Нарушение функции печени как фактор риска развития нежелательных реакций
Нарушение функции печени как фактор риска развития нежелательных реакций
Остроумова О.Д., Переверзев А.П. Нарушение функции печени как фактор риска развития нежелательных реакций. Consilium Medicum. 2021;23(12):939–948. DOI:10.26442/20751753.2021.12.201234
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Ostroumova OD, Pereverzev AP. Hepatic impairment as a risk factor of adverse drug reactions. Consilium Medicum. 2021;23(12):939–948. DOI:10.26442/20751753.2021.12.201234
Нарушение функции печени как фактор риска развития нежелательных реакций
Остроумова О.Д., Переверзев А.П. Нарушение функции печени как фактор риска развития нежелательных реакций. Consilium Medicum. 2021;23(12):939–948. DOI:10.26442/20751753.2021.12.201234
________________________________________________
Ostroumova OD, Pereverzev AP. Hepatic impairment as a risk factor of adverse drug reactions. Consilium Medicum. 2021;23(12):939–948. DOI:10.26442/20751753.2021.12.201234
Нарушение функции печени – частое явление в клинической практике. Оно может протекать как бессимптомно, длительно, так и в форме острой печеночной недостаточности и фульминантного гепатита. Нарушение функции печени – полиэтиологичный синдром. Так, по данным эпидемиологического исследования, проведенного в США в период с 1998 по 2008 г., основными причинами нарушения функции печени были: передозировка парацетамола (46%); идиопатическое нарушение функции печени (14%); лекарственные средства (ЛС), кроме парацетамола (11%); вирусный гепатит В (7%), другие инфекционные и неинфекционные заболевания, протекающие с поражением печени, кроме вирусных гепатитов (7%); аутоиммунный гепатит (5%); ишемический гепатит [синонимы: гипоксический гепатит, инфаркт печени (4%)]; вирусный гепатит А (3%) и болезнь Вильсона (2%). Изменение функции печени оказывает прямое влияние на фармакокинетику и фармакодинамику ЛС. Печень играет важную роль в фармакокинетике большинства ЛС. При печеночной недостаточности не только происходит снижение клиренса и элиминации ЛС, но также может нарушаться связывание ЛС с белками плазмы крови, вследствие чего изменяются процессы распределения и выведения. Портосистемное шунтирование, которое часто применяется для лечения портальной гипертензии у пациентов с циррозом печени, может существенно снизить пресистемную элиминацию ЛС, тем самым увеличивая их абсорбцию. Также печень является основным органом метаболизма ЛС, а нарушение ее функции изменяет активность различных ферментов цитохрома Р450. Более того, у пациентов с циррозом печени часто встречается сопутствующее нарушение функции почек, что также требует корректировки дозы ЛС, выводимых с помощью почечной экскреции. И наконец, у пациентов с тяжелым нарушением функции печени (например, циррозом) отмечаются изменения фармакологических эффектов ЛС, например снижение терапевтического эффекта β-адреноблокаторов, диуретиков, опиатов и др. Учет изменений фармакокинетики и фармакодинамики ЛС, которые могут иметь место у пациентов с нарушением функции печени, будет способствовать повышению качества жизни, оказания медицинской помощи и снижать риски развития нежелательных реакций у пациентов с заболеваниями печени.
Ключевые слова: лекарственные средства, безопасность, нежелательные лекарственные реакции, лекарственно-индуцированные заболевания, нарушение функции печени
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There are a lot of clinical variants of hepatic impairment ranging from asymptomatic increase in transaminases to acute liver failure and fulminant hepatitis. Hepatic impairment is a polietiologic syndrome. According to the epidemiological study conducted in the United States (1998–2008), the main causes of hepatic impairment were paracetamol overdose (46%), idiopathic liver dysfunction (14%), other drugs (excluding paracetamol, 11%), viral hepatitis B (7%), other infectious and non-infectious diseases with liver damage (except for viral hepatitis) – 7%, autoimmune hepatitis (5%), ischemic hepatitis (syn. hypoxic hepatitis, liver infarction) – 4%, viral hepatitis A (3%) and Wilson's disease (2%). Hepatic impairment have a direct impact on the pharmacokinetics and pharmacodynamics of drugs decreasing clearance, elimination and excretion of drugs. Also Transjugular intrahepatic porto-systemic shunts, which are often used to treat portal hypertension in patients with liver cirrhosis, can significantly reduce the presystemic elimination of drugs, thereby increasing their absorption. Moreover, in patients with liver cirrhosis, concomitant renal dysfunction also requires an adjustment of the dose of drugs. Correction of pharmacotherapy in accordance to pharmacokinetic and pharmacodynamic changes of drugs ingested by patients with impaired liver function will improve the quality of medical care and reduce the risks of adverse drug reactions.
Keywords: medicines, safety, adverse drug reactions, drug-induced diseases, hepatic impairment
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1. Lee WM, Squires RH Jr, Nyberg SL, et al. Acute liver failure: Summary of a workshop. Hepatology. 2008;47(4):1401-15. DOI:10.1002/hep.22177
2. Ichai P, Faria L, Saliba F, et al. Improvement of survival in fulminant hepatitis in the recent years. Hepatology. 2006;44(Suppl. 4):371A.
3. Brandsaeter B, Höckerstedt K, Friman S, et al. Fulminant hepatic failure: outcome after listing for highly urgent liver transplantation – 12 years experience in the nordic countries. Liver Transpl. 2002;8(11):1055-62. DOI:10.1053/jlts.2002.35556
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Авторы
О.Д. Остроумова1,2, А.П. Переверзев*1
1 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*acchirurg@mail.ru
________________________________________________
Olga D. Ostroumova1,2, Anton P. Pereverzev*1
1 Russian Medical Academy of Continuous Professional Education, Moscow, Russia;
2 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*acchirurg@mail.ru