚËÓ‚‡ÎË ÌË Ó‰ÌÓ„Ó ÒÎÛ˜‡fl ÒÔÓÌÚ‡ÌÌÓÈ ˝ÎËÏË̇ˆËË HCV RNA, ıÓÚfl ÔË ıÓÌ˘ÂÒÍÓÈ HBV-ËÌÙÂ͈ËË ËÌÓ„‰‡ ̇·Î˛‰‡Î‡Ò¸ ÒÔÓÌÚ‡Ì̇fl ˝ÎËÏË̇ˆËfl HBV DNA [2]. ãˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ‚ ‡Ì‡ÏÌÂÁ ÔË Ôӂ‰ÂÌËË èÇí Ú‡‰ËˆËÓÌÌÓ ‚˚‰ÂÎfl˛Ú ‚ “ÚÛ‰ÌÛ˛” „ÛÔÔÛ ·ÓθÌ˚ı ïÉë, ˜ÚÓ Ó·ÛÒÎÓ‚ÎÂÌÓ ÒÓı‡ÌÂÌËÂÏ ËÒ͇ ‚ÓÁ‚‡Ú‡ Í Ì‡ÍÓÚËÁ‡ˆËË, ‚ ÚÓÏ ˜ËÒΠÒÓ ÒÏÂÌÓÈ Ì‡ÍÓÚË͇, ËÎË Ú‡ÌÒÙÓχˆËÂÈ ‚ ÁÎÓÛÔÓÚ·ÎÂÌË ‡ÎÍÓ„ÓÎÂÏ. ÑÎfl ·ÓθÌ˚ı ‰‡ÌÌÓÈ Í‡Ú„ÓËË Ò‚ÓÈÒÚ‚ÂÌÌ˚ ÔÂʉ‚ÂÏÂÌÌÓ ÔÂ͇˘ÂÌË èÇí, ÌÂÒӷβ‰ÂÌË ÂÊËχ ‰ÓÁËÓ‚‡ÌËfl ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚, ‡‰ÂÍ‚‡ÚÌÓÈ ÍÓÌÚ‡ˆÂÔˆËË, ÒÓÍÓ‚ ÍÓÌÚÓθÌÓ„Ó Ó·ÒΉӂ‡ÌËfl. Ç ÚÓÊ ‚ÂÏfl, ÔË‚Ó‰flÚÒfl ‰‡ÌÌ˚Â Ó ÚÓÏ, ˜ÚÓ ÔË ‰ÎËÚÂθÌÓÈ Ì‡ÍÓÎӄ˘ÂÒÍÎÈ ÂÏËÒÒËË ÔË‚ÂÊÂÌÌÓÒÚ¸ Í Î˜ÂÌ˲ ÒÓÔÓÒÚ‡‚Ëχ Ò Ú‡ÍÓ‚ÓÈ Û ·ÓθÌ˚ı, Ì Ëϲ˘Ëı ÓÔ˚Ú‡ ÔËÂχ ̇ÍÓÚËÍÓ‚ ‚ ‡Ì‡ÏÌÂÁ [15,18,19]. LJÊÌÓ ÔÓÏÌËÚ¸ Ó ÚÓÏ, ˜ÚÓ ·ÓθÌ˚Ï Ò ‰ÎËÚÂθÌÓÈ Ì‡ÍÓÎÓГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2007, 3 Таблица 2. Сравнительная гепатотоксичность антидепрессантов èÂÔ‡‡Ú ÄÏËÚËÔÚËÎËÌ ÅÛÒÔËÓÌ åˇÌÒÂËÌ äÎÓÏËÔ‡ÏËÌ íˇÌÂÔÚËÌ ñËÚ‡ÎÓÔ‡Ï îÎÛÓÍÒÂÚËÌ îÎÛ‚ÓÍÒ‡ÏËÌ è‡ÓÍÒÂÚËÌ ëÂÚ‡ÎËÌ ó‡ÒÚÓÚ‡ ÎÂ͇ÒÚ‚ÂÌÌÓ„Ó „ÂÔ‡ÚËÚ‡, % 13,8 10,2 18,8 16,4 17,0 10,8 13,0 11,2 11,8 11,3 „˘ÂÒÍÓÈ ÂÏËÒÒËÂÈ Ú‡ÍÊ ҂ÓÈÒÚ‚ÂÌÂÌ ÔÓ‚˚¯ÂÌÌ˚È ËÒÍ ‡Á‚ËÚËfl ‰ÂÔÂÒÒËË ‚ ıӉ èÇí (‚ ÚÓÏ ˜ËÒΠÌÂÍÓÌÚÓÎËÛÂÏÓÈ). èË ‚‰ÂÌËË Ú‡ÍËı ·ÓθÌ˚ı ÒΉÛÂÚ Ï‡ÍÒËχθÌÓ Ó·˙ÂÍÚË‚ËÁËÓ‚‡Ú¸ ÔÒËıÓÎӄ˘ÂÒÍËÈ ÒÚ‡ÚÛÒ Ò ÔÓÏÓ˘¸˛ ‡ÌÍÂÚ-ÓÔÓÒÌËÍÓ‚ (ÔÓ ñÛÌ„Û, ɇÏËθÚÓÌÛ, ÅÂÍÛ Ë ‰). åÌÓ„Ë ·ÓθÌ˚ ÌÛʉ‡˛ÚÒfl ‚ ‰ÎËÚÂθÌÓÈ ÔÒËıÓهχÍÓÚ‡ÔËË ‰Îfl ÔÓ‰‰ÂʇÌËfl ̇ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË, ‚ ÔÂ‚Û˛ Ә‰¸ – ‚ ‡ÌÚˉÂÔÂÒÒ‡ÌÚ‡ı. èË ‰ÎËÚÂθÌÓÈ Ú‡ÔËË ÒΉÛÂÚ Û˜ËÚ˚‚‡Ú¸ Ëı „ÂÔ‡ÚÓÚÓÍÒ˘ÂÒÍËÈ ÔÓÚÂ̈ˇÎ, ÍÓÚÓ˚È Û ‡ÁÌ˚ı ÔÂÔ‡‡ÚÓ‚ ÏÓÊÂÚ ÒÛ˘ÂÒÚ‚ÂÌÌÓ ‡Á΢‡Ú¸Òfl Ë ‚ ÏÂ̸¯ÂÈ ÒÚÂÔÂÌË Ô‰ÒÚ‡‚ÎÂÌ Û ˆËÚ‡ÎÓԇχ Ë ÙÎÛ‚ÓÍÒ‡ÏË̇ (Ú‡·Î. 2) [30]. ì „ÂÓËÌÓ‚˚ı ̇ÍÓχÌÓ‚ ÒΉÛÂÚ ÓÚ‰‡‚‡Ú¸ Ô‰ÔÓ˜ÚÂÌË ÙÎÛ‚ÓÍÒ‡ÏËÌÛ, ÔÓÒÍÓθÍÛ ˆËÚ‡ÎÓÔ‡Ï Ó·Î‡‰‡ÂÚ Á̇˜ËÚÂθÌÓ ·Óθ¯ËÏ ÒÓ‰ÒÚ‚ÓÏ Í H1-ˆÂÔÚÓ‡Ï Ë, ÒΉӂ‡ÚÂθÌÓ, ‰ËωÓÎÓÔÓ‰Ó·Ì˚Ï ˝ÙÙÂÍÚÓÏ [31]. ä‡Í ËÁ‚ÂÒÚÌÓ, „ÂÓËÌ ˜‡ÒÚÓ ÛÔÓÚ·ÎflÂÚÒfl ‚ ÒÏÂÒË Ò ‰ËωÓÎÓÏ Ë ‰ËωÓÎÓÔÓ‰Ó·Ì˚ÏË ÔÂÔ‡‡Ú‡ÏË, ÔÓ˝ÚÓÏÛ ˆËÚ‡ÎÓÔ‡Ï ÏÓÊÂÚ ‡ÍÚÛ‡ÎËÁËÓ‚‡Ú¸ Û ·ÓθÌ˚ı ÓÔˇÚÌÓÈ Ì‡ÍÓχÌËÂÈ Ô‡ÚÓÎӄ˘ÂÒÍÓ ‚ΘÂÌËÂ Í Ì‡ÍÓÚËÍÛ. àÁ ‡ÌÚˉÂÔÂÒÒ‡ÌÚÓ‚ ÌÂÓ·ıÓ‰ËÏÓ Ú‡ÍÊ ËÁ·Â„‡Ú¸ ÔËÏÂÌÂÌËfl ÚˇÌÂÔÚË̇, ÔÓÒÍÓθÍÛ ÓÌ Ó·Î‡‰‡ÂÚ Ì‡ÍÓ„ÂÌÌ˚Ï ÔÓÚÂ̈ˇÎÓÏ [32,33]. Заключение ç‡ ÓÒÌÓ‚‡ÌËË Ô‰ÒÚ‡‚ÎÂÌÌ˚ı ÒÓ·ÒÚ‚ÂÌÌ˚ı ‰‡ÌÌ˚ı [26,34,35] Ë ‰‡ÌÌ˚ı ÎËÚ‡ÚÛ˚ ÏÓÊÌÓ Á‡Íβ˜ËÚ¸ ÒÎÂ‰Û˛˘ÂÂ: - èÇí ïÉë ‚ÓÁÏÓÊ̇ ̇ β·ÓÏ ˝Ú‡Ô Ú˜ÂÌËfl ̇ÍÓχÌËË, Ӊ̇ÍÓ ÓÔ‰ÂÎfl˛˘ËÏ Ù‡ÍÚÓÓÏ Â ˝ÙÙÂÍÚË‚ÌÓÒÚË fl‚ÎflÂÚÒfl ÔË‚ÂÊÂÌÌÓÒÚ¸ ·ÓθÌÓ„Ó Í Î˜ÂÌ˲; - èÇí ïÉë Û ‰ÂÈÒÚ‚Û˛˘Ëı ̇ÍÓχÌÓ‚ ‰ÓÎÊ̇ ÔÓ‚Ó‰ËÚ¸Òfl ‚ ÛÒÎÓ‚Ëflı Á‡ÏÂÒÚËÚÂθÌÓÈ Ú‡ÔËË ÏÂÚ‡‰ÓÌÓÏ ËÎË ËÌ˙Â͈ËÓÌÌ˚Ï „ÂÓËÌÓÏ. ì ·ÓθÌ˚ı ̇ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛, ÛÔÓÚ·Îfl˛˘Ëı “Û΢Ì˚” ÓÔˇÚ˚, èÇí ÒΉÛÂÚ ÔËÁ̇ڸ χÎÓÔÂÒÔÂÍÚË‚ÌÓÈ ‚ Ò‚flÁË Ò ÌÂÒӷβ‰ÂÌËÂÏ ÂÊËχ ‰ÓÁËÓ‚‡ÌËfl Ë ÍËÏË̇θÌ˚Ï Ó·‡ÁÓÏ ÊËÁÌË ·ÓθÌ˚ı; - ‚ Ô‚˚ 3 ÏÂÒflˆ‡ Ò ÏÓÏÂÌÚ‡ ÓÚ͇Á‡ ÓÚ Ì‡ÍÓÚË͇ Ôӂ‰ÂÌË èÇí ïÉë Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ̈ÂÎÂÒÓÓ·‡ÁÌÓ ËÁ-Á‡ ‚˚ÒÓÍÓÈ ‚ÂÓflÚÌÓÒÚË ‚ÓÁ‚‡Ú‡ Í ÛÔÓÚ·ÎÂÌ˲ ̇ÍÓÚËÍÓ‚ Ë ÌÂÓ·ıÓ‰ËÏÓÒÚË Ù‡Ï‡ÍÓÎӄ˘ÂÒÍÓÈ ÍÓÂ͈ËË ÔÓÒÚ‡·ÒÚËÌÂÌÚÌÓ„Ó ÒÓÒÚÓflÌËfl; 19 ЛЕКЦИЯ - ÒÓÍ ÙÓÏËÓ‚‡ÌËfl ̇ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË ÓÚ 3 ‰Ó 6 ÏÂÒflˆÂ‚ – ‚˚ÒÓÍÓ ËÒÍÓ‚‡ÌÌ˚È ÔÂËÓ‰, Ë èÇí ̇ ˝ÚÓÏ ˝Ú‡Ô ‚ÓÁÏÓÊ̇ ÔË ‚˚ÒÓÍÓÏ ÛÓ‚Ì ‡·ËÎËÚ‡ˆËÓÌÌÓ„Ó ÔÓÚÂ̈ˇ·, ÓÚÒÛÚÒÚ‚ËË ÌÂÓ·ıÓ‰ËÏÓÒÚË ‚ هχÍÓÎӄ˘ÂÒÍÓÈ ÔÓ‰‰ÂÊÍ ̇ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË, ÒÓ‚ÏÂÒÚÌÓÏ ‚‰ÂÌËË ·ÓθÌÓ„Ó Ò ÔÒËıˇÚÓÏ-̇ÍÓÎÓ„ÓÏ, ÔË Ì‡Î˘ËË ÏÓÚË‚‡ˆËË ·ÓθÌÓ„Ó, ÔË ˝ÚÓÏ èÇí ÏÓÊÌÓ ËÒÔÓθÁÓ‚‡Ú¸ Í‡Í ‰ÓÔÓÎÌËÚÂθÌÛ˛ ÏÓÚË‚‡ˆË˛ ÔÓ‰‰ÂʇÌËfl ÂÏËÒÒËË; - ÒÓÍ ‚ÓÁ‰ÂʇÌËfl ÓÚ ÔËÂχ ̇ÍÓÚËÍÓ‚ ‚ Ú˜ÂÌË 6-12 ÏÂÒflˆÂ‚ ÓÚÌÓÒËÚÒfl Í ÛÏÂÂÌÌÓÏÛ ËÒÍÛ Ò˚‚‡ ‚ÓÁ‰ÂʇÌËfl. ã˜ÂÌË ïÉë ̇ ˝ÚÓÏ ÒÓÍ ÂÏËÒÒËË ÔÓ‚Ó‰ËÚÒfl ÒÓ‚ÏÂÒÚÌÓ Ò ÔÒËıˇÚÓÏ-̇ÍÓÎÓ„ÓÏ; - ÒÓÍ Ì‡ÍÓÎӄ˘ÂÒÍÓÈ ÂÏËÒÒËË Ò‚˚¯Â 12 ÏÂÒflˆÂ‚ fl‚ÎflÂÚÒfl ÓÔÚËχθÌ˚Ï ÔÂËÓ‰ÓÏ Ì‡˜‡Î‡ èÇí. ê¯ÂÌËÂ Ó èÇí ïÉë Û Îˈ Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ ÔËÌËχÂÚÒfl ̇ ÓÒÌÓ‚‡ÌËË ‡Ì‡ÎËÁ‡ ÒÓÓÚÌÓ¯ÂÌËfl ÔÓÚÂ̈ˇθÌÓÈ ÔÓθÁ˚ Ë ËÒ͇ ‚ ͇ʉÓÏ ÍÓÌÍÂÚÌÓÏ ÒÎÛ˜‡Â. èË ‡·ÓÚÂ Ò Îˈ‡ÏË Ò Ì‡ÍÓÚ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚ¸˛ (‚ ÚÓÏ ˜ËÒΠ‚ ‡Ì‡ÏÌÂÁÂ) ÌÂÓ·ıÓ‰ËÏÓ ÒÓ‚ÏÂÒÚÌÓ ‚‰ÂÌË ·ÓθÌ˚ı Ò ÔÒËıˇÚÓÏ-̇ÍÓÎÓ„ÓÏ, ÓÒÓ·ÂÌÌÓ Ì‡ ‡ÌÌËı ÒÓ͇ı ÓÚ͇Á‡ ÓÚ Ì‡ÍÓÚËÍÓ‚, Ò Â„ÛÎflÌÓÈ ÓˆÂÌÍÓÈ ÔÒËı˘ÂÒÍÓ„Ó ÒÚ‡ÚÛÒ‡ Ë ÔË‚ÂÊÂÌÌÓÒÚË, ̇ÒÚÓÓÊÂÌÌÓÒÚ¸˛ ‚ ÓÚÌÓ¯ÂÌËË ‰ÂÔÂÒÒËË. 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