Нестероидные противовоспалительные препараты: что нового в международных публикациях за 2015 г.?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the classes of drugs that are most needed by modern medicine. Hundreds of new articles on the efficiency and safety of NDAIDs are published in Russian and foreign scientific journals every year. It is difficult for the practitioners to keep track of so a large amount of constantly changing information. So we have decided to present to our readers a concise overview of some of the most interesting, in our opinion, and the newest papers that discuss different aspects of using NSAIDs.Нестероидные противовоспалительные препараты (НПВП) являются одним из наиболее востребованных современной медициной классов лекарственных препаратов. Ежегодно в российских и зарубежных научных изданиях появляются сотни новых статей, посвященных эффективности и безопасности НПВП. Практикующим врачам порой трудно отслеживать столь большой объем постоянно меняющейся информации. Поэтому мы решили представить вниманию читателей краткий обзор некоторых наиболее интересных, на наш взгляд, и самых новых работ, в которых обсуждаются различные аспекты применения НПВП

ЛЕЧЕНИЕ ОСТРОЙ/ПОДОСТРОЙ СКЕЛЕТНОМЫШЕЧНОЙ БОЛИ С ИСПОЛЬЗОВАНИЕМ АЛГОРИТМА ПОШАГОВОГО ВЫБОРА НАЗНАЧЕНИЯ И КОНТРОЛЯ ЭФФЕКТИВНОСТИ АНАЛЬГЕТИЧЕСКИХ СРЕДСТВ. ПРЕДВАРИТЕЛЬНЫЕ ДАННЫЕ ПРОГРАММЫ АЛИСА (АНАЛЬГЕТИЧЕСКОЕ ЛЕЧЕНИЕ С ИСПОЛЬЗОВАНИЕМ СИСТЕМНОГО АЛГОРИТМА)

To optimize treatment for musculoskeletal pain (MSP) is a topical medical and social problem. A meeting of experts was held inMoscowin June 2015 to discuss the possibility of forming an interdisciplinary approach and elaborating a unified MSP treatment algorithm based on the com prehensive pathogenetically justified use of different classes of medicines. The Analgesic Treatment Using a Systemic Algorithm (ATUSA) trial is a retrospective observational study of the effectiveness of this approach in clinical practice.Objective: to investigate the efficiency of combination treatment for MSP in real clinical practice.Patients and methods. A study group consisted of 3304 patients (women (54.3%) and men (45.7%); mean age 48.9±14.6 years) with osteoarthritis, nonspecific back pain, and rheumatic juxta-articular soft tissue pathology who had visited their doctors for acute/subacute MSP. Treatment was performed in accordance with the following algorithm: the first appointment was a nonsteroidal anti-inflammatory drug (NSAID), such as aceclofenac), in case of contraindications, paracetamol and/or tramadol + a topical NSAID, in case of indications, muscle relaxants. The therapeutic efficiency was monitored every 7 days (a total of 4 visits); during each visit, therapy could be changed: switching to another NSAID, local administration of glucocorticoids (GC), as well as antidepressants or anticonvulsants. The dynamics of pain (a 0–10 pain intensity numeric rating scale), the number of patients in whom MSP had been resolved completely, as well as treatment satisfaction were taken into account to assess the results of treatment.Results. The first appointment in 97.5% of the patients was NSAIDs, mainly aceclofenac (93.7%), that was used in combination with a muscle relaxant in 67.7%. By Visit 4, there was a reduction in MSP from 6.9±1.5–2.2±1.3 scores. MSP was completely resolved in 77.0% of the patients. The vast majority (88.4%) of the patients rated their treatment outcome as good or excellent. There was a need for switching to another NSAID in 8.1% of cases, local administration of GC in 1.9%; use of an antidepressant or an anticonvulsant in 1.5%, and hospitalization in 0.25%. Adverse reactions were noted in 2.2% of the patients.Conclusion. The application of the treatment algorithm based on a pathogenetic approach ensures effective and relatively safe relief of MSP in most patients. Оптимизация лечения скелетно-мышечной боли (СМБ) – актуальная медицинская и социальная проблема. В июне2015 г. в Москве состоялось совещание экспертов, обсуждавших возможность формирования междисциплинарного подхода и единого алгоритма лечения СМБ, основанного на комплексном патогенетически обоснованном применении различных классов лекарственных средств. Исследование АЛИСА представляет собой ретроспективное наблюдательное исследование эффективности данного подхода в реальной клинической практике. Цель исследования – изучение эффективности комплексного лечения СМБ в реальной клинической практике.Пациенты и методы. Исследуемую группу составили 3304 больных (женщин – 54,3%, мужчин – 45,7%, средний возраст – 48,9±14,6 года) с остеоартритом, неспецифической болью в спине и ревматической патологией околосуставных мягких тканей, обратившихся к врачам по поводу острой/подострой СМБ. Лечение проводилось в соответствии со следующим алгоритмом: первое назначение – нестероидный противовоспалительный препарат (НПВП; ацеклофенак), при наличии противопоказаний – парацетамол и/или трамадол + локальные форма НПВП, по показаниям – миорелаксанты. Эффективность терапии контролировали каждые 7 дней (всего 4 визита), причем в ходе каждого визита терапию можно было изменять: переключение на другой НПВП, назначение локального ведения глюкокортикоидов (ГК), а также антидепрессантов или антиконвульсантов. При оценке результатов лечения учитывали динамику боли (по числовой рейтинговой шкале 0–10 пунктов), число больных, у которых СМБ была полностью купирована, а также удовлетворенность лечением.Результаты. Первым назначением у 97,5% больных были НПВП, в основном ацеклофенак (93,7%), который у 67,6% пациентов использовали в сочетании с миорелаксантом. К 4-му визиту СМБ уменьшилась с 6,9±1,5 до 2,2±1,3 пунктов. СМБ была полностью купирована у 77,0% пациентов. Подавляющее большинство пациентов (88,4%) оценили результат лечения как «хороший» или «превосходный». Переключение на другой НПВП потребовалось в 8,1% случаев, локальное введение ГК – в 1,9%, назначение антидепрессанта или антиконвульсанта – в 1,5%, госпитализация – в 0,25%. Нежелательные реакции отмечены у 2,2% больных.Выводы. Применение алгоритма лечения, основанного на комплексном патогенетическом подходе, обеспечивает эффективное и относительно безопасное купирование СМБ у большинства больных.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ АТЕРОСКЛЕРОТИЧЕСКИХ АНЕВРИЗМ БРЮШНОГО ОТДЕЛА АОРТЫ ПРИ ПОДКОВООБРАЗНОЙ ПОЧКЕ

One of the factors determining the frequency of intra- and postoperative complications during operations on the abdominal part of the aorta is anatomical variations and abnormalities of renal arteries and veins. Among the renal structure anomalies the most common is a fused kidney. This anomaly is of great interest in patients with abdominal aortic aneurysm. The article highlights the historical aspects of the study of this group of patients, presents the classification, the features of surgical access, the advantages and disadvantages of each of them, the experience presented in the world literature, as well as the authors’ own experience in carrying out such operations for 30 years in the walls of the A.V. Vishnevsky National Medical Research Institute of Surgery. Peculiarities of surgical tactics in this group of patients were discussed: prevention of such complications as urinary leakage, addition of infection, bleeding, kidney ischemia and postoperative acute renal failure arising after routine intersection of the isthmus of the fused kidney, features in the placement of the prosthesis, data of CT, 3D reconstruction, CT-angiography, intraoperative photos were presented. The main issues that the surgeon faces during surgeries are considered: the choice of surgical access, the choice of the method of renal parenchyma protection, the choice of the method of reconstruction of the renal artery, the decision to preserve or intersect the isthmus of the fused kidney. The aspects of tactics definition in case of both planned and emergency operative interventions are considered. The authors also considered not only the possibility of performing open surgeries, but also X-ray endovascular operations, with a discussion of the advantages and disadvantages of each type of intervention.Одним из факторов, определяющих частоту интра- и послеоперационных осложнений при выполнении операций на брюшном отделе аорты, являются анатомические вариации и аномалии почечных артерий и вен. Среди аномалий строения почек наиболее часто встречается подковообразная почка. Эта аномалия представляет собой исключительный интерес у больных с аневризмой брюшного отдела аорты. В статье освещаются исторические аспекты изучения данной группы пациентов, представлена классификация, особенности хирургического доступа, достоинства и слабые стороны каждого из способов, опыт, представленный в мировой литературе, а также собственный опыт авторов в проведении подобных операций в течение 30 лет в стенах НМИЦ хирургии им А.В. Вишневского. Обсуждены особенности хирургической тактики у этой группы пациентов: профилактики таких осложнений, как мочеистечение, присоединение инфекции, кровотечение, ишемии почки и послеоперационная острая почечная недостаточность, возникающих после рутинного пересечения перешейка подковообразной почки, особенности в размещении протеза. Представлены данные КТ, 3D-реконструкции, КТ-ангиографии, интраоперационные фотографии. Рассмотрены главные вопросы, которые встают перед хирургом во время операций: выбор хирургического доступа, выбор метода защиты почечной паренхимы, выбор метода реконструкции добавочных почечных артерии, принятие решения о сохранении или пересечении перешейка подковообразной почки. Рассмотрены аспекты определения тактики в случае как плановых, так и экстренных оперативных вмешательств. Также авторами рассмотрена не только возможность выполнения не только открытых операций, но и рентгенэндоваскулярных, с обсуждением преимуществ и слабых сторон каждого из видов вмешательств

TREATMENT FOR ACUTE/SUBACUTE MUSCULOSKELETAL PAIN, BY USING AN ALGORITHM FOR STEPWISE CHOICE OF ANALGESIC DRUGS AND FOR MONITORING THEIR EFFICACY: PRELIMINARY DATA OF THE ANALGESIC TREATMENT USING SYSTEMIC ALGORITHM (ATUSA) PROGRAM

To optimize treatment for musculoskeletal pain (MSP) is a topical medical and social problem. A meeting of experts was held inMoscowin June 2015 to discuss the possibility of forming an interdisciplinary approach and elaborating a unified MSP treatment algorithm based on the com prehensive pathogenetically justified use of different classes of medicines. The Analgesic Treatment Using a Systemic Algorithm (ATUSA) trial is a retrospective observational study of the effectiveness of this approach in clinical practice.Objective: to investigate the efficiency of combination treatment for MSP in real clinical practice.Patients and methods. A study group consisted of 3304 patients (women (54.3%) and men (45.7%); mean age 48.9±14.6 years) with osteoarthritis, nonspecific back pain, and rheumatic juxta-articular soft tissue pathology who had visited their doctors for acute/subacute MSP. Treatment was performed in accordance with the following algorithm: the first appointment was a nonsteroidal anti-inflammatory drug (NSAID), such as aceclofenac), in case of contraindications, paracetamol and/or tramadol + a topical NSAID, in case of indications, muscle relaxants. The therapeutic efficiency was monitored every 7 days (a total of 4 visits); during each visit, therapy could be changed: switching to another NSAID, local administration of glucocorticoids (GC), as well as antidepressants or anticonvulsants. The dynamics of pain (a 0–10 pain intensity numeric rating scale), the number of patients in whom MSP had been resolved completely, as well as treatment satisfaction were taken into account to assess the results of treatment.Results. The first appointment in 97.5% of the patients was NSAIDs, mainly aceclofenac (93.7%), that was used in combination with a muscle relaxant in 67.7%. By Visit 4, there was a reduction in MSP from 6.9±1.5–2.2±1.3 scores. MSP was completely resolved in 77.0% of the patients. The vast majority (88.4%) of the patients rated their treatment outcome as good or excellent. There was a need for switching to another NSAID in 8.1% of cases, local administration of GC in 1.9%; use of an antidepressant or an anticonvulsant in 1.5%, and hospitalization in 0.25%. Adverse reactions were noted in 2.2% of the patients.Conclusion. The application of the treatment algorithm based on a pathogenetic approach ensures effective and relatively safe relief of MSP in most patients

Digestive comorbidity in patients with rheumatic diseases: Not only NSAID-induced gastropathy

Digestive comorbidity is a serious problem that significantly aggravates the course of rheumatic diseases. Diseases of the gastrointestinal tract (GIT), liver, and pancreatobiliary system may present a threat to life and substantially worsen its quality. The incidence of many digestive diseases, such as gastric ulcer (including its complicated forms), cholelithiasis, and acute pancreatitis, in patients with rheumatic diseases (at least in those with rheumatoid arthritis) is considerably higher than in the population. The presence of this comorbidity poses substantial challenges during active anti-rheumatic therapy. Rheumatologists are very familiar with issues in the prevention of GIT complications due to the use of nonsteroidal anti-inflammatory drugs. However, new time presents new challenges. The widespread use of immunosuppressive agents and biologic agents requires careful monitoring of complications associated with liver and bowel diseases. This review considers a relationship of rheumatic diseases and anti-rheumatic therapy to comorbidities, such as cholelithiasis, acute pancreatitis, viral hepatitis B and C, and intestinal diverticula

Nonsteroidal anti-inflammatory drugs: What is new in international publications in 2015?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the classes of drugs that are most needed by modern medicine. Hundreds of new articles on the efficiency and safety of NDAIDs are published in Russian and foreign scientific journals every year. It is difficult for the practitioners to keep track of so a large amount of constantly changing information. So we have decided to present to our readers a concise overview of some of the most interesting, in our opinion, and the newest papers that discuss different aspects of using NSAIDs

Is Helicobacter pylori eradication required for non-steroidal anti-inflammatory drug-associated erosions and ulcers?

Aim of review. To present rational on expediency of Helicobacter pylori (H. pylori) eradication for erosions and ulcers that develop on the background of nonsteroid anti-inflammatory drugs (NSAIDs) therapy. Summary. According to the data of Maastricht consensus (2012), H. pylori infection and NSAIDs are the two major independent etiological factors of peptic ulcer development and upper gastro-intestinal bleeding. However the effect of H. pylori and NSAIDs on gastrointestinal diseases remains uncertain. This is a crucial question as the most of patients (in the Russian population over 50%), that require NSAIDs and low doses of aspirin (LDA) are infected by H. pylori. According to series of studies, H. pylori is significantly more common in patients with NSAID-related gastropathy. H. pylori eradication is capable to decrease the risk of gastrointestinal diseases if carried out prior to NSAIDs prescription. At the same time, severe complicated forms of gastrointestinal diseases are common in H. pylori-negative patients, and H. pylori eradication in patients with NSAID-associated ulcers or ulcer bleeding does not provide essential decrease in recurrence rate at ongoing NSAID intake. In the analysis of large-scale NSAID safety studies no significant difference in endoscopic ulcer rate in the groups of H. pylori-infected and H. pylori-negative patients were detected. Available data allow to conclude that anti-H. pylori therapy requires differential approach in patients with indications for NSAID and LDA treatment. Conclusion. Diagnostics of H. pylori infection and eradication is indicated at development of severe complications (ulcer, bleeding), however they should not be used in routine practice at treatment in patients with low risk of complications. Anyway, H. pylori eradication does not eliminate necessity of other methods for NSAID gastropathy prophylaxis: application of COX-2 selective inhibitors and PPI preventive prescription

VIRAL HEPATITIS B AND C AS COMORBIDITY IN RHEUMATIC DISEASES: ANALYSIS OF THE DATA OF THE V.A. NASONOVA RESEARCH INSTITUTE OF RHEUMATOLOGY CLINIC OVER 4 YEARS

<p>Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is a serious problem that substantially hinders the treatment of patients with rheumatic diseases (RD) particular when there is a need for using cytotoxic and biological agents (BAs).</p><p><strong>Objective:</strong> to estimate the rate of HBV and HCV infection in RD patients followed up at the V.A. Nasonova Research Institute of Rheumatology Clinic in 2011 to 2014.</p><p><strong>Subjects and methods.</strong> All case histories of the RD patients hospitalized in the given period were analyzed. Infection with HBV and HCV was assessed from the presence of HBsAg and anti-HCV, respectively.</p><p><strong>Results and discussion.</strong> There were a total of 16,553 admissions to the V.A. Nasonova Research Institute of Rheumatology Clinic over 4 years. HBV and HCV were detected in 0.33 and 0.74%, respectively; their combination was found in 0.03% (a total of 1.1%) of the patients. About half of the patients took cytotoxic agents and glucocorticoids; 29.8% received BAs, mainly rituximab. Moderate and high chronic hepatitis activity was noted in 4.9% of the patients; liver cirrhosis was observed in 2.7%. Over the follow-up period, alanine aminotransferase and aspartate aminotransferase levels were not elevated in the vast majority of patients.</p><p><strong>Conclusion.</strong> HBV and HCV infection is often detected in patients with RD. The infected patients and persons with chronic viral hepatitis require careful follow-up and the decision whether to perform prophylactic antiviral therapy when using cytotoxic agents and BAs.</p

Проникающие ранения сердца и перикарда

Проведений аналіз результатів лікування 219 постраждалих із пораненнями серця і перикарду. Розглянуті питання діагностики поранень серця. Зроблений висновок, що встановлений діагноз поранення серця слугує абсолютним показом до екстреної операції. - Проанализированы результаты лечения 219 пациентов с ранениями сердца и перикарда. Рассмотрены вопросы диагностики и лечения ранений сердца и перикарда. Эффективность лечения ранений сердца и перикарда зависит от длительности периода с момента травмы до начала оказания специализированной медицинской (хирургической) помощи; согласованности деятельности всех служб и подразделений во время оказания помощи; квалификации и опыта хирурга; адекватности диагностических и лечебных мероприятий, консервативной терапии больного в послеоперационный период, а также своевременного выявления и лечения послеоперационных осложнений. Диагностические мероприятия в случае подозрения на ранения сердца и перикарда должны быть минимальными, их следует проводить преимущественно на операционном столе. Установление факта ранения сердца и (или) перикарда, а иногда и подозрение на такое ранение является показанием к экстренному оперативному вмешательству. Все ранения сердца следует ушивать с обязательным дренированием перикарда. Большинство случаев ранений сердца и перикарда в послеоперационный период сопровождаются легочно-сердечными осложнениями, которые требуют ранней профилактики и лечения с привлечением реанимационной и кардиологической служб. - The analysis of the results of the treatment of 219 patients with wounding of heart and pericardium was made. The problems of diagnostics and treatment of wounding of heart and pericardium are considered. Success of treatment of wounding of heart and pericar¬dium depends on duration of period from the moment of trauma to the beginning of rendering of specialised medical (surgical) care; consensus of all service activity and subdivisions during management; qualifications and experience of surgeon; adequacy of diagnostic and treat¬ment actions, conservative therapy in a postoperative period, as well as well-timed diagnostics and treatment of postoperative complications. Diagnostic measures in suspicion on wounding of heart and pericardium must be minimal, they should de carried out mainly on the operating table. Determination of wounding of heart and (or) pericardium, and sometimes — suspicion on such wounding is an indication to emergency surgical operation. All wounding of heart should be sutured with obligatory drainage of pericardium. Majority of wounding of heart and pericardium in a postoperative period are accompanied with pulmonary-cardial complications, which require an early preventive maintenance and treatment with involving of réanimation and cardiological services