Нежелательные явления нестероидных противовоспалительных препаратов: возможные варианты выхода из ситуации
Нежелательные явления нестероидных противовоспалительных препаратов: возможные варианты выхода из ситуации
Котова О.В., Акарачкова Е.С. Нежелательные явления нестероидных противовоспалительных препаратов: возможные варианты выхода из ситуации. Consilium Medicum. 2017; 19 (2.2. Неврология и Ревматология): 85–90.
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Kotova O.V., Akarachkova E.S. Undesirable effects of non-steroidal anti-inflammatory drugs: possible options for resolving the situation. Consilium Medicum. 2017; 19 (2.2. Neurology and Rheumatology): 85–90.
Нежелательные явления нестероидных противовоспалительных препаратов: возможные варианты выхода из ситуации
Котова О.В., Акарачкова Е.С. Нежелательные явления нестероидных противовоспалительных препаратов: возможные варианты выхода из ситуации. Consilium Medicum. 2017; 19 (2.2. Неврология и Ревматология): 85–90.
________________________________________________
Kotova O.V., Akarachkova E.S. Undesirable effects of non-steroidal anti-inflammatory drugs: possible options for resolving the situation. Consilium Medicum. 2017; 19 (2.2. Neurology and Rheumatology): 85–90.
Нестероидные противовоспалительные препараты (НПВП) обладают многочисленными серьезными, потенциально опасными для жизни побочными реакциями или нежелательными явлениями, но все же они относятся к наиболее широко прописываемым и применяемым лекарствам во всем мире. В развитых странах эти препараты получают 20–30% лиц пожилого возраста, среди которых около 30% пожилых людей вынуждены принимать эти препараты, несмотря на наличие факторов риска развития нежелательных явлений, как со стороны желудочно-кишечного тракта, так и сердечно-сосудистой системы. В статье описаны побочные явления при применении НПВП. Предложено альтернативное НПВП лечение пациентов, нуждающихся в обезболивающей терапии, – флупиртин (Нолодатак). Флупиртин относится к принципиально новому классу препаратов для лечения болевых синдромов, является селективным активатором нейрональных калиевых каналов. Флупиртин – неопиоидный анальгетик, у которого есть антиспастическое действие на поперечно-полосатую мускулатуру. Нолодатак выпускается компанией ОАО «Акрихин» (капсулы 100 мг) и биоэквивалентен оригинальному флупиртину (капсулы 100 мг – «Плива Краков, Фармацевтический завод А.О.», Польша).
Non-steroidal anti-inflammatory drugs (NSAIDs) have many serious, potentially life-threatening adverse reactions or adverse events, but still belong to the most widely prescribed and used medications worldwide. In developed countries, these drugs are received by 20–30% of the elderly, among whom about 30% of the elderly are forced to take these drugs, despite the presence of risk factors for the development of adverse events, both from the gastrointestinal tract and the cardiovascular system. The article describes the side effects of NSAIDs. An alternative NSAID treatment for patients in need of analgesic therapy is suggested, flupirtine (Nolodatak). Flupirtine belongs to a fundamentally new class of drugs for the treatment of pain syndromes, it is a selective activator of neuronal potassium channels. Flupirtine is a non-opioid analgesic, which has an antispastic effect on the striated muscle. Nolodactak is produced by the company Akrikhin (capsules 100 mg) and bioequivalent to the original flupirtin (capsules 100 mg – Pliva Krakow, Pharmaceutical Plant AO, Poland).
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2. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs. N Engl J Med 1999; 340: 1888–91.
3. Каратеев А.Е., Насонова В.А. Развитие и рецидивирование язв желудка и двенадцатиперстной кишки у больных, принимающих НПВП: влияние стандартных факторов риска. Терапевт. арх. 2008; 5: 62–6. / Karateev A.E., Nasonova V.A. Razvitie i retsidivirovanie iazv zheludka i dvenadtsatiperstnoi kishki u bol'nykh, prinimaiushchikh NPVP: vliianie standartnykh faktorov riska. Terapevt. arkh. 2008; 5: 62–6. [in Russian]
4. Varga Z, Sabzwari SRA, Vargova V. Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue. Cureus 2017; 9 (4): e1144. DOI: 10.7759/cureus.1144
5. Walshe JJ, Venuto RC. Acute oliguric renal failure induced by indomethacin: possible mechanism. Ann Intern Med 1979; 91: 47–9.
6. Cannon PJ. Prostaglandins in congestive heart failure and the effects of non steroidal anti-inflammatory drugs. Am J Med 1986; 81: 123–32.
7. Bombardier C, Laine L, Reicin R. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. New Engl J Med 2000; 343: 1520–28.
8. Süleyman H, Demircan B, Karagöz Y. Anti-inflammatory and side effects of cyclooxygenase inhibitors. Pharmacol Rep 2007; 59: 3: 247–58.
9. Котова О.В. НПВП: в поисках золотой середины – соотношение безопасность/эффективность. Справочник поликлинического врача. 2013; 1: 15–8. / Kotova O.V. NPVP: v poiskakh zolotoi serediny – sootnoshenie bezopasnost'/effektivnost'. Handbook for Practitioners Doctors. 2013; 1: 15–8. [in Russian]
10. Hla T, Neilson K. Human cyclooxygenase-2 cDNA. Proc Nat Acad Sci USA 1992; 89: 7384–88.
11. Seibert K, Zhang Y, Leahy K et al. Distribution of COX-1 and COX-2 in normal and inflamed tissues. Adv Exp Med Biol 1997; 400A: 167–70.
12. Seibert K, Zhang Y, Leahy K et al. Pharmacological and biochemical demonstration of the role of cyclooxygenase-2 in inflammation and pain. Proc Nat Acad Sci USA 1994; 91: 12013–17.
13. Mitchell JA, Warner TD. Cyclooxygenase-2: pharmacology, physiology, biochemistry and relevance to NSAID therapy. Br J Pharmacol 1999; 128: 1121–32.
14. Smith WL, De Witt DL, Garavito RM. Cyclooxygenases: structural, cellular and molecular biology. Ann Rev Biochem 2000; 69: 145–82.
15. Radford MG, Holley KE, Grande JP et al. Reversible membranous nephropathy associated with the use of nonsteroidal anti-inflammatory drugs. JAMA 1996; 276: 466–8.
16. Насонова В.А. Клиническая оценка нестероидных противовоспалительных препаратов в конце ХХ века. РМЖ. 2000; 8 (17): 714–7. / Nasonova V.A. Klinicheskaia otsenka nesteroidnykh protivovospalitel'nykh preparatov v kontse XX veka. RMZh. 2000; 8 (17): 714–7. [in Russian]
17. Zeidler H, Kaltwasser J, Leonard J et al. Prescription and tolerability of meloxicam in day-to-day practice. Postmarketing observational cohort study of 13.307 patients in Germany. J Clin Rheumatol 2002; 8: 305–15.
18. Котова О.В. Вопросы безопасности длительной терапии нимесулидом. Фарматека. 2013; 9 (262): 54–8. / Kotova O.V. Voprosy bezopasnosti dlitel'noi terapii nimesulidom. Farmateka. 2013; 9 (262): 54–8. [in Russian]
19. Garcia-Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet 1994; 343: 769–72.
20. McDonald TM, Morant SV, Robinson GC et al. Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study. BMJ 1997; 315: 1333–7.
21. Silverstein FE, Graham DY, Senior JR et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1995; 123: 241–9.
22. Bresalier R, Sandler R, Quan H et al. Cardiovascular Events Associated with Rofecoxib in a Colorectal Adenoma Chemoprevention Trial. N Engl J Med 2005; 352: 1092–102.
23. Merck announces voluntary worldwide withdrawal of VIOXX. http://www.vioxx.com/vioxx/documents/english/hcp_notification_physicians.pdf
24. Nissen SE, Yeomans ND, Solomon DH et al. Cardiovascular safety of celecoxib, naproxen, oribuprofen for arthritis. N Engl J Med 2016; 375: 2519–29.
25. Михайлов И.Б. Настольная книга врача по клинической фармакологии. Руководство для врачей. СПб.: Фолиант, 2001; с. 736. / Mikhailov I.B. Nastol'naia kniga vracha po klinicheskoi farmakologii. Rukovodstvo dlia vrachei. SPb.: Foliant, 2001; s. 736. [in Russian]
26. Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Ann Intern Med 1994; 121: 289–300.
27. Aw TJ, Haas S, Liew D. Meta-analysis of cyclooxygenase-2 inhibitors and their effects on blood pressure. Arch Intern Med 2005; 165: 490–6.
28. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: asystematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase-2. JAMA 2006; 296: 1633–44.
29. Strom BL, Carson JL, Schinnar R et al. Nonsteroidal anti-inflammatory drugs and neutropenia. Arch Intern Med 1993; 153: 2119–22.
30. Patton W, Duffull S. Idiosyncratic drug-induced hematological abnormalities. Drug Safety 1994; 11 (6): 445–62.
31. Зборовский А.Б., Тюренков И.Н. Осложнения фармакотерапии. М.: Медицина, 2003. / Zborovskii A.B., Tiurenkov I.N. Oslozhneniia farmakoterapii. M.: Meditsina, 2003. [in Russian]
32. Harrington LS, Lucas R, McMaster SK et al. COX-1, and not COX-2 activity, regulates airway function: relevance to aspirin-sensitive asthma. FASEB J 2008; 22 (11): 4005–10.
33. Teoh NC, Farrell GC. Hepatotoxicity associated with non-steroidal anti-inflammatory drugs. Clin Liver Dis 2003; 7: 401–13.
34. Bort R, Ponsoda X, Jover R et al. Diclofenac toxicity to hepatocytes: a role for drug metabolism in cell toxicity. J Pharmacol Exp Ther 1999; 288 (1): 65–72.
35. Palmer R, Weiss R, Zusman RM et al. Effects of nabumetone, celecoxib, and ibuprofen on blood pressure control in hypertensive patients on angiotensin converting enzyme inhibitors. Am J Hypertens 2003; 16: 135–9.
36. Schwartz JI, Vandormael K, Malice MP et al. Comparison of rofecoxib, celecoxib, and naproxen on renal function in elderly subjects receiving a normal salt diet. Clin Pharmacol Ther 2002; 72: 50–61.
37. Murray MD, Brater DC, Tierney WM. Ibuprofen-associated renal impairment in a large general internal medicine practice. Am J Med Sci 1990; 299: 222–9.
38. Pathan E, Gaitonde S, Rajadhyaksha S et al. A longitudinal study of serum creatinine levels in patients of rheumatoid arthritis on long term NSAID therapy. J Assoc Physicians India 2003; 51: 1045–9.
39. Galesic K, Morovic-Vergles J. Drug-induced acute interstitial nephritis. Reumatizam 2003; 50 (1): 14–7.
40. Ueberall M, Mueller-Schwefe G, Terhaag B. Efficacy and tolerability of flupirtine in subacute/chronic musculoskeletal pain – results of a patient level, pooled re-analysis of randomized, double-blind, controlled trials. Int J Clin Pharmacol Ther 2011; 49: 637–47.
41. Perovic S, Pialoglou P, Schroder HC et al. Flupirtine increases the levels of glutathione and Bc1-2 in hNT (human Ntera/D1) neurons: mode of action of the drug-mediated anti-apoptotic effect. Eur J Pharmacol 1996; 12: 157–64.
42. Jakob R, Krieglstein J. Influence of flupirtine on a G-protein coupled inwardly rectifying potassium current in hippocampal neurons. Br J Pharmacol 1997; 122: 1333–38.
43. Wörz R, Müller-Schwefe G, Stroehmann I et al. Back pain: Guidelines for drug therapy. Fortschr Med 2000; 142 (5): 27–33.
44. Котова О.В., Акарачкова Е.С. Боль в шее: распространенность, факторы возникновения, возможности терапии. Фарматека. 2014; 9: 45–9. / Kotova O.V., Akarachkova E.S. Bol' v shee: rasprostranennost', faktory vozniknoveniia, vozmozhnosti terapii. Farmateka. 2014; 9: 45–9. [in Russian]
45. Котова О.В. Острая боль в нижней части спины: не дать болезни затянуться. Фарматека. 2012; 14 (247): 60–4. / Kotova O.V. Ostraia bol' v nizhnei chasti spiny: ne dat' bolezni zatianut'sia. Farmateka. 2012; 14 (247): 60–4. [in Russian]
46. Herrmann W, Hiersemenzel R, Aigner M et al. Long-term tolerance of flupirtine. Open multicenter study over one year. Fortschr Med 1993; 111 (15): 266–70.
47. Mueller-Schwefe G. Flupirtine in acute and chronicpain associated with мuscle tenseness. Results of a postmarketing surveillance study. Forschr Med 2003; 121: 3–10.
48. Müller-Schwefe G, Uberall M. Analgesic and muscle tonus normalizing effect of flupirtine retard in chronic back pain. Result of a standardized therapeutic evaluation applying objective methods for measuring pain pressure threshold, pain pressure tolerance and muscle tension. MMW Fortschr Med 2008; 4: 153–61.
49. Singal R, Gupta P, Jain N, Gupta S. Role of flupirtine in the treatment of pain – chemistry and its effects. Maedica (Buchar) 2012; 7 (2): 163–6.
50. Котова О.В., Акарачкова Е.С. Место препарата Нолодатака в лечении боли в спине. Фарматека. 2015; 13: 70–3. / Kotova O.V., Akarachkova E.S. Mesto preparata Nolodataka v lechenii boli v spine. Farmateka. 2015; 13: 70–3. [in Russian]
________________________________________________
1. Kotova O.V., Akarachkova E.S., Danilov A.B. Voprosy dlitel'noi terapii bolevykh sindromov. Rus. med. zhurn. 2015; 23 (30): 16–8. [in Russian]
2. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs. N Engl J Med 1999; 340: 1888–91.
3. Karateev A.E., Nasonova V.A. Razvitie i retsidivirovanie iazv zheludka i dvenadtsatiperstnoi kishki u bol'nykh, prinimaiushchikh NPVP: vliianie standartnykh faktorov riska. Terapevt. arkh. 2008; 5: 62–6. [in Russian]
4. Varga Z, Sabzwari SRA, Vargova V. Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue. Cureus 2017; 9 (4): e1144. DOI: 10.7759/cureus.1144
5. Walshe JJ, Venuto RC. Acute oliguric renal failure induced by indomethacin: possible mechanism. Ann Intern Med 1979; 91: 47–9.
6. Cannon PJ. Prostaglandins in congestive heart failure and the effects of non steroidal anti-inflammatory drugs. Am J Med 1986; 81: 123–32.
7. Bombardier C, Laine L, Reicin R. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. New Engl J Med 2000; 343: 1520–28.
8. Süleyman H, Demircan B, Karagöz Y. Anti-inflammatory and side effects of cyclooxygenase inhibitors. Pharmacol Rep 2007; 59: 3: 247–58.
9. Kotova O.V. NPVP: v poiskakh zolotoi serediny – sootnoshenie bezopasnost'/effektivnost'. Handbook for Practitioners Doctors. 2013; 1: 15–8. [in Russian]
10. Hla T, Neilson K. Human cyclooxygenase-2 cDNA. Proc Nat Acad Sci USA 1992; 89: 7384–88.
11. Seibert K, Zhang Y, Leahy K et al. Distribution of COX-1 and COX-2 in normal and inflamed tissues. Adv Exp Med Biol 1997; 400A: 167–70.
12. Seibert K, Zhang Y, Leahy K et al. Pharmacological and biochemical demonstration of the role of cyclooxygenase-2 in inflammation and pain. Proc Nat Acad Sci USA 1994; 91: 12013–17.
13. Mitchell JA, Warner TD. Cyclooxygenase-2: pharmacology, physiology, biochemistry and relevance to NSAID therapy. Br J Pharmacol 1999; 128: 1121–32.
14. Smith WL, De Witt DL, Garavito RM. Cyclooxygenases: structural, cellular and molecular biology. Ann Rev Biochem 2000; 69: 145–82.
15. Radford MG, Holley KE, Grande JP et al. Reversible membranous nephropathy associated with the use of nonsteroidal anti-inflammatory drugs. JAMA 1996; 276: 466–8.
16. Nasonova V.A. Klinicheskaia otsenka nesteroidnykh protivovospalitel'nykh preparatov v kontse XX veka. RMZh. 2000; 8 (17): 714–7. [in Russian]
17. Zeidler H, Kaltwasser J, Leonard J et al. Prescription and tolerability of meloxicam in day-to-day practice. Postmarketing observational cohort study of 13.307 patients in Germany. J Clin Rheumatol 2002; 8: 305–15.
18. Kotova O.V. Voprosy bezopasnosti dlitel'noi terapii nimesulidom. Farmateka. 2013; 9 (262): 54–8. [in Russian]
19. Garcia-Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet 1994; 343: 769–72.
20. McDonald TM, Morant SV, Robinson GC et al. Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study. BMJ 1997; 315: 1333–7.
21. Silverstein FE, Graham DY, Senior JR et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1995; 123: 241–9.
22. Bresalier R, Sandler R, Quan H et al. Cardiovascular Events Associated with Rofecoxib in a Colorectal Adenoma Chemoprevention Trial. N Engl J Med 2005; 352: 1092–102.
23. Merck announces voluntary worldwide withdrawal of VIOXX. http://www.vioxx.com/vioxx/documents/english/hcp_notification_physicians.pdf
24. Nissen SE, Yeomans ND, Solomon DH et al. Cardiovascular safety of celecoxib, naproxen, oribuprofen for arthritis. N Engl J Med 2016; 375: 2519–29.
25. Mikhailov I.B. Nastol'naia kniga vracha po klinicheskoi farmakologii. Rukovodstvo dlia vrachei. SPb.: Foliant, 2001; s. 736. [in Russian]
26. Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Ann Intern Med 1994; 121: 289–300.
27. Aw TJ, Haas S, Liew D. Meta-analysis of cyclooxygenase-2 inhibitors and their effects on blood pressure. Arch Intern Med 2005; 165: 490–6.
28. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: asystematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase-2. JAMA 2006; 296: 1633–44.
29. Strom BL, Carson JL, Schinnar R et al. Nonsteroidal anti-inflammatory drugs and neutropenia. Arch Intern Med 1993; 153: 2119–22.
30. Patton W, Duffull S. Idiosyncratic drug-induced hematological abnormalities. Drug Safety 1994; 11 (6): 445–62.
31. Zborovskii A.B., Tiurenkov I.N. Oslozhneniia farmakoterapii. M.: Meditsina, 2003. [in Russian]
32. Harrington LS, Lucas R, McMaster SK et al. COX-1, and not COX-2 activity, regulates airway function: relevance to aspirin-sensitive asthma. FASEB J 2008; 22 (11): 4005–10.
33. Teoh NC, Farrell GC. Hepatotoxicity associated with non-steroidal anti-inflammatory drugs. Clin Liver Dis 2003; 7: 401–13.
34. Bort R, Ponsoda X, Jover R et al. Diclofenac toxicity to hepatocytes: a role for drug metabolism in cell toxicity. J Pharmacol Exp Ther 1999; 288 (1): 65–72.
35. Palmer R, Weiss R, Zusman RM et al. Effects of nabumetone, celecoxib, and ibuprofen on blood pressure control in hypertensive patients on angiotensin converting enzyme inhibitors. Am J Hypertens 2003; 16: 135–9.
36. Schwartz JI, Vandormael K, Malice MP et al. Comparison of rofecoxib, celecoxib, and naproxen on renal function in elderly subjects receiving a normal salt diet. Clin Pharmacol Ther 2002; 72: 50–61.
37. Murray MD, Brater DC, Tierney WM. Ibuprofen-associated renal impairment in a large general internal medicine practice. Am J Med Sci 1990; 299: 222–9.
38. Pathan E, Gaitonde S, Rajadhyaksha S et al. A longitudinal study of serum creatinine levels in patients of rheumatoid arthritis on long term NSAID therapy. J Assoc Physicians India 2003; 51: 1045–9.
39. Galesic K, Morovic-Vergles J. Drug-induced acute interstitial nephritis. Reumatizam 2003; 50 (1): 14–7.
40. Ueberall M, Mueller-Schwefe G, Terhaag B. Efficacy and tolerability of flupirtine in subacute/chronic musculoskeletal pain – results of a patient level, pooled re-analysis of randomized, double-blind, controlled trials. Int J Clin Pharmacol Ther 2011; 49: 637–47.
41. Perovic S, Pialoglou P, Schroder HC et al. Flupirtine increases the levels of glutathione and Bc1-2 in hNT (human Ntera/D1) neurons: mode of action of the drug-mediated anti-apoptotic effect. Eur J Pharmacol 1996; 12: 157–64.
42. Jakob R, Krieglstein J. Influence of flupirtine on a G-protein coupled inwardly rectifying potassium current in hippocampal neurons. Br J Pharmacol 1997; 122: 1333–38.
43. Wörz R, Müller-Schwefe G, Stroehmann I et al. Back pain: Guidelines for drug therapy. Fortschr Med 2000; 142 (5): 27–33.
44. Kotova O.V., Akarachkova E.S. Bol' v shee: rasprostranennost', faktory vozniknoveniia, vozmozhnosti terapii. Farmateka. 2014; 9: 45–9. [in Russian]
45. Kotova O.V. Ostraia bol' v nizhnei chasti spiny: ne dat' bolezni zatianut'sia. Farmateka. 2012; 14 (247): 60–4. [in Russian]
46. Herrmann W, Hiersemenzel R, Aigner M et al. Long-term tolerance of flupirtine. Open multicenter study over one year. Fortschr Med 1993; 111 (15): 266–70.
47. Mueller-Schwefe G. Flupirtine in acute and chronicpain associated with мuscle tenseness. Results of a postmarketing surveillance study. Forschr Med 2003; 121: 3–10.
48. Müller-Schwefe G, Uberall M. Analgesic and muscle tonus normalizing effect of flupirtine retard in chronic back pain. Result of a standardized therapeutic evaluation applying objective methods for measuring pain pressure threshold, pain pressure tolerance and muscle tension. MMW Fortschr Med 2008; 4: 153–61.
49. Singal R, Gupta P, Jain N, Gupta S. Role of flupirtine in the treatment of pain – chemistry and its effects. Maedica (Buchar) 2012; 7 (2): 163–6.
50. Kotova O.V., Akarachkova E.S. Mesto preparata Nolodataka v lechenii boli v spine. Farmateka. 2015; 13: 70–3. [in Russian]
Авторы
О.В.Котова*, Е.С.Акарачкова
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М.Сеченова» Минздрава России. 119991, Россия, Москва, ул. Трубецкая, д. 8, стр. 2 *ol_kotova@mail.ru
________________________________________________
O.V.Kotova*, E.S.Akarachkova
I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation. 119991, Russian Federation, Moscow, ul. Trubetskaia, d. 8, str. 2 *ol_kotova@mail.ru