Оценка эффективности дифференцированной терапии неалкогольной жировой болезни печени
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Vakhrushev Ya.M., Suchkova E.V., Lukashevich А.Р. Evaluation of the effectiveness of differentiated therapy of non-alcoholic fatty liver disease. Therapeutic Archive. 2020; 92 (2): 29–33. DOI: 10.26442/00403660.2020.02.000400
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Материалы и методы. В исследование включены 168 пациентов с НАЖБП (60 мужчин и 108 женщин, возраст пациентов – 30–70 лет). Для лечения в зависимости от особенностей течения заболевания сформированы три группы пациентов. В первую группу вошли больные (n=47) со стеатозом печени с повышенным содержанием липидов в крови и увеличенным коэффициентом атерогенности, они получали терапию урсодезоксихолевой кислотой (УДХК) в сочетании с аторвастатином. Вторую группу составили больные (n=65) со стеатозом печени с повышенным уровнем гликемии, инсулина и инсулинорезистентностью, им назначалась терапия УДХК и метформином. Пациенты третьей группы (n=56) со стеатогепатитом с сопутствующим избыточным бактериальным ростом получали терапию эссенциале форте Н в сочетании с риофлорой иммуно. Оценивали в динамике лечения клинические данные, биохимические показатели крови, уровень инсулина и HOMA-IR, состояние микробиоты кишечника, а также регрессию стеатоза печени и стеатогепатита.
Результаты. В ходе лечения отмечено уменьшение клинических проявлений заболевания во всех наблюдаемых группах пациентов, улучшение показателей липидного обмена и показателей функционального состояния печени, восстановление кишечной микробиоты. На основании ультразвукового исследования, эластографии и фибротеста установлено обратное развитие стеатоза печени у 20% и стеатогепатита – у 66,6% пациентов.
Заключение. Полученные данные указывают на целесообразность дифференцированного лечения пациентов с НАЖБП в зависимости от особенностей ее течения и стадии.
Ключевые слова: неалкогольная жировая болезнь печени, ранняя диагностика, дифференцированная терапия, избыточный бактериальный рост.
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Aim. Study of the effectiveness of differentiated therapy of non-alcoholic fatty liver disease taking into account the clinical and pathogenetic features of its course.
Materials and methods. 168 patients with non-alcoholic fatty liver disease were examined, 108 of them were women and 60 men aged from 30 to 70 years. For treatment, depending on the characteristics of the course of the disease, 3 groups of patients were formed. The first group included patients (n=47) with liver steatosis with a high content of lipids in the blood and an increased atherogenic coefficient; they received therapy with ursodeoxycholic acid with atorvastatin. The second group consisted of patients (n=65) with liver steatosis with an increased level of glycemia, insulin and insulin resistance, they were prescribed therapy with ursodeoxycholic acid and metformin. Patients of the third group (n=56) with steatohepatitis with concomitant bacterial overgrowth received еssentiale forte H therapy with rioflora immuno. Clinical data, blood biochemical parameters, insulin and HOMA-IR levels, intestinal microbiota status, as well as regression of liver steatosis and steatohepatitis were evaluated in the dynamics of treatment.
Results. In the dynamics of treatment, there was a decrease in the clinical manifestations of the disease in all observed groups of patients, an improvement in lipid metabolism and indicators of the functional state of the liver, a decrease in excessive bacterial growth. On the basis of ultrasound, elastography and fibrotest, the reverse development of liver steatosis was found in 20% and steatohepatitis in 66.6% of patients.
Conclusion. The data obtained indicate the feasibility of differentiated treatment of patients with non-alcoholic fatty liver disease depending on the characteristics of its course and stage.
Keywords: non-alcoholic fatty liver disease, early diagnostics, differentiated therapy, bacterial overgrowth syndrome.
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1. Ivashkin VT, Drapkina OM, Mayev IV, Trukhmanov AS, Blinov DV, Palgova LK, et al. Prevalence of non-alcoholic fatty liver disease in out-patients of the Russian Federation: DIREG 2 study results. Rossiiskii Zhurnal Gastroenterologii, Gepatologii, Koloproktologii. 2015;25(6):31-41 (In Russ.)
2. Podymova SD. The modern view on pathogenesis and treatment of nonalcoholic fatty liver disease. Eksperimentalnaya i Klinicheskaya Gastroenterologiya. 2016;(5):74-82 (In Russ.)
3. Suchkova EV, Gorbunov AYu, Vakhrushev YaM. About the issue of contributing factors, development mechanisms and treatment of fatty hepatosis. Medicinskij Almanah. 2012;20(1):73-5 (In Russ.)
4. Hohlacheva NA, Suchkova EV, Vahrushev YaM. Ways to improve efficiency of patients with early stage clinical examination of cholelithiasis. Eksperimentalnaya i Klinicheskaya Gastroenterologiya. 2013;(6):15-20 (In Russ.)
5. Suchkova EV. Functional state of the hepatobiliary system in case of non-alcoholic fatty liver disease in patients with diabetes mellitus. Eksperimentalnaya i Klinicheskaya Gastroenterologiya. 2009;(8):26-9 (In Russ.)
6. Komova AT, Maevskaya MV, Ivashkin VT. Principles of effective diagnosis of diffuse liver diseases at the outpatient stage. Rossijskij Zhurnal Gastroenterologii, Gepatologii i Koloproktologii. 2014;24(5):36-41 (In Russ.)
7. Aijaz Ahmed MD, Ryan B, Perumpail MD, Stephen А, Harrison MD. Hige prevalence of hepatic fibrosis in the setting of coexisting diabetes and hepatic steatosis: A case for selective screening in the general population? Hepatology. 2016;63(1):20-2. doi: 10.1002/hep.28277
8. Younossi ZM, Koening АВ, Abdelatif DA, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease. Meta-analytic assement of prevalence, incidence and outcomes. Hepatology. 2016;64(1):73-84. doi: org/10.1002/hep.28431
9. Miura K, Ohnishi Н. Role of gut microbiota and Toll-like receptors in nonalcoholic fatty liver disease. World J Gastroenterol. 2014;20(23):7381-91. doi: 10.3748/wjg.v20.i23.7381
10. Rolfe LD. Interactions among microorganisms of the indigenous intestinal flora and their influence on the host. Rev Infect Dis. 1984;6(1):73-9. doi: 10.1093/clinids/6.supplement_1.s73
11. Mouzaki M, Comelli EM, Arendt BM, Bonengel J, Fang SK, Fischer SE, et al. Intestinal microbiota in patients with nonalcoholic fatty liver disease. Hepatology. 2013;58:120-7. doi: 10.1002/hep.26319
12. Zhu L, Baker SS, Gill C, Liu W, Alkhouri R, Baker RD, Gill SR. Characterization of gut microbiomes in nonalcoholic steatohepatitis (NASH) patients: A connection between endogenous alcohol and NASH. Hepatology. 2012;57:601-9. doi: 10.1002/hep.26093
13. Volkova NI, Porksheyan MI. Nonalcoholic fatty liver disease: What do we know and what will we have to learn? Therapeutic Archive. 2017;89(2):91-8 (In Russ.)
14. Lazo M, Hernaez R, Bonekamp S, Kamel IR, Brancati FL, Guallar E, Clark JM. Non-alcoholic fatty liver disease and mortality among US adults: prospective cohort study. Brit Med J. 2011;343:6891. doi: 10.1136/bmj.d6891
15. Martinez SM, Crespo G, Navasa M, Forns X. Noninvasive assessment of liver fibrosis. Hepatology. 2011;53(1):325-35. doi: 10.1002/hep.24013
16. Ratziu V, Bellentani S, Cortez-Pinto H, Day C, Marchesini G. Position statement on NAFLD/NASH based on the EASL 2009 Special Conference. J Hepatol. 2010;53:372-84. doi: 10.1016/j.jhep.2010.04.008
17. Tacuma Y, Nouso K. Nonalcoholic steatohepatitis associated hepatocellular carcinoma: our case series and literature review. Wld J Gastroenterol. 2010;16(12):1436-41. doi: 10.3748/wjg.v16.i12.1436
18. Rutishauser J. The role of statins in clinical medicine – LDL-cholesterol lowering end beyond. Swiss Med Wkly. 2006;131:41-9. doi: 10.4414/smw.2011.13310
19. Klebanova EM, Varijchuk ZhI. The role of metformin (glyformin) in the treatment of patients with diabetes mellitus. Russkij Medicinskij Zhurnal. 2010;18(14):919-23 (In Russ.)
20. Vakhrushev YaM, Suchkova EV. Ursodeoxycholic acid reduces the risk of cholelithogenesis in fatty hepatosis. Vrach-aspirant. 2011;4.5(47):727-31 (In Russ.)
21. Xiang Z, Chen YP, Ma KF. The role of ursodeoxycholic acid in non-alcoholic steatohepatitis: a systematic review BMC. Gastroenterology. 2013;13:140. doi: 10.1186/1471-230x-13-140
22. Starostina EG. On the question of cardiovascular efficacy and safety of metformin. Atmosfera. Novosti Kardiologii. 2015;(3):38-46 (In Russ.)
23. Athyros VG, Mikhailidis DP, Didangelos TP, Giouleme OI, Liberopoulos EN, Karagiannis A, et al. Effect of multifactorial treatment on non-alcoholic fatty liver disease in metabolic syndrome: a randomised study. Curr Med Res Opin. 2006;22:873-83. doi: 10.1185/030079906x104696
24. Korrenaga M, Kawaguchi K, Korrenaga K, Uchida K, Sakaida I. Insulin sensitizer anti-diabetic drugs, metformin and pioglitazone that can improve insulin resistance. Nippon Rinsho. 2006;64(6):1157-64.
25. Viollet B, Guigas В, Sanz Garcia N, Leclerc J, Foretz M, Andreelli F. Сellular and molecular mechanisms of metformin: an overview. Clin Sci (Lond.). 2012;122:253-70. doi: 10.1042/cs20110386
26. Ilchenko LYu, Oskanova RS, Fedorov IG. Essential phospholipids: from pharmacological properties to therapeutic effect. Terapiya. 2015;2(2):56-63 (In Russ.)
27. Zverkov IV, Minushkin ON. Comparative characteristics of the effectiveness of essential phospholipids and ursodeoxycholic acid in the treatment of chronic liver diseases. Russkij Medicinskij Zhurnal. Medicinskoe Obozrenie. 2018;(7-1):33-6 (In Russ.)
ФГБОУ ВО «Ижевская государственная медицинская академия» Минздрава России, Ижевск, Россия
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Ya.M. Vakhrushev, E.V. Suchkova, А.Р. Lukashevich
Izhevsk State Medical Academy, Izhevsk, Russia