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Хронический запор: актуальность, проблемы и современные возможности лечения
Кучерявый Ю.А., Андреев Д.Н., Черемушкин С.В. Хронический запор: актуальность проблемы и современные возможности лечения. Consilium Medicum. 2017; 19 (8): 116–120. DOI: 10.26442/2075-1753_19.8.116-120
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Kucheriavyi Yu.A., Andreev D.N., Cheremushkin S.V. Chronic constipation: actuality, problems and modern treatment options. Consilium Medicum. 2017; 19 (8): 116–120. DOI: 10.26442/2075-1753_19.8.116-120
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Аннотация
Хронический запор является важнейшей глобальной медико-социальной проблемой, а вопросы рациональной терапии данного состояния – одной из самых актуальных тем в современной гастроэнтерологии. Терапевтические подходы в лечении хронического запора должны характеризоваться стадийной последовательностью. Лечение должно начинаться с модификации образа жизни пациента, увеличения потребления жидкости до 1,5–2 л в сутки, включения в рацион питания пищевых продуктов, содержащих большое количество пищевых волокон, в частности пшеничных отрубей, или использования псиллиума. При неэффективности данных мероприятий целесообразно применение фармакотерапии, в рамках которой приоритет следует отдавать невсасывающимся дисахаридам, в частности представителю последнего поколения – лактитолу (Экспортал®). Данный препарат в рамках лечения хронического запора характеризуется эквивалентной и в ряде случаев большей эффективностью по сравнению с невсасывающимся дисахаридом раннего поколения (лактулоза) и обладает лучшим профилем безопасности (частота побочных явлений в 1,5–2 раза ниже), а также лучшими вкусовыми качествами, что позволяет его рассматривать как терапию 1-й линии при лечении хронического запора.
Ключевые слова: хронический запор, функциональный запор, Римские критерии IV пересмотра, слабительные, невсасывающиеся дисахариды, лактулоза, лактитол.
Ключевые слова: хронический запор, функциональный запор, Римские критерии IV пересмотра, слабительные, невсасывающиеся дисахариды, лактулоза, лактитол.
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Chronic constipation is the greatest global medical social health problem, and rational therapy of this disorder is one of the most topical themes in modern gastroenterology. Therapeutic approaches in the treatment of chronic constipation should be characterized by the stage of sequence. The treatment should started lifestyle changes of the patients, increase of water intake to over 1.5–2 liters per day, include a diet rich in dietary fiber, in particular wheat bran, or the use of psyllium. In case of inefficiency of these activities, it is important to use pharmacotherapy, and the priority should be given to the non-absorbable disaccharides, in particular the next generation drug – lactitol (Exportale®). This drug within the framework of the treatment of chronic constipation is characterized by an equivalent and in some cases more effective, in comparison with first generation non-absorbable disaccharides (lactulose) and has a better safety profile (decrease the frequency of side effects by 1.5–2 times), as well as that drug has the best taste, that allows to consider this drug as first-line therapy in the treatment of chronic constipation.
Key words: chronic constipation, functional constipation, the Rome IV criteria, laxatives, non-absorbable disaccharides, lactulose, lactitol.
Полный текст
Список литературы
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2. Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011; 106 (9): 1582–91.
3. Choung RS, Locke GR 3rd, Schleck CD et al. Cumulative incidence of chronic constipation: a population-based study 1988–2003. Aliment Pharmacol Ther 2007; 26 (11–12): 1521–8.
4. Прилепская С.И., Парфенов А.И., Лазебник Л.Б. Распространенность и факторы риска запоров у взрослого населения Москвы по данным популяционного исследования «МУЗА». Эксперим. и клин. гастроэнтерология. 2011; 3: 68–73. / Prilepskaia S.I., Parfenov A.I., Lazebnik L.B. Rasprostranennost' i faktory riska zaporov u vzroslogo naseleniia Moskvy po dannym populiatsionnogo issledovaniia «MUZA». Eksperim. i klin. gastroenterologiia. 2011; 3: 68–73. [in Russian]
5. Belsey J, Greenfield S, Candy D, Geraint M. Systematic review: impact of constipation on quality of life in adults and children. Aliment Pharmacol Ther 2010; 31: 938–49.
6. Dennison C, Prasad M, Lloyd A et al. The health-related quality of life and economic burden of constipation. Pharmacoeconomics 2005; 23: 461–76.
7. Johanson IF, Kralsteln J. Chronic constipation: a survey of the patient perspective. Aliment Pharmacol Ther 2007; 25: 599–608.
8. Самсонов А.А., Кучерявый Ю.А., Андреев Д.Н. Хронический запор: проблемы терапии. Врач. 2011; 4: 24–9. / Samsonov A.A., Kucheriavyi Iu.A., Andreev D.N. Khronicheskii zapor: problemy terapii. Vrach. 2011; 4: 24–9. [in Russian]
9. Gwee KA, Ghoshal UC, Gonlachanvit S et al. Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool. J Neurogastroenterol Motil 2013; 19 (2): 149–60.
10. Lacy BE, Levenick JM, Crowell M. Chronic constipation: new diagnostic and treatment approaches. Ther Adv Gastroenterol 2012; 5 (4): 233–47.
11. Андреев Д.Н., Заборовский А.В., Трухманов А.С. и др. Эволюция представлений о функциональных заболеваниях желудочно-кишечного тракта в свете Римских критериев IV пересмотра (2016 г.). РЖГГК. 2017; 1: 4–11. / Andreev D.N., Zaborovskii A.V., Trukhmanov A.S. i dr. Evoliutsiia predstavlenii o funktsional'nykh zabolevaniiakh zheludochno-kishechnogo trakta v svete Rimskikh kriteriev IV peresmotra (2016 g.). RZhGGK. 2017; 1: 4–11. [in Russian]
12. Lacy BE, Mearin F, Chang L et al. Bowel Disorders. Gastroenterology 2016; 150: 1393–1407.
13. Черемушкин С., Кучерявый Ю. Доказательная медицина и лечение хронического запора. Врач. 2012; 10: 42–7. / Cheremushkin S., Kucheriavyi Iu. Dokazatel'naia meditsina i lechenie khronicheskogo zapora. Vrach. 2012; 10: 42–7. [in Russian]
14. Маев И.В., Дичева Д.Т., Андреев Д.Н. Новые возможности лечения хронического запора. Врач. 2012; 3: 45–7. / Maev I.V., Dicheva D.T., Andreev D.N. Novye vozmozhnosti lecheniia khronicheskogo zapora. Vrach. 2012; 3: 45–7. [in Russian]
15. Маев И.В., Самсонов А.А., Дичева Д.Т., Андреев Д.Н. Обстипационный синдром. Медицинский вестник МВД. 2012; 4: 42–5. / Maev I.V., Samsonov A.A., Dicheva D.T., Andreev D.N. Obstipatsionnyi sindrom. Meditsinskii vestnik MVD. 2012; 4: 42–5. [in Russian]
16. De Schryver AM, Keulemans YC, Peters HP et al. Effects of regular physical activity on defecation pattern in middle-aged patients complaining of chronic constipation. Scand J Gastroenterol 2005; 40: 422–9.
17. Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol 2003; 98: 1790–6;
18. Ashraf W, Park F, Lof J, Quigley EM. Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation. Aliment Pharmacol Ther 1995; 9: 639–47.
19. Ивашкин В.Т., Маев И.В., Шептулин А.А. и др. Клинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению взрослых пациентов с хроническим запором. Рос. журн. гастроэнтерологии, гепатологии, колопроктологии. 2017; 27 (3): 75–83. / Ivashkin V.T., Maev I.V., Sheptulin A.A. i dr. Klinicheskie rekomendatsii Rossiiskoi gastroenterologicheskoi assotsiatsii po diagnostike i lecheniiu vzroslykh patsientov s khronicheskim zaporom. Ros. zhurn. gastroenterologii, gepatologii, koloproktologii. 2017; 27 (3): 75–83. [in Russian]
20. Маевская Е.А. Хронический запор: тактика ведения на основе научных фактов. Фарматека. 2014; 14: 17–23. / Maevskaia E.A. Khronicheskii zapor: taktika vedeniia na osnove nauchnykh faktov. Farmateka. 2014; 14: 17–23. [in Russian]
21. Маев И.В., Самсонов А.А., Андреев Д.Н. Современный алгоритм ведения пациентов с синдромом хронического запора с позиций внедрения новых фармакологических препаратов. Фарматека. 2012; 13 (246): 37–43. / Maev I.V., Samsonov A.A., Andreev D.N. Sovremennyi algoritm vedeniia patsientov s sindromom khronicheskogo zapora s pozitsii vnedreniia novykh farmakologicheskikh preparatov. Farmateka. 2012; 13 (246): 37–43. [in Russian]
22. Mueller-Lissner S, Kamm MA, Wald A et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol 2010; 105: 897–903.
23. Kamm MA, Mueller-Lissner S, Wald A et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011; 9: 577–83.
24. Маев И.В., Андреев Д.Н., Дичева Д.Т., Гуртовенко И.Ю. Риск длительного применения слабительных препаратов. Врач. 2014; 1: 26–30. / Maev I.V., Andreev D.N., Dicheva D.T., Gurtovenko I.Iu. Risk dlitel'nogo primeneniia slabitel'nykh preparatov. Vrach. 2014; 1: 26–30. [in Russian]
25. Badiali D, Marcheggiano A, Pallone F et al. Melanosis of the rectum in patients with chronic constipation. Dis Colon Rectum 1985; 28: 241–5.
26. Stanghellini V, Vandeplassche L, Kerstens R. Best response distribution of 12-week treatment with prucalopride (RESOLOR) in patients with chronic constipation: combined results of three randomized, double-blind, placebo-controlled phase III trials. Gut 2011; 60 (Suppl. 1): A159–A160.
27. Tack J, Müller-Lissner S. Treatment of chronic constipation: current pharmacologic approaches and future directions. Clin Gastroenterol Hepatol 2009; 7: 502–8.
28. Хронический запор: метод. рекомендации ГБУЗ МКНЦ и ЦНИИГ. М.: Прима Принт, 2016. / Khronicheskii zapor: metod. rekomendatsii GBUZ MKNTs i TsNIIG. M.: Prima Print, 2016. [in Russian]
29. Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev 2010; 7: CD007570.
30. Gordon M, Naidoo K, Akobeng AK, Thomas AG. Cochrane Review: Osmotic and stimulant laxatives for the management of childhoodconstipation (Review). Evid Based Child Health 2013; 8 (1): 57–109.
31. Corazziari E, Badiali D, Habib FI et al. Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation. Dig Dis Sci 1996; 41: 1636–42.
32. Минушкин О.Н. Еще раз о выборе слабительных препаратов при функциональных запорах. Эффективная фармакотерапия. Гастроэнтерология. 2013; 17: 12–8. / Minushkin O.N. Eshche raz o vybore slabitel'nykh preparatov pri funktsional'nykh zaporakh. Effektivnaia farmakoterapiia. Gastroenterologiia. 2013; 17: 12–8. [in Russian]
33. Schiller LR. Review article: the therapy of constipation. Aliment Pharmacol Ther 2001; 15 (6): 749–63.
34. Greer JB, O'Keefe SJ. Microbial induction of immunity, inflammation, and cancer. Front Physiol 2011; 1: 168.
35. Illanes A, Guerrero C, Vera C et al. Lactose-Derived Prebiotics: A Process Perspective. UK, 2016.
36. Wright RA. Lactulose-induced megacolon. Gastrointest Endosc 1988; 34: 489–90.
37. Faruqui AA, Joshi C. Lactitol: a review of its use in the treatment of constipation. Int J Recent Adv Pharm Res 2012; 2 (1): 1–5.
38. Maydeo A. Lactitol or lactulose in the treatment of chronic constipation: result of a systematic. J Indian Med Assoc 2010; 108 (11): 789–92.
39. Chen C, Li L, Wu Z et al. Effects of lactitol on intestinal microflora and plasma endotoxin in patients with chronic viral hepatitis. J Infect 2007; 54 (1): 98–102.
40. Минушкин О.Н., Ардатская М.Д., Елизаветина Г.А. и др. Функциональные запоры: некоторые лечебные подходы. Эффективная фармакотерапия. Гастроэнтерология. 2011; 3: 9–13. / Minushkin O.N., Ardatskaia M.D., Elizavetina G.A. i dr. Funktsional'nye zapory: nekotorye lechebnye podkhody. Effektivnaia farmakoterapiia. Gastroenterologiia. 2011; 3: 9–13. [in Russian]
41. Miller LE, Tennilä J, Ouwehand AC. Efficacy and tolerance of lactitol supplementation for adult constipation: a systematic review and meta-analysis. Clin Exp Gastroenterol 2014; 7: 241–8.
42. Xu Z, Dai J, Shi R et al. A multicenter, randomized, single-blinded, parallel-controlled trial on lactitol in treatment of constipation. Chin J Gastroenterology 2012; 17 (3): 168–72.
43. Doffoel M, Berthel M, Bockel R et al. Comparative study of lactitol and lactulose in the treatment of functional constipation in elderly subjects. Medecine Chirurgie Digestives (Paris) 1990; 19 (4): 257–9.
44. Hammer B, Ravelli GP. Chronic functional constipation: lactitol maintenance dose, a multicentre comparative study with lactulose. Ther Schweiz 1992; 8: 328–35.
45. Heitland W, Mauersberger H. A clinical investigation comparing the laxative effect of lactitol to that of lactulose in a randomised, open, parallel study. Schweiz Rundsch Med Prax 1988; 77 (18): 493–5.
46. Минушкин О.Н., Ардатская М.Д., Воскобойникова И.В., Колхир В.К. Экспортал (Лактитол) – эффективное и безопасное осмотическое слабительное. РЖГГК. 2010; 5S36: 118. / Minushkin O.N., Ardatskaia M.D., Voskoboinikova I.V., Kolkhir V.K. Eksportal (Laktitol) – effektivnoe i bezopasnoe osmoticheskoe slabitel'noe. RZhGGK. 2010; 5S36: 118. [in Russian]
47. Pitzalis G, Deganello F, Mariani P et al. Lactitol in chronic idiopathic constipation in children. Pediatr Med Chir 1995; 17 (3): 223–6.
48. Santhosh KM, Jagadeesh K, Shreenivas PR. Clinical efficacy and safety of lactitol versus lactulose in the treatment of constipation. Int J Institut Pharm Life Sci 2015; 5 (2): 265–71.
49. Cammà C, Fiorello F, Tinè F et al. Lactitol in treatment of chronic hepatic encephalopathy. A meta-analysis. Dig Dis Sci 1993; 38 (5): 916–22.
50. Gluud LL, Vilstrup H, Morgan MY. Nonabsorbable disaccharides for hepatic encephalopathy: A systematic review and meta-analysis. Hepatology 2016; 64 (3): 908–22.
________________________________________________
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22. Mueller-Lissner S, Kamm MA, Wald A et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol 2010; 105: 897–903.
23. Kamm MA, Mueller-Lissner S, Wald A et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011; 9: 577–83.
24. Maev I.V., Andreev D.N., Dicheva D.T., Gurtovenko I.Iu. Risk dlitel'nogo primeneniia slabitel'nykh preparatov. Vrach. 2014; 1: 26–30. [in Russian]
25. Badiali D, Marcheggiano A, Pallone F et al. Melanosis of the rectum in patients with chronic constipation. Dis Colon Rectum 1985; 28: 241–5.
26. Stanghellini V, Vandeplassche L, Kerstens R. Best response distribution of 12-week treatment with prucalopride (RESOLOR) in patients with chronic constipation: combined results of three randomized, double-blind, placebo-controlled phase III trials. Gut 2011; 60 (Suppl. 1): A159–A160.
27. Tack J, Müller-Lissner S. Treatment of chronic constipation: current pharmacologic approaches and future directions. Clin Gastroenterol Hepatol 2009; 7: 502–8.
28. Khronicheskii zapor: metod. rekomendatsii GBUZ MKNTs i TsNIIG. M.: Prima Print, 2016. [in Russian]
29. Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev 2010; 7: CD007570.
30. Gordon M, Naidoo K, Akobeng AK, Thomas AG. Cochrane Review: Osmotic and stimulant laxatives for the management of childhoodconstipation (Review). Evid Based Child Health 2013; 8 (1): 57–109.
31. Corazziari E, Badiali D, Habib FI et al. Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation. Dig Dis Sci 1996; 41: 1636–42.
32. Minushkin O.N. Eshche raz o vybore slabitel'nykh preparatov pri funktsional'nykh zaporakh. Effektivnaia farmakoterapiia. Gastroenterologiia. 2013; 17: 12–8. [in Russian]
33. Schiller LR. Review article: the therapy of constipation. Aliment Pharmacol Ther 2001; 15 (6): 749–63.
34. Greer JB, O'Keefe SJ. Microbial induction of immunity, inflammation, and cancer. Front Physiol 2011; 1: 168.
35. Illanes A, Guerrero C, Vera C et al. Lactose-Derived Prebiotics: A Process Perspective. UK, 2016.
36. Wright RA. Lactulose-induced megacolon. Gastrointest Endosc 1988; 34: 489–90.
37. Faruqui AA, Joshi C. Lactitol: a review of its use in the treatment of constipation. Int J Recent Adv Pharm Res 2012; 2 (1): 1–5.
38. Maydeo A. Lactitol or lactulose in the treatment of chronic constipation: result of a systematic. J Indian Med Assoc 2010; 108 (11): 789–92.
39. Chen C, Li L, Wu Z et al. Effects of lactitol on intestinal microflora and plasma endotoxin in patients with chronic viral hepatitis. J Infect 2007; 54 (1): 98–102.
40. Minushkin O.N., Ardatskaia M.D., Elizavetina G.A. i dr. Funktsional'nye zapory: nekotorye lechebnye podkhody. Effektivnaia farmakoterapiia. Gastroenterologiia. 2011; 3: 9–13. [in Russian]
41. Miller LE, Tennilä J, Ouwehand AC. Efficacy and tolerance of lactitol supplementation for adult constipation: a systematic review and meta-analysis. Clin Exp Gastroenterol 2014; 7: 241–8.
42. Xu Z, Dai J, Shi R et al. A multicenter, randomized, single-blinded, parallel-controlled trial on lactitol in treatment of constipation. Chin J Gastroenterology 2012; 17 (3): 168–72.
43. Doffoel M, Berthel M, Bockel R et al. Comparative study of lactitol and lactulose in the treatment of functional constipation in elderly subjects. Medecine Chirurgie Digestives (Paris) 1990; 19 (4): 257–9.
44. Hammer B, Ravelli GP. Chronic functional constipation: lactitol maintenance dose, a multicentre comparative study with lactulose. Ther Schweiz 1992; 8: 328–35.
45. Heitland W, Mauersberger H. A clinical investigation comparing the laxative effect of lactitol to that of lactulose in a randomised, open, parallel study. Schweiz Rundsch Med Prax 1988; 77 (18): 493–5.
46. Minushkin O.N., Ardatskaia M.D., Voskoboinikova I.V., Kolkhir V.K. Eksportal (Laktitol) – effektivnoe i bezopasnoe osmoticheskoe slabitel'noe. RZhGGK. 2010; 5S36: 118. [in Russian]
47. Pitzalis G, Deganello F, Mariani P et al. Lactitol in chronic idiopathic constipation in children. Pediatr Med Chir 1995; 17 (3): 223–6.
48. Santhosh KM, Jagadeesh K, Shreenivas PR. Clinical efficacy and safety of lactitol versus lactulose in the treatment of constipation. Int J Institut Pharm Life Sci 2015; 5 (2): 265–71.
49. Cammà C, Fiorello F, Tinè F et al. Lactitol in treatment of chronic hepatic encephalopathy. A meta-analysis. Dig Dis Sci 1993; 38 (5): 916–22.
50. Gluud LL, Vilstrup H, Morgan MY. Nonabsorbable disaccharides for hepatic encephalopathy: A systematic review and meta-analysis. Hepatology 2016; 64 (3): 908–22.
Авторы
Ю.А.Кучерявый, Д.Н.Андреев*, С.В.Черемушкин
ФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И.Евдокимова» Минздрава России. 127473, Россия, Москва, ул. Делегатская, д. 20, стр.1
*dna-mit8@mail.ru
ФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И.Евдокимова» Минздрава России. 127473, Россия, Москва, ул. Делегатская, д. 20, стр.1
*dna-mit8@mail.ru
________________________________________________
Yu.A.Kucheriavyi, D.N.Andreev*, S.V.Cheremushkin
A.I.Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of the Russian Federation. 127473, Russian Federation, Moscow, ul. Delegatskaia, d. 20, str. 1
*dna-mit8@mail.ru
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