No 4 (2018)

22-23 мая 2018 г. в здании Правительства Москвы прошли II форум «Мультидисциплинарный больной» и II Всероссийская конференция молодых терапевтов. Организаторами мероприятия выступили Российское научное медицинское общество терапевтов (РНМОТ), Министерство здравоохранения РФ, Комитет по социальной политике Совета Федерации, Общество врачей России, Российская академия наук, Российский национальный исследовательский медицинский университет им. Н.И. Пирогова, РОО «Амбулаторный врач» при участии Международного общества внутренней медицины, Европейской федерации внутренней медицины (EFIM) и Евразийской ассоциации терапевтов. Как и все мероприятия РНМОТ в 2018 г., конференция была приурочена к 120-летию со дня рождения выдающегося отечественного ученого и клинициста И.А. Кассирского.

The article touches upon the modern aspects of pathogenesis of spondyloarthrites, Russian experience of secukinumab - genetically engineered biological medicine, first in Russia monoclonal 17A interleukin antibody use for that group of the diseases. The data of performing analysis show, that biological therapy with secukinumab inclusion helps significantly decrease ankylosing spondylitis and psoriatic arthritis activity, improve functional condition of resistant patients without adverse events risk increase. Significant and fast decrease of laboratory inflammation indexes, articular syndrome decrease in case of spondyloarthrites gives us the basis to consider secukinumab to be a perspective medicine for "switching” the patients with insufficient efficacy of a anti-tumor necrosis factor agents in anamnesis to biological agent with another mechanism of action.

Article contains recommendations from European League Against Rheumatism of 2016 and national recommendations concerning management of rheumatic arthritis patients from 2017. Also results of treatment the patients with early stage of the disease in accordance with these recommendations are introduced. Aim of the research. Estimation of the efficacy and acceptability of subcutaneous form of methotrexate while perspective observation of early rheumatic arthritis patients. Material and methods. Subcutaneous form of methotrexate (15 mg/week in combination with 1-2 mg of folic acid) was prescribed to 67 patients with firm rheumatic arthritis diagnosis according to ACR/EULAR criteria of 2010. During 12 months 65 patients (97%) were treated, 24 months - 47, and 36 months - 22 patients. Treatment was performed in accordance with the strategy of RA treatment principles «Treat to Target». Initial activity of RA according to DAS28 in 43patients (64%) was moderate and in 24 (36%) - high. Results. Practically in all the patients the first symptoms of improvement were fixed after 4-5 weeks of methotrexate use in 15mg/week dosage; up to the 8th week of therapy the effect was fixed in all the patients. After 6 months of therapy was fixed no signs of high rheumatic arthritis activity, moderate activity took place in 32 from 65 (49%) of patients, and low - in 33 (51%) cases. In 2 years of treatment 43% of patients had a remission, the rest of patients had low activity of RA; in 3 years more than half of the patients had a remission. Conclusion. Subcutaneous form of methotrexate has a high efficacy to the activity and progressing of early rheumatic arthritis, long-lasting good acceptability and lets to reach the goal in majority of patients after 6-12 months of therapy (while using principles of controlled treatment including teaching patients). In case of controlled treatment with timely therapy correction in case of insufficient antiinflammatory effect, and teaching of patients, it is possible significantly improve the results of rheumatic arthritis treatment, get clinical laboratory remission more than in half of patients and avoid the destruction of joints.

Objectives. To examine of the renal dysfunction in patients with rheumatoid arthritis (RA), to identify the relationship of these indicators with risk factors for cardiovascular disease (CVD). Material and methods. The study included 73 patients with RA at the age 18 to 60 years without an associated renal diseases. We investigated the urinary excretions of a1-microglobulin (a1-Mg), albumin (Al), enzymes and glomerular filtration rate. Results. The urinary excretion of a1-Mg, Al and enzymes in patients with RA was higher than in healthy individuals. The most early marker of renal dysfunction was a1-Mg. The concentration of a1-Mg in urine was higher than in controls even in patients with normal urinary albumin excretion. The markers of the renal dysfunction in patients with RA correlated with the features of the development of the RA and with risk factors for CVD. Conclusions. It is important to assess of the renal function for risk stratification of CVD in patients with RA.

Measuring of arterial pressure by volumetric compressive osvillometry method have shown, that in case of measuring by the auscultative method (AM) errors with high reliability reach tens of millimeters of mercury. As a result, misdiagnoses are taking place, wrong medications for blood pressure decrease are prescribed in case of its low values. As a result, a large number of examined patients have complications due to disorder of blood circulation in vitally important organs, threatening their health and life. Aim of the research. Development of a scientifically grounded method for measuring blood pressure and determination of the degree of divergence of the obtained data with AM, as well as an assessment of the risks arising from the use of AM in medical practice. Material and methods. In a multicenter BP study measured by means of AM, were examined 1,086 persons, 495 residents of Novokhopersky district of the Voronezh region were added to them. At the same time another group of physicians registered blood pressure by the method of volumetric compression oscillometry (VCO). Results. The first registrations have shown, that there are significant differences between the contour of volumetric oscillograms recorded in practically healthy people and patients with isolated systolic arterial hypertension (ISAH) and hypertensive disease (HD). Healthy persons have the amplitude of the oscillations decreased after reaching the pressure in the cuff of the brachial artery value of AD med.; in patients with ISAH and HD - in most cases that value increases. The conclusion. The results of the performed study show that physicians, following the definition of blood pressure by the Korotkov method, make mistakes in the diagnosis and prescription of medicaments, often putting at risk health and life of elderly examined patients.

Metabolic syndrome (MS) is widespread in the population, occuring in 10-24% of cases. Combination of cardiovascular diseases and metabolic disorders increases the risk of mortality from cardiovascular complications. Endothelial dysfunction together with hypersympathicotonia plays an imprtant role in pathophysiology of vascular diseases, arterial hypertension and cardiac insufficiency. Taking into account the important role of increased activity of sympathetiic nervous system in the development of cardiovascular diseases in case of MS, the question of possible use of ß-adrenoblockers, primarily having vasodilating effect and having influence at endothelial function is actual for treatment of the certain category of patients. Nebivolol is a ß-adrenoblocker with most high selectivity to ß1-adrenergic receptors and causes the dilatation by increasing of nitrogen oxide production. Double mechanism of action is basing on the row of haemodynamic effects of nebivolol including heart rate and arterial pressure decrease, improve of systolic and diastolic left ventricle myocardium function. High clinical significance are having the identified advantages of nebivolol concerning metabolic profile: decrease of blood lipid level, increase of insuline sensitivity and abscence of new cases of diabetes melitus development. These advantages take place also in case of its use in MS patients. Nebivolol gives antihypertensive effect which could be compared with the same of other groups of medicaments and ß-adrenoblockers, but at the same time it has a row of advantages in treatment of arterial hypertension in patients with diabetes melitus, adiposity and in elderly people in whom endothelial dysfunction is more expressed.