Фармакотерапия отеков при циррозе печени и хронической сердечной недостаточности: фокус на петлевые диуретики

Кетова Г.Г., Попов А.Ю., Бабич А.Э., Лучинина Е.В. Фармакотерапия отеков при циррозе печени и хронической сердечной недостаточности: фокус на петлевые диуретики. Consilium Medicum. 2018; 20 (1): 79–83. DOI: 10.26442/2075-1753_2018.1.79-83

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Ketova G.G., Popov A.Yu., Babich A.E., Luchinina E.V. Edema pharmacotherapy in patients with hepatic cirrhosis and congestive heart failure: loop diuretics in focus. Consilium Medicum. 2018; 20 (1): 79–83. DOI: 10.26442/2075-1753_2018.1.79-83

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Аннотация

В статье рассмотрены общность и различие патогенеза отечного синдрома при хронической сердечной недостаточности и циррозе печени, точки приложения разных подгрупп диуретиков. В реальной клинической практике недостаточно используются режим ограничения потребления соли и возможности применения спиронолактона, эплеренона и ацетазоламида. Торасемид является более востребованным диуретиком в сравнении с фуросемидом в связи с лучшим фармакодинамическим профилем и уровнем безопасности. Торасемид – это лекарственное средство с антиальдостероновым и антигипертензивным свойствами, обладающее дозозависимым диуретическим эффектом. В дозировках 2,5–5 мг оказывает преимущественно антигипертензивное и антиальдостеровое действие со слабым натрийуретическим эффектом, что позволяет использовать торасемид для ежедневной постоянной терапии артериальной гипертензии. В средних дозах 5–20 мг наиболее часто применяется для лечения отечного синдрома как в качестве монотерапии, так и в комбинации с другими диуретическими препаратами за исключением петлевых диуретиков. Антиальдостероновый механизм, в основе которого лежит способность торасемида блокировать альдостероновые рецепторы в почках, сердце и снижать секрецию альдостерона надпочечниками, обеспечивает замедление процессов ремоделирования сердца при хронической сердечной недостаточности и позитивные эффекты для лечения отеков разного генеза.

Ключевые слова: отеки, цирроз печени, хроническая сердечная недостаточность, артериальная гипертензия, петлевые диуретики, фуросемид, торасемид.

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The article covers similarities and differences of edema syndrome pathogenesis in congestive heart failure and hepatic cirrhosis as well as sites of action of different diuretics types. The regimen of salt restriction and such medications as spironolactone, eplerenone and acetazolamide are not widely used in everyday clinical practice. Compared with furosemide, torasemide is a more popular diuretic because of better pharmacodynamics profile and safety. Torasemide is a pharmacologic agent with anti-aldosterone and antihypertensive effects. It also has dose-related diuretic effect. When used in dosage of 2.5–5 mg it predominantly has antihypertensive and anti-aldosterone effects with weak natriuretic action that allows its use in everyday hypertension therapy. In medium dosage of 5–20 mg it is more often used in edema syndrome treatment whether in monotherapy or in combination with other diuretics except for loop diuretics. The anti-aldosterone mechanism is based on torasemide ability to block aldosterone receptors in kidneys and heart and lower aldosteron secretion in adrenal glands. It allows to slow down remodeling processes of heart muscle in patients with congestive heart failure and explains positive effects in edema of different genesis management.

Key words: edema, hepatic cirrhosis, congestive heart failure, hypertension, loop diuretics, furosemide, torasemide.

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14. Ponomareva A.I., Kompaniets O.G., Averin E.E. Novye vozmozhnosti farmakoterapii arterial'noi gipertenzii. RMZh. Kardiologiya. 2012; 25 (20): 1–6. [in Russian]

15. Ponomareva A.I., Ketova G.G., Kompaniets O.G. Clinical-pharmacological priorities in the election of blockators of the renin-angiotenzine system and diuretics in patients with uncompleted hypertension. Systemic Hypertension. 2017; 14 (2): 75–9. DOI: 10.26442/2075-082X_14.2.75-79 [in Russian]

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20. Domanski M, Norman J, Pitt B et al. Diuretic use, progressive heart failure, and death in patients in the Studies of Left Ventricular Dysfunction (SOLVD). J Am Coll Cardiol 2003; 42: 705–8.

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23. Cosín J, Díez J. TORIC investigators. Torasemide in chronic heart failure: results of the TORIC study. Eur J Heart Fail 2002; 4: 507–13.

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29. Lopez B, Gonzalez A, Hermida N et al. Myocardial fibrosis in chronic kidney disease: potential benefits of torasemide. Kidney Int 2008; 111: 19–23.

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