Нестероидные противовоспалительные препараты (НПВП) являются одними из наиболее часто используемых лекарств в мире, при этом частота их побочных эффектов очень высока. В первую очередь, это НПВП-гастропатии, но в долгосрочной перспективе у 50–70% пациентов НПВП вызывают повреждение тонкой кишки (НПВП-энтеропатия), иногда с серьезными последствиями. До настоящего времени не предложено ни одного лекарства с доказанной эффективностью для предотвращения данного побочного эффекта. По-видимому, это объясняется не до конца выясненным механизмом его патогенеза. Наиболее перспективной представляется гипотеза участия отдельных представителей микрофлоры в развитии энтеропатии. Поэтому модулирование кишечной флоры с помощью пробиотиков может стать базисной терапевтической стратегией для профилактики и лечения такого повреждения.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used drugs in the world, and their side effects are very high. First of all, these are NSAID gastropathy, but in the long term, 50–70% of NSAIDs cause damage to the small intestine (NSAID enteropathy), sometimes with serious consequences. To date, no drugs have been proposed with proven effectiveness to prevent this side effect. Apparently, this is not due to the fully clarified mechanism of pathogenesis. The most promising is the hypothesis of the participation of individual representatives of microflora in the development of enteropathy. Therefore, modulating the intestinal flora with the help of probiotics can be the basic therapeutic strategy for the prevention and treatment of such damage.
1. Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects ofnon-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2010;24:121-32. doi: 10.1016/j.bpg.2009.11.005
2. Ливзан М.А., Лялюкова Е.А., Костенко М.Б. Нестероидные противовоспалительные препараты: оценка рисков и пути повышения безопасности терапии. Лечащий врач. 2016;(5):78-82 [Livzan MA, Lyalyukova EA, Kostenko MB. Non-steroid anti-inflammatory preparations: risk assessment and ways of the therapy safety enhancement. Lechashchiy Vrach. 2016;(5):78-82 (In Russ.)].
3. Шостак Н.А., Рябкова А.А., Савельев В.С., Малярова Л.Н. Желудочно-кишечное кровотечение как осложнение гастропатий, связанных с приемом нестероидных противовоспалительных препаратов. Терапевтический архив. 2003;75(5):70-4 [Shostak NA, Ryabkova AA, Savelyev VS, Malyarova LP. Gastrointestinal hemorrhages as complications of gastropathies associated with intake of nonsteroid anti-inflammatory drugs. Therapeutic Archive. 2003;75(5):70-4 (In Russ.)].
4. Montalto M, Gallo A, Gasbarrini A, Landolfi R. NSAID enteropathy: could probiotics prevent it? J Gastroenterol. 2013;48:689-97. doi: 10.1007/s00535-012-0648-2
5. Maiden L. Capsule endoscopic diagnosis of nonsteroidal anti-inflammatory drug-induced enteropathy. J Gastroenterol. 2009;19:64-71. doi: 10.1007/s00535-008-2248-8
6. Свистунов А.А., Осадчук М.А., Киреева Н.В., Хударова А.А., Ачкасов Е.Е. НПВП-индуцированная энтеропатия: современное состояние проблемы. Терапевтический архив. 2018;90(8):95-100 [Svistunov AA, Osadchuk MA, Kireeva NV, Hudarova AA, Achkasov EE. NSAID-induced enteropathy: the current state of the problem. Therapeutic Archive. 2018;90(8):95-100 (In Russ.)]. doi: 10.26442/terarkh201890895-100
7. Graham DY, Opekun AR, Willingham FF, Qureshi WA. Visiblesmall-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol. 2005;3:55-9.
8. Zeino Z, Sisson G, Bjarnason I. Adverse effects of drugs on small intestine and colon. Best Pract Res Clin Gastroenterol. 2010;24:133-41. doi: 10.1016/j.bpg.2010.02.008
9. Gallo A, Passaro G, Gasbarrini A, Landolfi R, Montalto M. Modulation of microbiota as treatment for intestinal inflammatory disorders: An uptodate. World J Gastroenterol. 2016;22(32):7186-202. doi: 10.3748/wjg.v22.i32.7186
10. Shimada S, Tanigawa T, Watanabe T, Nakata A, Sugimura N, Itani S, et al. Involvement of gliadin, a component of wheat gluten, in increased intestinal permeability leading to non-steroidal anti-inflammatory drug-induced small-intestinal damage. PLoS One. 2019;14(2):e0211436. doi: 10.1371/journal.pone.0211436. eCollection 2019.
11. Otani K, Tanigawa T, Watanabe T, Shimada S, Nadatani Y, Tanaka F, et al. Microbiota plays a key role in non-steroidal anti-inflammatory drug-induced small intestinal damage. Digestion. 2017;95:22-8. doi: 10.1159/000452356
12. Парфенов А.И., Белостоцкий Н.И., Хомерики С.Г., Ахмадуллина О.В., Быкова С.В. Сабельникова Е.А., Дбар С.Р. Ребамипид повышает активность дисахаридаз у больных энтеропатией с нарушением мембранного пищеварения. Пилотное исследование. Терапевтический архив. 2019;91(2):25-31 [Parfenov AI, Belostotsky NI, Khomeriki SG, Akhmadullina OV, Bykova SV, Sabelnikova EA, Dbar SR. Rebamipide increases the disaccharidases activity in patients with enteropathy with impaired membrane digestion. Pilot study. Therapeutic Archive. 2019;91(2):25-31 (In Russ.)]. doi: 10.26442/00403660.2019.02.000123
13. Robert A, Asano T. Resistance of germfree rats to indomethacin-induced intestinal lesions. Prostaglandins. 1977;14(2):333-41.
14. Uejima M, Kinouchi T, Kataoka K, Hiraoka I, Ohnishi Y. Role of intestinal bacteria in ileal ulcer formation in rats treated with a nonsteroidal antiinflammatory drug. Microbiol Immunol. 1996;40:553-60.
15. Konaka A, Kato S, Tanaka A, Kunikata T, Korolkiewicz R, Takeuchi K. Roles of enterobacteria, nitric oxide and neutrophil in pathogenesis of indomethacin-induced small intestinal lesions in rats. Pharmacol Res. 1999;40(6):517-24. doi: 10.1006/phrs.1999.0550
16. Cani PD, Bibiloni R, Knauf C, Waget A, Neyrinck AM, Delzenne NM, Burcelin R: Changes in gut microbiota control metabolic endotoxemia-induced inflammation in high-fat diet-induced obesity and diabetes in mice. Diabetes. 2008;57(6):1470-81. doi: 10,2337/DB07-1403
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18. Henao-Mejia J, Elinav E, Jin C, Hao L, Mehal WZ, Strowig T, et al. Inflammasome-mediated dysbiosis regulates progression of NAFLD and obesity. Nature. 2012;482(7384):179-85. doi: 10.1038/nature10809
19. Donaldson RM Jr. Normal bacterial populations of the intestine and their relation to intestinal function. N Engl J Med. 1964;270:1050-6. doi: 10.1056/NEJM196405142702007
20. Muraki M, Fujiwara Y, Machida H, Okazaki H, Sogawa M, Yamagami H, et al. Role of small intestinal bacterial overgrowth in severe small intestinal damage in chronic non-steroidal anti-inflammatory drug users. Scand J Gastroenterol. 2014;49(3):267-73. doi: 10.3109/00365521.2014.880182
21. Wallace JL, Syer S, Denou E, de Palma G, Vong L, McKnight W, et al. Proton pump inhibitors exacerbate NSAID-induced small intestinal injury by inducing dysbiosis. Gastroenterology. 2011;141(4):1314-22, e1-5. doi: 10.1053/j.gastro.2011.06.075
22. Watanabe T, Tanigawa T, Nadatani Y, Nagami Y, Sugimori S, Okazaki H, et al. Risk factors for severe nonsteroidal anti-inflammatory drug-induced small intestinal damage. Dig Liver Dis. 2013;45(5):390-5. doi: 10.1016/j.dld.2012.12.005
23. Endo H, Sakai E, Taniguchi L, Kessoku T, Komiya Y, Ezuka A, et al. Risk factors for small-bowel mucosal breaks in chronic low-dose aspirin users: data from a prospective multicenter capsule endoscopy registry. Gastrointest Endosc. 2014;80(5):826-34. doi: 10.1016/j.gie.2014.03.024
24. Lo WK, Chan WW. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis. Clin Gastroenterol Hepatol. 2013;11(5):483-90. doi: 10.1016/j.cgh.2012.12.011
25. Higuchi K, Umegaki E, Watanabe T, Yoda Y, Morita E, Murano M, et al. Present status and strategy of NSAIDs-induced smallbowel injury. J Gastroenterol. 2009;44(9):879-88. doi: 10.1007/s00535-009-0102-2
26. Somasundaram S, Hayllar H, Rafi S, Wrigglesworth JM, Macpherson AJ, Bjarnason I. The biochemical basis of non-steroidalanti-inflammatory drug-induced damage to the gastrointestinaltract: a review and a hypothesis. Scand J Gastroenterol. 1995;30(4):289-99. doi: 10.3109/00365529509093280
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28. Watanabe T, Tanigawa T, Nadatani Y, Otani K, Machida H, Okazaki H, et al. Mitochondrial disorders in NSAIDs-induced small bowel injury. J Clin Biochem Nutr. 2011;48(2):117-21.
29. Wallace JL. Mechanisms, prevention and clinical implications of nonsteroidal anti-inflammatory drug-enteropathy. World J Gastroenterol. 2013;19(12):1861-76. doi: 10.3748/wjg.v19.i12.1861
30. Adebayo D, Bjarnason I. Is non-steroidal anti-inflammatory drug (NSAID) enteropathy clinically more important than NSAID gastropathy? Postgrad Med J. 2006;82(965):186-91. doi: 10.1136/pgmj.2005.039586
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1. Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects ofnon-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2010;24:121-32. doi: 10.1016/j.bpg.2009.11.005
2. Livzan MA, Lyalyukova EA, Kostenko MB. Non-steroid anti-inflammatory preparations: risk assessment and ways of the therapy safety enhancement. Lechashchiy Vrach. 2016;(5):78-82 (In Russ.)
3. Shostak NA, Ryabkova AA, Savelyev VS, Malyarova LP. Gastrointestinal hemorrhages as complications of gastropathies associated with intake of nonsteroid anti-inflammatory drugs. Therapeutic Archive. 2003;75(5):70-4 (In Russ.)
4. Montalto M, Gallo A, Gasbarrini A, Landolfi R. NSAID enteropathy: could probiotics prevent it? J Gastroenterol. 2013;48:689-97. doi: 10.1007/s00535-012-0648-2
5. Maiden L. Capsule endoscopic diagnosis of nonsteroidal anti-inflammatory drug-induced enteropathy. J Gastroenterol. 2009;19:64-71. doi: 10.1007/s00535-008-2248-8
6. Svistunov AA, Osadchuk MA, Kireeva NV, Hudarova AA, Achkasov EE. NSAID-induced enteropathy: the current state of the problem. Therapeutic Archive. 2018;90(8):95-100 (In Russ.) doi: 10.26442/terarkh201890895-100
7. Graham DY, Opekun AR, Willingham FF, Qureshi WA. Visiblesmall-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol. 2005;3:55-9.
8. Zeino Z, Sisson G, Bjarnason I. Adverse effects of drugs on small intestine and colon. Best Pract Res Clin Gastroenterol. 2010;24:133-41. doi: 10.1016/j.bpg.2010.02.008
9. Gallo A, Passaro G, Gasbarrini A, Landolfi R, Montalto M. Modulation of microbiota as treatment for intestinal inflammatory disorders: An uptodate. World J Gastroenterol. 2016;22(32):7186-202. doi: 10.3748/wjg.v22.i32.7186
10. Shimada S, Tanigawa T, Watanabe T, Nakata A, Sugimura N, Itani S, et al. Involvement of gliadin, a component of wheat gluten, in increased intestinal permeability leading to non-steroidal anti-inflammatory drug-induced small-intestinal damage. PLoS One. 2019;14(2):e0211436. doi: 10.1371/journal.pone.0211436. eCollection 2019.
11. Otani K, Tanigawa T, Watanabe T, Shimada S, Nadatani Y, Tanaka F, et al. Microbiota plays a key role in non-steroidal anti-inflammatory drug-induced small intestinal damage. Digestion. 2017;95:22-8. doi: 10.1159/000452356
12. Parfenov AI, Belostotsky NI, Khomeriki SG, Akhmadullina OV, Bykova SV, Sabelnikova EA, Dbar SR. Rebamipide increases the disaccharidases activity in patients with enteropathy with impaired membrane digestion. Pilot study. Therapeutic Archive. 2019;91(2):25-31 (In Russ.) doi: 10.26442/00403660.2019.02.000123
13. Robert A, Asano T. Resistance of germfree rats to indomethacin-induced intestinal lesions. Prostaglandins. 1977;14(2):333-41.
14. Uejima M, Kinouchi T, Kataoka K, Hiraoka I, Ohnishi Y. Role of intestinal bacteria in ileal ulcer formation in rats treated with a nonsteroidal antiinflammatory drug. Microbiol Immunol. 1996;40:553-60.
15. Konaka A, Kato S, Tanaka A, Kunikata T, Korolkiewicz R, Takeuchi K. Roles of enterobacteria, nitric oxide and neutrophil in pathogenesis of indomethacin-induced small intestinal lesions in rats. Pharmacol Res. 1999;40(6):517-24. doi: 10.1006/phrs.1999.0550
16. Cani PD, Bibiloni R, Knauf C, Waget A, Neyrinck AM, Delzenne NM, Burcelin R: Changes in gut microbiota control metabolic endotoxemia-induced inflammation in high-fat diet-induced obesity and diabetes in mice. Diabetes. 2008;57(6):1470-81. doi: 10,2337/DB07-1403
17. Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Microbial ecology: human gut microbes associated with obesity. Nature. 2006;444(7122):1022-3. doi: 10.1038/4441022a
18. Henao-Mejia J, Elinav E, Jin C, Hao L, Mehal WZ, Strowig T, et al. Inflammasome-mediated dysbiosis regulates progression of NAFLD and obesity. Nature. 2012;482(7384):179-85. doi: 10.1038/nature10809
19. Donaldson RM Jr. Normal bacterial populations of the intestine and their relation to intestinal function. N Engl J Med. 1964;270:1050-6. doi: 10.1056/NEJM196405142702007
20. Muraki M, Fujiwara Y, Machida H, Okazaki H, Sogawa M, Yamagami H, et al. Role of small intestinal bacterial overgrowth in severe small intestinal damage in chronic non-steroidal anti-inflammatory drug users. Scand J Gastroenterol. 2014;49(3):267-73. doi: 10.3109/00365521.2014.880182
21. Wallace JL, Syer S, Denou E, de Palma G, Vong L, McKnight W, et al. Proton pump inhibitors exacerbate NSAID-induced small intestinal injury by inducing dysbiosis. Gastroenterology. 2011;141(4):1314-22, e1-5. doi: 10.1053/j.gastro.2011.06.075
22. Watanabe T, Tanigawa T, Nadatani Y, Nagami Y, Sugimori S, Okazaki H, et al. Risk factors for severe nonsteroidal anti-inflammatory drug-induced small intestinal damage. Dig Liver Dis. 2013;45(5):390-5. doi: 10.1016/j.dld.2012.12.005
23. Endo H, Sakai E, Taniguchi L, Kessoku T, Komiya Y, Ezuka A, et al. Risk factors for small-bowel mucosal breaks in chronic low-dose aspirin users: data from a prospective multicenter capsule endoscopy registry. Gastrointest Endosc. 2014;80(5):826-34. doi: 10.1016/j.gie.2014.03.024
24. Lo WK, Chan WW. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis. Clin Gastroenterol Hepatol. 2013;11(5):483-90. doi: 10.1016/j.cgh.2012.12.011
25. Higuchi K, Umegaki E, Watanabe T, Yoda Y, Morita E, Murano M, et al. Present status and strategy of NSAIDs-induced smallbowel injury. J Gastroenterol. 2009;44(9):879-88. doi: 10.1007/s00535-009-0102-2
26. Somasundaram S, Hayllar H, Rafi S, Wrigglesworth JM, Macpherson AJ, Bjarnason I. The biochemical basis of non-steroidalanti-inflammatory drug-induced damage to the gastrointestinaltract: a review and a hypothesis. Scand J Gastroenterol. 1995;30(4):289-99. doi: 10.3109/00365529509093280
27. Petruzzelli M, Vacca M, Moschetta A, CinziaSasso R, PalascianoG, van Erpecum KJ, et al. Intestinal mucosal damage causedby non-steroidal anti-inflammatory drugs: role of bile salts. ClinBiochem. 2007;40(8):503-10. doi: 10.1016/j.clinbiochem.2007.01.015
28. Watanabe T, Tanigawa T, Nadatani Y, Otani K, Machida H, Okazaki H, et al. Mitochondrial disorders in NSAIDs-induced small bowel injury. J Clin Biochem Nutr. 2011;48(2):117-21.
29. Wallace JL. Mechanisms, prevention and clinical implications of nonsteroidal anti-inflammatory drug-enteropathy. World J Gastroenterol. 2013;19(12):1861-76. doi: 10.3748/wjg.v19.i12.1861
30. Adebayo D, Bjarnason I. Is non-steroidal anti-inflammatory drug (NSAID) enteropathy clinically more important than NSAID gastropathy? Postgrad Med J. 2006;82(965):186-91. doi: 10.1136/pgmj.2005.039586
31. Livzan MA, Osipenko MF, Lyalyukova EA. Affection of digestion organs in patients taking non steroid antipyretic preparations: the factors of risk, strategy of conducting the patients. Lechashchiy Vrach. 2013;(7):27-34 (In Russ.) Available at: https://www.lvrach.ru/2013/07/15435749/
32. Vakhrushev YaM, Zagrebina EA. Enteropathy induced by nonsteroid anti-inflammatory drugs: pathogenesis, diagnosis, treatment. Terapeutic Archive. 2012;84(5):74-9 (In Russ.)
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Авторы
Е.Н. Карева1,2
1 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
2 ФГБОУ ВО «Российский научно-исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия
________________________________________________
E.N. Kareva1,2
1 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russiа;
2 Pirogov Russian National Research Medical University, Moscow, Russia