Данный обзор посвящен проблеме лекарственно-индуцированной артериальной гипертонии (АГ). В нем обобщены литературные данные о лекарственных средствах и веществах, которые могут повышать артериальное давление, рассматриваются механизмы их гипертензивного действия. Многие классы лекарственных средств, такие как стероиды, нестероидные противовоспалительные препараты, симпатомиметики, иммунодепрессанты, оральные контрацептивы, антидепрессанты, эритропоэтин и другие, могут вызывать лабильное или стойкое повышение артериального давления, стать причиной неконтролируемой АГ, уменьшать эффективность антигипертензивных препаратов. Развитие лекарственно-индуцированной АГ реализуется посредством ряда патофизиологических механизмов: задержка натрия c последующим увеличением объема циркулирующей крови, активация симпатической нервной системы, прямое воздействие на гладкую мускулатуру артериол, существуют и другие, не до конца изученные механизмы. Лекарственно-индуцированная АГ может также являться результатом фармакокинетического или фармакодинамического взаимодействия лекарственных средств. Подозревать наличие лекарственно-индуцированной АГ, в первую очередь, следует у лиц с впервые диагностированной АГ, а также у пациентов, ранее имевших хорошо контролируемую АГ (стабильные целевые цифры артериального давления – АД) при возникновении у них эпизодов необъяснимого повышения АД без четкой взаимосвязи с физической или психоэмоциональной нагрузкой. Очень важен правильно собранный анамнез с фокусом на тщательную оценку принимаемых пациентом лекарственных средств, особенно вновь назначенных, а также купленных в аптеке самостоятельно, в том числе безрецептурных, это позволит избежать лишних и/или дорогостоящих исследований и ненужных назначений дополнительных антигипертензивных препаратов. В статье приведены меры по профилактике и коррекции лекарственно-индуцированной АГ. Назначение врачом новых лекарственных средств пациентам, получающим антигипертензивную терапию, в обязательном порядке должно учитывать их влияние на риск развития лекарственно-индуцированной АГ. Назначения препаратов, вызывающих повышение АД, следует либо избегать, либо, в том случае, если альтернативные схемы лечения невозможны, обязателен строгий контроль уровня АД у пациента (включая метод домашнего мониторирования АД) и, при необходимости, коррекция проводимой антигипертензивной терапии. При отмене лекарственного средства, вызывающего лекарственно-индуцированную АГ, АД возвращается к исходным значением, что является доказательством ятрогенной причины АГ.
This review is devoted to the problem of drug-induced hypertension (H). It summarizes the literature data on drugs and substances that can increase blood pressure, discusses the mechanisms of their hypertensive action. Many classes of drugs such as steroids, nonsteroidal anti-inflammatory drugs, sympathomimetics, immunosuppressants, oral contraceptives, antidepressants, erythropoietin, etc. can cause episodic or persistent increase in blood pressure, cause uncontrolled hypertension, reduce the effectiveness of antihypertensive drugs. The development of drug-induced hypertension is realized through a number of pathophysiological mechanisms: sodium retention with subsequent increase in the volume of circulating blood, activation of the sympathetic nervous system, direct effect on the smooth muscles of arterioles, there are other, not fully studied mechanisms. Drug-induced H may also be the result of pharmacokinetic or pharmacodynamic drug interactions. To suspect the presence of drug-induced hypertension, in the first place, should be in persons with newly diagnosed hypertension, as well as in patients who previously had a well-controlled hypertension (stable target blood pressure – BP levels) when they have episodes of unexplained increase in BP without a clear relationship with physical or psycho-emotional stress. It is very important to have a properly collected history with a focus on a thorough assessment of the medicines taken by the patient, especially newly prescribed, as well as those purchased at the pharmacy independently, including over-the-counter, this will avoid unnecessary and/or expensive studies and unnecessary prescriptions of additional antihypertensive drugs. The article presents these measures for the prevention and correction of drug-induced H. The appointment of new drugs by a doctor to patients receiving antihypertensive therapy should necessarily take into account their impact on the risk of drug-induced hypertension. Prescribing drugs that cause an increase in BP levels should either be avoided or, if alternative treatment regimens are not possible, strict control of the patient's BP level (including the method of home monitoring of BP) and, if necessary, the correction of antihypertensive therapy. When canceling a drug that causes drug-induced hypertension, BP returns to its original level, which is proof of the iatrogenic cause of hypertension.
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1. Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39 (33): 3021–104. DOI: 10.1093/eurheartj/ehy339
2. Diaconu CC, Dediu GN, Lancu MA. Drug-induced arterial hypertension – a frequently ignored cause of secondary hypertension: a review. Acta Cardiol 2018; 1: 1–7. DOI: 10.1080/00015385.2017.1421445
3. Gyamlani G, Geraci SA. Secondary Hypertension due to Drugs and Toxins. South Med J 2007; 100 (7): 692–9; quiz 700, 708. DOI: 10.1097/SMJ.0b013e318063c3e8
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Авторы
Остроумова Ольга Дмитриевна – д-р мед. наук, проф., проф. каф. факультетской терапии и профболезней ФГБОУ ВО «МГМСУ им. А.И. Евдокимова», зав. лаб. клин. фармакологии и фармакотерапии ФГБОУ ВО «РНИМУ им. Н.И. Пирогова» –
ОСП «Российский геронтологический научно-клинический центр».
E-mail: ostroumova.olga@mail.ru; ORCID: https://orcid.org/0000-0002-0795-8225
Куликова Мария Игоревна – студентка 6-го курса ФГБОУ ВО «МГМСУ им. А.И. Евдокимова». E-mail: mariakulikova123@yandex.ru
________________________________________________
Olga D. Ostroumova – D. Sci. (Med.), Full Prof., Prof. A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Pirogov Russian National Research Medical University. E-mail: ostroumova.olga@mail.ru; ORCID: https://orcid.org/0000-0002-0795-8225
Mariia I. Kulikova – Student, A.I. Yevdokimov Moscow State University of Medicine and Dentistry. E-mail: mariakulikova123@yandex.ru