lco erAartlrec ruilt r pouroe, HacroF u_lee tA 6y4yulee

lco erAartlrec
ruiltapTpr,{T:
r pouroe, HacroF
u_lee
tA6y4yulee
ga6ollcopralaqecrrfr
aprpmr (ncA)
I
reBaHr,re, accoul/NpoBaHHoe c ncopha3oM,
BXOAFU{ee
B rpynny cepoHeraTilBHbrxcnoHAl4noaprpl/roe (CCA), xapaKrepil3yroueecn pa3BrrmeM epo3yrBHoro aprpr{Ta, caKporne[Ta,
cnoHlilnoapTpilTa, pa3nilqHbrMil BapilaHTaMu
rocrHofi peeop6qilr,r,MHoxecrBeHHbrMileHTe3VraMtA.
PacnpocrpaHeHHocru llcA .qocraroqHa BbrcoKa il Mo)KeTGpaBHilBaTbcFc pacnpocTpaHeHHocrbo peBMarorAHoro aprp/ra (PA). no
aBTopoBflcA e nonynnLlrLr
AaHHbrMpa3firLrHbrx
Bcrpeqaercq or 0,0560/o lo 2 o/o,3a6oneBaeMocrb or 3 Ao 23 cnyvaea Ha 100 000 HaceneHVA (29) .Cpegn nauileHroB, crpaAalou-ll4x
ncopila3oM, qacrora BcrpeqaeMocrvr f1cA <one6nercq or 13, 5o/ogo 47o/o(e cpeAHeM 360/o)
(26,51 ). Taran eapua6enbHocrb crarilcrrqecKrx AaHHbrxcBq3aHa c oTCyTCTBrleM
eArHbrx
AilarHocruqecKrlx u <naccuQil KaqnoHHbrx Kp14
T.,Q.Tn6yr,
A .E. Syr noea
SerMAtlO
ravr 6oruHoro r o6ulecraa B LleroM, a raoKe
nporHo3y ero sa6oneBaHile He ycrynaer PA
(28,42). Y naqreHroB, crpaAao4ilx rn)Kerbrvrm Qopvavr
llcA, orveqaercfl noBbrlxeHhe
c M e p r H o c r i l n o c p a B H e H i l oc n o n y n q u r o H H o f r
( y v y x . r r a Hn a 5 9 o / o ,y x e H q r H H a 6 5 % ) ( 2 7 , 5 9 ) .
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v npvlvHaMil fl erafl bHbrx vrcxoAoB
flBneorcq vera6onrqecKile Hapy[xeHrfl v Bbt3BaHHbrerML,rarepocKaeporilqecKile nopaxeHilfl Cep.qllar cocyAoB, xpoHTrqecKa9
noqeqHaff
HeAOCTaTOq
HOCTbKaKCneACTBne aMV nOttgttOil
HeQponarrn,
6onesHr cilcreMbr D;txa+nfl,
3noKaL{ecTBeHHbre
onyxorr, ocnoxHeHfiq npoeogrvoil Tepanilil (naHqmroneHtAtA,
xeflyAorrHo- Kl4LreLrHbre KpoBoreLreH
fi fl , tzHQerqiloH Hbre
ocnoxHeHrF, neqeHoqHaF He,qocTaToqHocTb).
Hanucve nponBneHril <oxHoro ncopila3a
TaoKe cKa3brBaercflHa QrsmrecroM m ncilxoeMoul4oHafibHoMcocroqHilil nauileHToB, cHrlXAq
KALIECTBO X]/I3HLI IA BIIIAA9 HA OTHOI.XEHilE K
TepileB ilcA, ourqatoulrMr4cn B3raFAaMil Ha f l e q e H i l o ( 1 2 ) . n o A a H H b r M
c n e u i l a n b H b r xo n p o cycraeHofr crHApoM cneqilanncroB pa3nrvc o B , n p o B o A t 4 M b t xA e p M a r o n o r a M n , M H e H r e
Horo npoQtAnfl,a raKxe 3HaqrrenbHbrMpa3Ho- 6 o n u H u r xn c o p m a 3 o Mo H a 3 H a q a e M o M
reqeHrn
o6paemev KJl4HrlLrecKrlx
npoqBnenuh AaHHoro BecbMaHeorqH03HaqHo:
. Hau6onee e$QeKrreuoil, Ho rpyAoev<ofr
sa6oneaaHnq.
pa3Brrbcq
flcA voxer
B np6ov Bo3pacre,
n pil3Haercn Qorore panv+
qaue ot 25 Ao 55 ner, Ho Mo)Ker HaqilHarbcn . 30o/o 6orusurx He AoBorqqr Ha3HaqaeMoro
B AercrBe. CoorHouleHre Myxrl4H r )KeHU-14H fieqeHilq Ao KoHLla
'1
. Soree nonoBnHbr6oruHurx 3arpaqnBaor Ha
:1 , ga mcKnoqeHileMcnyqaeB ncopilariltrecKor-o cnoHgrnoaprpnra, roropurfr e 2 pa3a
neqeHile ga6oreeaHilfl MeHee 15 MilHyr B
qaule BCTpeqaeTCff
y Myxrrl/lH.
,4eHb
. 10% 6oruHurx 3arpaqilBalor Ha re.{eHile 6oCouilansHaq 3HaqilMocrb AaHHoro sa6oneBaHrfl cpaBHilMa c PA (53). |1o rqxecrlr
ree 30 MilHyr B AeHb
. Sonee 40o/ocqvraror npo6fleMbr,cBr3aHHbre
KnilHhqecKrx npoRereHril, creneHil yrparbl
Tpygocnoco6Hocrr,
BnvAHtAto Ha KaqecrBo
c neqeHileM ncopl4aga, 6oree 3Haqu4TeflbX.l43Ht4
nallileHToB, no SKoHoMl4l-recKrlM
3aTpaH b r M 1L
4 r, e Mc a M o g a 6 o r e e a H r e .
4B
fT**pw*rn*u,**uH#
Ta6nuua 1.
fiffi ,fr?p F{rrisffinft
fi#Hs4*p#s,sfi &t#s .nffq,*,t4ti1t4
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il
9,8/10,4
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4,4/16,2
s 1# *{i 3* 4# 5fr S# ?SS* #CIlfi#
Pucyxox l .Ilcopraarn,{ecrufi cneKTpsrvroUufi
flo oruou-reHilCIK cyril 3a6oneBaHilq, K fleLteHr4rot l4cxoAaM 6onegHN, K xr3HeHHbtM
npo6fieMaM cKflaAbtBaercfl ncopvarwlecKLtll
cneKrp eMorjLlil, KoTopbtfi Heo6xoEl/Mo yr{hTbrBarb,o6u4ancuc AaHHoftKoroprof 6onuHurx
(cv. prlc.l )
.[,o oaccilqecKutx pa6or Wright V (1959,) r,r
Baker H (1963) aprpl4r BocnannrenbHoro xapaKrepa, Bo3HNKatouyrilaa QoHe ncopila3a,
paccMarpvBar'tce KaK PA y na4ileHTa c ncopila3oM. Wright V onucar oco6brlt BapilaHr
CyCTaBHOTO
nOpaXeHtAA,npoTeKaoulilfi C vacTbrM apTpmToMArlcTanbHbtx Mex(paraHroBbtx
cycraBoB (AMC), epo3meMr KoHLleBbtx
QaraHr;
coenagaoulril
c pa3BulrheM caKpoilfleilTa,
nopaxeHneM npoKct/MarbHbtx vexQalanroBbrx cycTaBoB nanb4eB cTonbt, xaparrepHurft
Myrl/nllpytou\tAil aprpt/T c ocreonnrrLtecKilMil npoqBneHVAMn.AveprraHcKaq Konnerrn
peBMaronoroB (ACR) BnepBbte onpeflenilfla
flcA rar orgenbHyo KnilHil.{ecKyo $opvy e
1964 roAy, BKflloel4Bero B rnaccrQrKallytro
peBMarnqecKrx 6oneeHelt. OAHaro, Ll Ao HacToflulero BpeMeHil coxpaHFeTce pep, BonpocoB, Kacaoulr4xcn Ho3onorilLtecKoil npilHaAnexHocn4 [1cA, vro no MHeHilroD.D.Gladman
(2005)ceq3aHo:
. C orcyrcrBueM yHraQr,r4r,rpoBaHHbtx
KpilTepreB
. KnrHnqecrofi rereporeHHocrbo flcA
. Bucorofi pacnpocrpaHeHHocrbroncopha3a
n pil peBMarrtlecKylx 3a6ofl eB atnex
A R S M E D I C AN S 5( 1 5 )
. OrcyrcrBheM narorHoMoHytt{Hbtx cLlMnroMoB, BKnrouanna6oparopHbte recrbl
. Hanucuev o6uqrx qepr c ApyrnMr BocnarmTer bHbrMyt 3a6oneBa HVflMtA
Ha o6uNpHov KnrHnqecKoM Marepnaae
(1677 nallileHroe) B.B,EaAo<rH (2003 r) noKa3afl BbrcoKytoLtacToTyBcTpeqaeMocTmncopila3a npil pa3nv\noh naronot-l4r:BurgeleHre
llcA ras u6orur-uofi peBMaroLlAHofr 6olesHyr"
ocHoBaHoHa [uhpoKoM cneKTpe ennAeMnonorrqecKrx, TeHerilqecK[x, vopQonorilt{ecKrx,
mMMyHOnOrh qec Krlx v KnvHVKo- peHTre Ho nof tALrecKrlxgauHurx(1 ).
TpygHoclrr Mn ycraHoBneHvt+ Ho3oflorrqecrcofi Sopvrur flcA ceqsaHbt c reM, qro sa6oneeaHrae[Meer Knt,tHhqecKrenpoqBneHnA,
cxoAHbreKaKc PA, rar r c cepoHerarhBHbtMu
cnoH.a,unoaprpilraMr (5 ).
KraccrqecKlrM ornl4tlileM or PA FBrFercc nopaxeHile n[,MC,coorHolxeHile MyxqnH H xeHu4nu 1:1, acrvverpnvHurft xapaKrep aprpilTa,
noqBneHne 3HTe3ilToB,AaKTilntATa,CUMnTOMOB
peMoAenilpOBaHilq,nopaxeHile noKOCTHOTO
3BOHOqHilKA.
B ourqre or aHKilro3Ltpytoqero cnoHAfinura (AC) gnn flcA xapaKrepHo 6eccrMnroMHoe
TeqeHhe cnoHALlflrTa, coqeTaHtAenopaxeHilq
no3BoHoqH14Ka
c nepuQeprqecKnM aprpl4ToM,
BO3MOXHOCTb
OAHOCTOpOH
HerO CaKpOilnetATa.
K HacronuleMy MoMeHTyHaKonhnocb .qocraTorlHo snaunil, noATBepxAaoulytx ocHoBHbte
pasnvqnn f1cA yr PA, vro xopotuo AeMoHCTpl4-
49
NCOPI/ATI/I=CQIN APTPI/T:
nPoL_rroE,HACTOFUEE/ svAvUEE
Pucynor
2. AnropurM E[arHocrnKn
c eHTe3mraun (pee2. He accollr4r/poBaHHbte
MarorAHbril
aprprr)
Ta6nwla2
Cyulecreyer nepBmqHutfranroprrM AHOOepeHlIil an bnoil gvar Hocr tAKtABocnaJIhrer bHbtx
MrureHu
nopaxeHilil cycraeoB, ocHoBaHHutilHa 3auHTep e c o B a H H o c r no H r e e o e ( p n c 2 ) :
SHte3rtur, ocrehr,
Hanu.twe ctaMMerprLrHoro nonuaprpvra npv
C14HOBLIT
ncopila3e B orcyrcrBile nopaxe nnh Av'rctarbHbtx
fl03eonovHr,t<,
CilHoeraruMOC il cepono3vrtABHocrtA no PO peKoMeHAyHbrecycTaBbl KpynHbrecycraBbl
ercn
crrrrarb coLreraHileMncopfia3a n PA.
Pevo4ynnqrn
Aecrpyrurq
y HLA-827-nosutuBHbrx naureHToB c no3.tr,KOCTT,[ecTpyKUl4fl
xpflua il
HilM ncopila3oM Moxer ua6nogarucn 6utcrpoe
xpqula v KocTvl
KOCTYI
n porpeccLrpoBaHile cnoH.qfinrra il caKpovnevflcoprarnqecrrfi
aprpr/T FBfiflercfl tlpKl4M Ta, pa3BilTne lAptATa,peAKo npilcoe,qnHqloTcF
nepr,roepntrecKileaprpmTbr.B gaHuol Cnyqae
nprMepoM oHTe3-accour4l/poBaHHoilnarorononararol tlTo 3To coLreTaHilencopila3a v aHnAt vt paccMarpilBaercff KaKqacrHutil eapnaHr
KNn03ilpyrouero cnoH,qilfloapTprra.
reHepanilsoeaHHofteHre3onaruw (47 .).
ilcA N ncopna3 FBflFtorcfl caMocroffTenbf'lo oruouleHro K 3afiHTepecoBaHHocrileHHblMr4ga6oneeaHlAqutA,nMeoqrMil onpeAeTe3oB BocnarilTeflbHbre ga6oreeaHilfl cycraneHHurfrcneKTp FeHerilqecrnx oco6eHHocrefr,
BOBAeflqTcrr Ha
pasHoo6pa3tAeKflrHrvecKilx nponBneawh (2).
1 . Accor-lz14poBaHHbre
c eHTe3vrauvt (ncoprarrqecrril aprpr4T,Apyrre cnoHroilnoaprpl4- Xopor-uo l43BecreH Oarr pagBtArvfr KoxHoro
aprpl4Ta, pa3nopaxeHilfl 14 Bo3HvrKHoBeHnc
rur/c n o H4iln oa pr po nantav)
pyror naroMopQonorrqecK/e AaHHbte(31 ):
50
AeneHHbleBOBpeMeHr: B 75o/oCn\eaeBAepMaro3 onepexaeT pa3BrTne aprpilra B cpeAHeM
H a 1 0 - 1 5 n e r , y 1 1 - 1 5 o / o6 o n t H b r x n c o p v a 3 u
a p r p l 4 r p a 3 B h B a o r c n o A H o B p e M e H H oH, o y 1 0 15o/ona4ueHTOBapTpl4TMOXOTHa AOflrne ro.qbl
onepexarb nopaxeuun roxr (46).
Cyutecreyer recHaq B3ailMocBn3b tA BgarMoo6ycnoBneHHocrb
erilx
za6oneeanuh,
qTo npoqBrqeTcq npexAe Bcero B o6ulHocTil
NATOFCHCTNqCCKilX
MCXAHil3MOB,
CXOXECT]/I
npoBoqr/pyrou-tl4x
Sa<ropoe pa3Bnrv+ (23). B
naroreHe3eKaKncopna3a,TaKN flcA rMeror
Pracyxor 3. cxeua (KacKa4Horoesr6poca>
npoBocnaruTer bHbrxul4ToKl4HoB
3HaqeHhe FeHerilqecKil o6ycnoBfleHHbreQa<Topbl, BHe[xHecpeAoBbre BrnAHtAfl (crpecc,
OcHoeHaq ponb B qenil nMMyHonoFrLrecKilx
crpenroKoKKoBaq rHQerqrn, BlAl, TpaBMa,
HapyueHilft nprrrgaercq He npocro grrrc6araHcy
npmeM fieKapcrBeHHbrxnpenaparoe - HflBC,
npo- 1/ nporl4BoBocnanilTeflbHbtxuLlroKilHoB,
KoprrKocrepoilloB,,[,-neurqvrnaunHa, 6erayBenrqeHro OHO-c , Koropurft paccrvarpva
6roraropoe, aHTnMaflffpnfiHurxnpenaparoB,
BaoT
KaK peryncTop npoqeccoB Bocnane{t A
conelr nutun), cocygrcrbre (rverarronporeilHa3br, aHFnonoerrHbr, rpaHcQopvr,rpyroulrril (enwnnne Ha oKcnpeccrro FeHoB, Mrrpa4rCI,
auQQepeHuilaumo, nponNQepaumo KreroK,
Qa<rop pocra-p) Qarropur (38,48,49).
Qarl-eHernqecras npegpacnoroxeHHocrb
K n poqeccbr anonro3a). llyrev aKrvBaL1Avr
(ngepHoro Qarropa rB)
ropoB rpaHcKpr4nLIAtA
pa3BLlTNroncopila3a r flcA npoqBnqerce cevrefiHofr arperallneil yraeaHHurx sa6o neeauuh OHO-o perynilpyer aKrlrBHocrb HecKonbKhx
(6onee 40o/o6ontHbrx c flcA r,rvreor poACTBeH- reHoB, KoAl/pyrou{14x cTrHTe3 npoBocnanilHrKoB nepeofi nvHvt/t poAcrBa, crpagaoulr4x TefibHbrxul4ToKLrHoB 14HTepneftruHoe 1, 6,
npoAyKqr4ro
LlrroKr4HoB
14
crilMynilpyer
Apyrrx
r.rhcro
ncopila3oM,
cfiyqaeB sa6oneeaeMocl4
KonoHilerpaHynounrapHoMarpoQararbHoro
yBenilqilBaercq B ceMbqx, nMetou-lr4x
6rt4sHe*
c r i l M y n r p y o u l e r o Q a r r o p a . ( 13 , 5 1 ) ( p r c . 3 )
uoB); no4rBepxAaerce HarhqheM 7 reHoe PSflpra flcA il AepMarose Ha6no,Eaercq npeORS, orBercrBeHHbrx3a pa3Brrme ncopila3a, a
npoBocnanilTefl bHbrx unroKl4HoB B
o6natranue
TaoKe noBbnreHuofr qacroroil aurqefleHngre6uonorncecKnx
cpeAax il TKaHrx opraHr3Ma
HOBrflaBHOr-O
KOMnfleKCa FilCTOCOBMeCTmMOC(49):
B
ncopna3a,
oqarax
eHTe3ax, ctAHoBtAr r H L A : B 13 , B 1 7 , 8 2 7 , 8 3 8 , D R 4 , D R 7 ,
anuuoft o6oroqre, ct HoBnanuuofi xilAKocn4,
Cxoxecru AepMaro3a railcA no.qrBepxAaercF TaoKe cxoAHbrMl4ilMMyHHbrMrHapyueHVA- KpoBm.B cr/HoemanuHofio6ono.rre nauileHToB
c flcA HaxoAFT 6onee BbrcoKoe coAepxaHne
tvtu. O6a sa6oneeaHilF orHocFT K naronorvtl,
a ilMeHHo,
cBq3aHHofic HapyueHnAMVT-rneroqHoFo 7rM- npoBocnarrTeflbHbrx r_u/ToKl4HoB,
MyHnrera. Begyu4ee gHaqeHile B naroreHe3e OHO-c il LrHrepfleit<una 10 no cpaBHeHilo
c PA. lloeurlueHHoe ilx coAepxaHt e crvMyntAsa6oreeaHilfr npLlgaercn CD8+T-nrvOounpyer aKrilBaLlLilo t nponr,rQepallilro Qr6poTaM, crrMyn+qtAtA nporrQepaL\tAtA KeparilHo.rro
tA
l-lulroBT-rnexavil
onmrqepMilca v cvHoBrAtA, 6nacroe Koxl4 crAtoBrAanuuoilo6onoqril,
-1,
l4MMyHorno- Beger r eurceo6oxr[,eHilo rurepnefrKrHa
o6napyxeHnr QrzrrcrapoeaHHbrx
rHrepneil
rrHa-6,
rpov6orlrrapHoro
Qarropa
6ynrHoe il KoMnfleMeHTaB noKpoBHoMil norqpocra (28) . Heo6xoArrrMoorMerhrb aKrvlBHoe
noKpoBHoM cnoffx ctAHoBnanuHofro6onovrn,
yqacrre OHO-a B KocrHoM peMo4enilpoBar HQrn urp aqtAtAr MMyHoKoMnereHTHbrMil KflerRAN KL- sa e Nc il N4
o r-oocre o rn ab KaMr cvHoBnanuHoil o6onoq<m il oHTe3ilcoB. Hl tA,yCn neHrarzr
TOreHe3a.
Tarne xe ilMMyHHbreHapyrxeHns ua6np4a!,nn l-1cAxapaKrepHbr cfleAyoulile BapilaHrbl
rorcrr B ncopilarilLrecKrx nanynax u 6nnw<ax.
peMoAenilpoeaHrn (52) :
KocrHoro
(56).
A R S M E D I C AN S s( 1 5 )
c l
NCOPI/ATI/IECKANAPTPI/T
nPoLrJroE,HACTOFUEE/ svAvUEE
Pncynox 4. l-lopaxeHue uorreh
. BHyrpncycraBHoil ocreonile
HtAfl. ConocraeneHile pa3flr4rrHbrxBapraHToB
' Pesop6qrff Horreeoil6yrpracrocrl4
AepMaTo3a c KnhHilqecKuMtAnpoflBneHneMlA
. lActuunafl KocrHaq arpoQt4n
flcA norasaHo B ra6nmue 3:
. AeQopMaUhff no rilny upensil-in-cap>><KapaHAalx B craKaHe>
. OopvrrrpoBaHileaHKilro3oB
. OrcyrcrBreocreonopo3a
Tsxeroe reqeHhe
Konr.{ecreo LlmpKynilpy}ou-ll4xnpeAruecrfi erroe fi cpe4He-rnxefl oe
BeHHTKoB ocreoKracroB (cynepceveftcreo
Arflc- nycryne3Hbfi n epmpoAepMilvecKnh ncoOHO) qBnfloulmxcq 6roMapKepaMr Bocnanilpna3
TefibHoTonpouecca B cycraBax il no3BoHotlHTr- OB l-lc-orpaHil,JeHHsrftByflbrapHbrftncopnas
Ke, yBerilqilBaercr npn ncopvage. B rocrHoft
TKaHil 6onuHurx c ilcA BbrqBflflercq 6oruluoe
Kpove eroro, aBTopoM 6una npoAeMoHKonrqecrBo ocreoKnacroB e yrny6nenunx, o6CTpl4pOBaHaKoppe neL\tAAKOXHbIXttgveHeHrfr
pagoBaBuVxcn Ha Mecre pesop6uiln Kocrt4 B c KnvHVKO-aHaroM
TltrecKrMil BapraHTaMil cyco6nactvt coe.qilHeHtA KoertAil naHHyca vnv B TaBHor-ocrlHgpoMa. TaK, npil orpaHrqeHHoM
o6nactu oHTe3oB.
AepMaroge qaue Ha6noAan ce trtAcTafiauathunu
BeailMoceqgb KoxHor-o Lr cycraBHot-o cr4H- MoHooflmroaprpr4Tl4.recrililBapilaHT f1cA, npN
armnilqHoMncopha3e - peBMarorgonoAo6Hurfr
ApoMa - BaxHoe npoqBneHl'le <nrurqecroil
KaprlrHbr ncopilarilqecKoro aprpilTa. OAHo- iln il cnoH4nnoaprprt uuec<uh BapraHTbt.
BpeMeHHOe pa3BrTile .qepMaTo3a il aprpilra
,.l,narHocrntlecKrgHaqnvofi FBrnercn cBq3b
ytrrrblBaercc KaK eaxHurfi AilarHocrtA\ecKwh aprphra AMC c 4rrrcrpoQmefiHorreBbrx nnac<pntepwil, paccMarpilBaerce KaK noKagarefib TrlHoK. l-lcopmarrqecKaFoHnxogr4crpoQrn neaKTtABV3aLlAnapr ptATa v nv Ae p Maro3a.
KOXHbIXttgVeuesril n
nfleTCCeKBilBafleHTOM
B p a 6 o r a x B . B . S a g o r r H a ( 2 0 0 1 r ) n p o e e g e - cqilraercn MapKepoMaprpilra AMC (6,'l 2,58)
HO COnOCTaBfleHile
KnilHh.recKre npoqBneHmF[1cA xapaKTepilAByX BapilaHTOBKOXHOro ncopra3a - orpaHiltreHHoro BynbrapHoro 3yorcq rereporeHHocTbto, cqilTaeTCc,qTo no
- c ocHoBHblMtl K'|14HvlqecKilM14pasHoo6p a3tAa nopaxeH nF KocrHo-cycraeuofi
v aTAntAg'HoFo
cilcreMbr eMy Her paBHbrx. flcA vtoxer MnQopvavr l-lcA. K arrnilqHoMy ncopt/a3y orHOCqTyHilBepcaflbHyro epilrpoAepMilto il nycTenbHo npoTeKarb c apTpanfvflMtA BocnanilrylesHurfi ncopila3, BapfiaHTbr sa6oreeaHVtfl, TerbHoro rvna ilflr MoHo- lAnv ofiilroaprpl4ToM
xapaKTepil3yloulmecfl TopnilAHblM TetleHfieM, Ha nporFXeHVtA pFAa ner. V tracrvr nauileHToB
i l c e p b e 3 H b r Mn p o r H o 3 o M .O r p a H r v e H H u t fnr c o TeMoxer pa3BilBarbcn nporpeccvtpynuyil
pra3 cqilTaercfl 6naronpnflTHbtMno nporHo3y Hepanil3oaaHHurilaprpr4T. flpr eoaneqeHilm B
v npaKTnrecKr He rpe6yer aKTrBHoFo reqenpouecc cycraBoB oceBoro cKenera Bo3MoxHo
qt
nopaxeHre KaKno Tnny il3onilpoBaHHoro6eccilMnToMHOrO CaKponnevra raK v TflxeroFo
aHKAnO3tApyro
ue ro cnoHArn oaprp hra ( 3, 8 ).
CpaeneHre BapraHToBreLteHilnPAu llcA noKa3brBael qro AfiF PA e 6onuunHcTBe cnyt{aeB
xapaKrepHo nporpecchpytoLrlee reqeHile. flcA
Moxer ilMerb AocraroqHo Henpegcraeyenauril
BapraHT TeqeHnn, 3aBnceu\nfi or pnga $arTOpOB, BKn|oqalou_ll4x:
XapaKTep r4epMaTo3a,
Bo3pacr Haqafla ga6oneeaHilfl, nor nallreHTa,
cevefrHurfraHaMHe3,npnBepxeHHocrb K neqeHVlo, a raKxe BHeuHecperqoBbreeos4eilcraun.
BosvoxHo pa3Bilnre 6urcrponporpeccrpyloulero TetreHhe c BoBneeeHileM B npouecc
6onuuroro KoJr14qecrBacycraBoB, BKntoqag
no3BoHor{HrK.3a6oreeaHile B eroM cfiyqae
nporeKaer c Bbrcoroil na6oparopHolr aKTtBpa3BilTreM BHeCyCTaBHbtx
HOCTbTO,
CNCTeMHbrxnpoeBneuuiar 6urcrpuv QopvrpoBaHileM
AecrpyKTurBHbrxrsMeHeHilft a cycraeax. flpvr
nopaxeHiln oro,Horonflil HecKoflbKl4xcycraBoB
6es nprrrrx BocnanrrerbHbtx npoFBneHuh AecTpyKr_u4q
B cycTaBax pa3BilBaeTcqcnycTq FoAbl
or Haqana ga6oreeaHn+ vtntAMoxer nporeKarb
no nceB4oaprpo3HoMy BapnaHry. Hanw\ve
nonffpHbrxBapilaHToBTeqeHilF He ilcKnotlaeT
v uoroo6pa3ile n poMexyrort Hbtx.
KraccmqecKr npmHsroBbtgeneru5 ocHoeHurx
Krlr4HrqecKwx
BapnaHroe flcA (Moll JM, Wright
V . , 19 7 3 r ) :
1. Aprprr AilcranbHurx vlexQaflaHroBbtx cycTaBoB<ucteh il cron
2. Myrunupyroutril aprpl4r c caKpol/nerroM
3. Cr,rvrverprrHuril aprpl4l noAb6HurlrpeBMaTol4AHoMyaprpl4Ty, Ho orpl/t-larensHuril no
peBMarohAHoMyQarropy
4. AcrarvrverprvHurfr,MoHo-oflt roaprptATc BoBfietreHreM MenKilx cycraBoB <ucteil H cron
5. AHrrno3ilpylou-u/il cnonArnoaprpt/r e vnv
6es nepr,rQepillecKoro aprpmra
Aprprr AMC Bcrpeqaerce no MHeHillo6onuLuurHcrBailccneAoBarenefr e 25-52% cnyqaeB
sa6oreeaHVfl,nptA eroM, oH qau1ecoqeraercq c
nopaxeHheM Lpyrilx MeflKilx cycTaBoB <ucteil
il cron. KpynHurecycraBbtnpilAaHHoM BapfiaHre flcA nopaxaorce peAKo. O6ulee cocronHile
npn lo,hcTafibHoMTilne Mo)KeTN3MeHcTbcgHe3HalrnTeflbHo,Ho AecTpyKTLlBHbte
r3MeHeHilH
(eposurN,aHKrlto3br)e !'MC BbtpaxeHbr6olee
A R S M E D I C AN S s( 1 5 )
lrleonupoeannur il aprpr4T Ar4cran bHbrx Me)KQanauroebrx cycraBoe rucreil c oHr4xog,l4crpoQnefi HorreBoro ro)Ka (B.B.Ea.4orrax,
2OO7r)
3Ha|-rilTefibHo,qeM npil apTptlTe npoKcilMaflbHurx vexQanaHroBbtx
vnw nncruoQanaHToBbtx
cycraeoe (40).
M yrNn n py puJrtriri(o 6 eso6 pa)KilBa lo ul uh) ap Tptlr Bcrpetraercn cpeAil nallileHToB c l-lcA
AocraroqHo peAKo (ao SZo1.!,nn Hero xapaKTepHbrpa3nilqHbreBh4br rocruoft pesop6qr,rra,
BKnoLfaF a KpanbHbfi u euy-rpucycra BHofi ocreo nns. BHyrpilcycraBHofi ocreoltz3 noKanil3yercff B MenKNXcycraBax rrcrefr yl cron, npilBoAc
K pa3BNTnroo6eso6paxilBaoqero aprpilTa c
p a 3 H o H a n p a B n e H H b r Mniol A B b t B N X a M hy,K o p o qeHileM QanaHr vntA nanbL\ee.,[,nn flcA xaparTepHbrM FBr9eTCq COqeTaHre MHOXeCTBeHHOrOOCTeOnil3aOAHOBpeMeHHO
C pa3BrrileM
KocrHbrxaHKrno3oe (52).
3HaqnrenbHo qaqe (no 75o/o) B npaKrilKe
Bcrpeqaerce 143onl4poBaHHulfr
acrMMerpilqHutfr MoHo-orHroaprpr/r KpynHbtx cycraBoB
tAnt4
ero coLreTaHNe
c nopaxeHileM MeaKhxcycraBoB <ucteh il cron. Tarofi BapnaHr flcA Hocr4T AocrarotrHo .qo6poraqecrBeHHbrfr xaparcTep, Moxer Ha6rpAarbcc KaK B Ae6ore, TaK L1
B pa3Bepnyrofr cratrw sa6oneeaHr,rn. O6uteBocnannrenbHbrecrMnroMbt Moryr 6urru qpKo
BblpaxeHbtunv Hocnr crepruril xapaKTep, 3aMerHo He r3MeHnau4nh cocroqHile naUNeHTa.
Cr,rvverpfi.riurfi aprpl4l no4o6Hsrfi PA, uo
orpiluarenuHurfi no peBMarorAHoMy Qarropy
Nnh nceBAopeBMaro uguttil [lcA q ensercfr Hant6onee rqxerbrM BapilaHToMTeqeHhc 6oreeHLl
no BblpaxeHHocTilBocnanrTeflbHbtx,AecTpyKTmBHbrx
r43MeHeHililu nporuosy. .[nn AaHHoro
BapraHTa xapaKTepHo BoBneqeHre B naToro-
53
I_"I
COPI/ATI/1IECK/N APTPI/T
/ svAvU_lEE
nPoLrroE, HACTOflUIEE
TeqeHilF caKponnenra AilKTytor ueo6xoArMocrb hccnegoBaHnfl Kpfl corneueuuil y Bcex
naLlheHToec ncA.
nogBoHoqHrKa BCTpeqaercn
[lopaxeHre
pexe, qeM npoqBfleHhfl t-lcA - or 10 ao 60%
cnyqaeB. !,nn ncopnarrqecKot-o cnoHAtr'nvra
TaK xe xapaKTepHa Bapna6eluHocrb KnvHt/1KlA
Moxer npoflBnflTbcn 6onnrttu, cKoBaHHocTblo, orpaHntreHreM noABhxHocrv nnvt npore<aru 6ecchMnroMHo. BoeneqeHile B npollecc
Cu vruerpn.{H urfi aprpl4T
KpecrlloBo-noAB3Aor.rHbtx coqneHeHuil w no(co6creex xoe na6np,qexrae)
y nallheHToBc f1cA, KaKnpaBhrlo,
3BoHor-rHl4Ka
Bcrpeqaercff npv Hanvqw nepnQeprqecKorrqecrmfi npollecc 6onuuloro qrcna MerKNX,
ro aprpl/Ta. B ornuqile or aHKilro3Ltpytoulero
cpeAHilx 14KpynHbrxcycraBoB. .4e6ror 3a6onecnoH,qilnoaprphra xapaKTepeH <nepecKaKilBaHtAfr
C nonilaprpl/Ta AHKTyer Heo6xoAl4Mocrb
eaoulilfi, Tnn nopaxeHtt+ no3BoHotlHilKa,a He
gil OOepe HLlrafl bHoh nnar nocr tAKtA
c ge6oro v
paCnpOCTpaHeHile
BBepX>.
npOUeCCa<CH1,43y
peBMarorAHoro aprpilra. Heo6xogravo o6paroAbr
K arhnilLrHbtMnposBneB nocrepHre
ulaTb BHrMaHfieHa BoBreqeHLleB npouecc TaK
HllcM flcA oruoccr pcA cl4HApoMoB,Koropbte
Ha3brBaeMbrx<cycraBoB r4cKrtoqeHrF>:MexMoryr BcrpeqaTbcF y na4reHToB c AepMaroQaraHroeurx cycraBoB 1-x nafibueB Kilcreil soM. K HilM orHoccr:
n cron, AMC, ManonoABvtxHbtxcoqleneHuil
. flepnQepilqecKile oHTe3ilTbr
(rpygmHo-KroqmtrHbre, rpygl/Ho-pe6epuute, .
fla<tunvt
Burcoq
Ho-HuxHeqefiocrH bte)
. lAzonupoeaHHurfieHre3hr
l-1pul-lcA Bo3MoxHo pasBilrhe aHKnflo3Llpyro- .
Cr,rHApovrSAPHO
u-lero cnoHArnoaprpilTa c caKpornerrov. Kar
. CraHApoMnepeAHefi rpyguoil rlet<u
npaBLrno, ra<ofi BapmaHTBcrpeqaerce B co. XpoHravect<tttirrluynslaQoraluuutft
pet1,vtrvtleraHVV c nopaxeHileM nepnQeprqecKrx cycBl4pyroull/ fr ocreo v n e nvr
TaBoB. flo AaHHurMpa3nntrHbrxaBTopoB npo. Ourrrxo-naxilAepMonepLrocl4T
ABneHVAcaKporflet ra npt flcA eutnennlorcq B
. CnoHgr notrwcwr
r.ul4poKoM
Amana3oHecnyqaeB - or 19 ao 85%
. lAsonupoBaHHbre aprpanrvn
(4,12,13). OH Moxer nporeKaru 6eccnvnroMB rrrurqeo<ofr rapruHe [lcA BaxHoe Mecro
HO,BbfqBfiCqCb
TOflbKOnpil UCnOfib3OBaHVnAO3aHilMa|oTnepilapTilKynFpHbrenpocBneHtAA,K
norHklTerbHbrx l/HcrpyMeHTafibHblxMeroAoB
KOTOpbTM
npexAe Bcero orHocflTCA EaKTnnvrbl
ilccfieAoBaHVfl. XaparrepHo oAHocropoHHee
m 3HTe3ilTbt.
wntA acrMMeTpilrrHoe AByxcropoHHee nopaflan<tunwt (aocnaneHre nansqa) BKrroqaer
xeHile c pasnnrHofr peHTreHonoril,.tecKoft
Boc n an e Hz e cyxo)Ku nvtin cr w6ane neil u apt prttt
ctagueit npoqecca. Y qacrr nallreHros c flcA
MO, nO r flnO cycraBoB oAHoro naflblla KACTIA
nOpaxeHne rorbKO
BO3MOXHO
r/3OnilpOBaHHOe
w/unw cronbr - oceeofi aprpr4T- THnrL{HoenpoKpecrqoBo-noAB3rqo[uHbrxcorneueHrfr, 6es
I BfleHh e cepo He raTn BHbrxcn oH.qNnoaprpl4ToB,
pacnpocrpaHeHre Ha Bbil.lefle)Kaulile orAenbl
BKrroqanu flcA. flo4auHutv Gladman D h coaer.
n03BOHOtlHl,lKa.
(2005r.) ra<ofi rnn nopaxeHun pa3BrBaercn y
B ourqre or Lpyrilx cepoHerarrBHbtx cnoH49o/o 6ontHurx flcA. flopaxeHrae nanbueB cron
Ennoaprpl4roB, caKpornenT npv flcA voxer
c nocneAyloull4M QopunpoBaHmeM AecrpyKnporeKarb lt3onilpoBaHHo, 6es coorBercrql4rl cycraBHbrx noBepxHocrefr ecrpeqaercn B
Byrou{ero nopa)KeHilq n03BoHoL{HtAKa.Bog65% cnyraee. CnerlraQnvHocrb traKrvnvra Me
MOXHOCTbpaHHerO BOBfieqeHrq B npoqecc
AnarHocrrrr [lcA cocraBnqer 90,5olo(no trauKpecrlloBo-noAB3AourHbrx
cottfleHeHnfr(Kpl-l),
HurvrlzlP PAMH). fia<tunwr Moxer nporeKarb
BepoqrHocrb flareHTHoro v v3onvpoBaHHol-o
KaK ocrpbrft npo4ecc c rrnflLtHbtMlt npoqBfie54
nanbqeB cron
flartunutbr
(B.B.Ea,qoxux,2OO7rl
- BblpaxeHHaF6onb, nprnyxflocrb, oTeK
HtAflMtA
Bcero naflblla, orpaHilqeHile noABLlxHocril 3a
c,.{er cril6aHlAfl, l-lraHorl4t{Hoe oKpaluilBaHile
<coculcKoo6pasHoiln
Koxlr c OopM14poBaHileM
geQopval1t,z'n,TaK r KaKxpoHl4qecKAh,c yron-
K nopaxeHmlo cepAlla Moryr 6utru orHeceHbl
nponBneHVfl LwcrpoQwvt Mt/oKapAa, MiloKapATrrbr,Bo3MoxHo pa3Bllrne aoprura. fl,nn cepoHerarilBHbrx cnoH.qrfioaprpl/ToB B qenoM il
Arq flcA B qacrHocril xapaKTepHo nopaxeHile
BOCXOA'IuleroorAena aopTbl c pacnpocTpaHeuleHNeMnanbqa 6ee6onw il noKpacHeHVe.
HileM Ha aopranbHble KranaHbl, ycrbe BeHeqSHresilrut - Ltacro Bcrpetlalouleecs Bocnal4
neHile B Mecrax npilKpenn9HVA CB93OK CyXO- Hbrxaprepmfr , vexnpeAceppHyo neperopoAKy.
Ta<oil Qrz6posttpytoutnftnpouecc Moxer cnoxvtnnh K KocrnM c nocneAyrouleft pe3op6llhefi
cy6xoHgpansuoft Kocrt4. Har6olee rilnhqHbl- co6creoearb pa3BLlrl4o aopraluHoil HeAocraTorlHocrn, oKa3btBatoulefiBnvAHVeHa nporHo3
oHTeGilToBnpil flcA cerqMil noKafiAsaLvtAMVt
ea6oneeaHilq. flo AaHHbtMnilTeparypbl aoprl4T
loTcq:
qaule accour/l/poBaHc ncopilarrqecKrM cnoH. 3aAne-BepxHflnnoBepxHocrbnqroL{HoftrocTr B MeCTe npilKpenneHnfl axilnaoBa cyxo[ilnoaprpr4roM ( 16, 17).
l-lopaxeHre noqeK npr flcA Moxer nporeKarb
xLlIbff
' Mecro npilKpenneHVfl noAotxBeHHoroanoB BhAeraoMepynoHeQpmra,cBff3aHHoroHenocpeACTBeHHoc ocHoBHbtMga6oneealtAeM vnv
HeBpo3aK HilxHeMy Kpao nnToqHoro6yrpa
. Syrprrrcrocrb 6onur-ue6eplloeoft Kocrrl
no6oqHutvtr eQQe<TaMil Tepanrfi, aMnnovtr. Beprenur 6e4peuHofi rocru
Hofr ne$ponar.Av il KaK cneAcrBme rilnepypl4. Mecra npilKpenneHnecBs3oKnneLla(pegro).
KeMilqecKnx vera6ofl ilvecKilx Hapyuenwh. Ha
TgXeCTbnOpaXeHilff noqeK cyulecrBeHHo BnvlffOqeHra BbrpaxeHHocrneHTe3ilToBocyqecrBrgercq no 13 ToqKaM c noMou-lblol/HAeKca er xapaKrep AepMarosa uf unra[lcA (1 5, 19).
XaparrepHbte nponBreHrfl cepoHerarhBHblx
MASES (Maastricht Ankylosing Spondilitis EnB BilAe nopaxeHrF' rna3 vl
cnoHALlJroapTpTlToB
tesisis Score).
cntA3vcrbrx o6oro.leK BCTpeLtaprcF c pasuoil
TeqeHue ncopilarilqecKoro aprpnra coqacrorofr v npv flcA, qto 3arpyAHtler eepnQrnpoBoxAaercq pa3BilTileM cilcreMHblx npoKaqmo AharHo3a BHyrpt4gaHHoil rpynnbl sa6oneneutah, qaule BcTpeqaou1ilxcn npil 6onee
neea+tAil.
Tnxenblx Qopvrax. lAs o6uJux npoqBaeHtah xaB Hacroqulee BpeMtl orcyrcrByror cneqr$npaKrepHo pa3Bmrmey nauileHToa o6ueeocnaqecKhe na6oparopHbte H ilMMyHorlorrltlecKre
rilTerbHoro cilHApoMa B BilAe nrxopaAKn, noxyAaHrR,nrrrvQa4eHonar/M.Kar npaerflo, oHTl MapKepbr flcA. Lnn noArBepxAeHVA aKrnBHocrr npoqecca rcnonb3yror o6ulenpLlHtlrble
Bcrpeqaorcfl npil rffxerbtx Qopvax AepMaro3a wnv arilnilqHblx ero BapHaHTax, pa3BlATtAtAocrpoQasoBbte noKa3arerr,r(CO3, CPE). Ans
naureHToB c ncopl4a3oM tt l-lcA Bo3MoxHa rilaprprra e 6onee MonoAoM Bo3pacre, gaule y
nponepyprKeMilq, HeKoppeflrpyoqafl c nopaxeMy)Kr.fr4H,
BoBfieqeHAVB naroflorilLtecKril
vlera6onrLlecKhe
HileM Koxr4, a orpaxaouatl
Llecc cepAlla, noqeK, neqeHn,
A R S M E D I C AN S 5( 1 5 )
55
T]COPIIATI/I=CKI/NAPTP'4_T
n P o L U ro E ,H AC T O fl UE E
/ svA vU E E
AHrunosn pynulufr cnoH,q,unoaprpnr
(co6creex noe na6n p.4enne)
Il apaeepre6pansx ue occuQurarsr
(co6creexnoe ua6atogenrae)
. epoerrrraKoHueBbrxQanaHr nanbqeB ntcteh
r cTon
. KoHqeaoe cy)KeHile OanaHr h qarxeo6paeHaA AeQopMaqilq npoKctlMaruHofi qacr/
6onuHurxonpe4eflcor nofloxnrenuHutil PO (y
QanaHr no rilny <KapaHAa[uB KornaqKe>
10-15o/o He3HaqilTeflbHoenoBbl[xeHtAeTVTpa. . Ocreorh3, qau-leacilMMerpw,tHatil
. AclrvvrerprvHurft r<ocrHurfr
(Gladman D, 2005r). B Ae6rore cycraBHoro cllHaHKNro3
. Carpon nettT,orqHocroponnuh ilnil AByxcronpoBeAeHtAA
npra
Heo6xoATrMocr/
AilO,qpoMa
poHHrrrfiacilMMerpmqHurlr
QepeHqnaflbHoro .qharHo3a c peBMaroilAHbtM
. flapaeepre6panuHbreoccnQrrarut
apTpl4TOMXenaTerbHo npoBo.qilTb l4ccfleAoK ocHoBHbrMpeHrreHovopQonorrLrecKnM
BaHile onpeAeneHnq aHTVTeaK LlilKnilqecKoMy
r-14rpynilHrpoBaHHoMy
nenrilAy (aHrN-CCP).
orrr4rryreMflcA r PA orHocqt (47):
. PacurrpeHhe cycraBHoh ulenu
flpra flcA ilMeor Mecro cBoeo6pa3HbtepeHrreHonorilqecKme cfiMnToMbl, no3Bo'|9lou-lre . ,[ecrpyruras AMO cycraBoB
. Co.leraHile ocreonv3a c Qopvr,rpoBaHreM
npoBoAl4Tb cnoxHurfr gilQQepeHqraruHstil
AHKHNOSOB
AilarHo3 KaK c PA, rar tA c aHKnllo3t/pytou-tnM
. CoqeraHhe nepilQepruecroro aprpvra co
cnor'Annvrov (45). K Hr,rworHeceHbt:
. AcrrtvrwerpilLrHocrbnopaxeHrF
cnoHAhnfiToM
. OAno vnv AByxcropoHHrrrfraccrMerpltqHutil
' OrcyrcrBile BbrpaxeHHorooKorocycraBHoFOOCTeOnOpo3a
caKpoilneilT
. l-lopaxeHile AncrarbHbrx vexQanaHToBbtx . uflepecrcarreaoulmil, TVn pacnonoxeHttfl
HapylxeHiln. prnn ficKnroqeHrq coqeraHilq noAarpbr n ncopra3a peKoMeHAyercF l4ccneAoBaHne cvHoB4anbHofrxilAKocrl4 c LleabCIBblqBreHVA KpncraflnoB MoqeBofi rncrorst. V .lacrrl
.
56
cycraBoB
KocrHan nporuQepaqrF B Mecrax npmKpenneHrc Mbrr.xu
'
cilHAecMoQrroa
Ceoeo6pa3Haq peHrreHovopQonorv+ ctAHgecvoQrroe
llepuocranbHbre HacnoeHng,oHTegurbt,
aprpr4Tbrraeo6egpeHHbrxcycraBoB,
caKpor4neur(co6creeHHoe na6nro.4enne)
. flapacnrHaflbHbreoccilOrKarbl
. OrcyrcrBne <recrHr4trHofr> HanpaBfleHHocrl4
B 3BOn|oqilil CnOHAVII'VTA
. flepNocraflbHbreHacfioeHrF
. Cy6xoHgpanuHsrftoreK Kocrneo6nacril eH-
eposnu KoHlleBbrxQananr
(co6creeu xoe xa6np4enyre)
TC3OB
cpaBH[TenuHurilaHafln3 AaHHbrx588 naqNeHToB c flcA N 536 6onuHbrxc cr4HApoMocxoAHbrilocraHoeKa AilarHosa ncA npoBo4r/rcq nyMil sa6oneBaHmnMr (PA-383, AC-72, HegrQTeM OLleHKrlTilnilqHbtx KfiTrHyrqecKvrx,
aHaMQepeHqrpoeaHHurfiaprpl4r - 38, A3CT - 14,
HecTiltlecKrx AaHHbrx l4 pe3ynbTaToB AonofiB
Apyrile -28). B 2006 roAy Ha <ouQepeHL\utA
HilTenbHbrxMeroAoB l/ccnegoBaHtt+. !,o 2006
Crorronuve 6urnn npilHflTbr<naccnQnKaqmoHroga ilcnorb3oBaflucs nau6onee qacro Kpr4- HbreKprreprr [1cA CASPAR:
repwt Moll and Wright (1973),rzveoune Bbr!,narHoe l-lcA rvoxer 6srru ycraHoBneH npkl
coKyro tryBCTBilTerbHocrb r cneqnQilqHocrb,
HantAqtAtA
BocnanilTen bHoro 3a6oneBaHilF cycno KoropbrMB cBoe BpeMfl tn6anta eur4eneHsr5 TaBoB (aprprl cnoHAr4nr4T,
oHTegilT)r He naeKnaccilqecrrx Qopvr flcA. OHil aKfltoqator:
Hee 3 nph3HaKoeils 5 npeAcraBfleHHbrxHhxe:
1. Aprprr BocnanilreflbHor-o xapaKTepa (ne. f l c o p m a r / q e c K r e B b r c b r n a H h nB, b r n B r e H H b r e
prQeprre c<uirraprpr4r u f wnu caKpol/flenl
Ha MoMeHr ocMorpa -2 6anna
cnougmnrr)
. f l c o p r , r a 3B a H a M H e 3 e- 1 6 a n n
2. Hanu\rAe ncopila3a
. CerueilHurfrncoprrae - 1 6ann
3. OrpNqarenbHbreceponorilqecKre recrbr Ha . Trnil.rnoe
.D,nnncopila3a nopaxeHhe HoFTePO
Bbfxnr|acTrH - oHl4xonn3nc,<cilMnToMHanepC qenuro eurpa6orril eAnHbrx<naccrSnracrKa>, rnnepKepaTo3, 3aperilcTpl4poBaHHoe
UroHHbrx Kphrepilee flcA c 2002 roAa MexAynpu SuswKaflbHoMo6cnegoealm - 1 6ann
HapoAHaqrpynna nccneAoBareneil (Classifica- . OrpnqarenuHuril pe3yflbrar Ha Hanvqve peBtion of PsoriaticArth ritis - CASPAR) gaHn vanacu
MarohgHoro Qa<ropa c Hcnonb3oBaHileM.ruonpocneKTHBHbrMn3ytleHileM KflilHl4qecKilxtA
6oro ueroga, KpoMe flareKc-recra - 1 6ann
peHTreHofloFr4qecKnxAaHHbrx na4reHToB c
. flawvn/T B MoMeHT ocMorpa (nprnyxaHile
pa3nrqHbtMl4BocnaflilTer|bHbtMunopaxeHhFBcero nanurla) nv6o yKa3aHile Ha EaKTtntAT
MvrKocrHo-cycraBHoro annapara (54). WccneB aHaMHe3e,3aperilcTp?lpoBaHHoepeBMaAoBaHmFoKoHrlnrncloe 2004 roAy. lpoeegeH
ToaoroM - 1 6ann
. (MRr)
A R S M E D I C AN A 5( 1 5 )
57
tICOPI/ATI/IECKI/NAPTPI/I
uPoLr_rroE,
HACTOFUEE
/ syAyUlEE
.
PeurreHonorrqecKoe noATBepx6eH.heKocrnofi npon wQepa4wu (occrrrQrzrratlAnKpaeB
cycraea) ricKfitovan Qopvr,tpoBaHile ocreoQrroe Ha peHTreHorpaMMaxrrcreft il cron
- 1 6ann.
. Cneqr,rQilqHocrb KprrepileB
cocraBneer
- 91,4o/o.
98,7o/o,LIyBCTBilTeIbHOCTb
flpn nocraHoBKertrnarHo3aAnF onpe4eneHne
aKTLlBHocrn, peHTreHonorh,lecrofi cra4nn v
QyH<4rrroHaluHofi HeAocraroq Hocrkl ilcnoab3yor re xe MeTolhqecKrle noAxoAbt, rlro rl npn PA.
O6uerv repaneBTilvecKrx Meponprq tah npu
retreHilil f'lcA onpeAeneercn cocronHl4eM r reqeHileM He ToJtbKocycTaBHoro, Ho il KoxHoro
cl4HLpoMoe..[nn netieHiln ilcnonb3yCITocHoBH b r er p y n n b t n p e n a p a T o B ,n p r 4 M e H q e M b then p H
Apyrmx BocnanhreflbHbtx sa6oreeaHilnx cycTaBoB - HnBC, rlpKoKoprtAKotA4lt, 6asilcHure
n porl4 BoBocnanhrefl bHbte n penaparu ( 5f1B f1),
aHrruilroKfi HoBbtecpeAcrea ('16).
l-ereporeHHocrb flcA ArKryer Heo6xoAilMOCTbVtHtrtABtAAyan
bHOro n pr MeHeHrfl yKa3aH-
cana3vH,
leQnoHaMVE,
t1lAKfi
ocnopilH,
vHrtA-
6mropurOHO-o.f1onoeogyconeft3onorahMe-
roTcFn poTl4BopeqilBbte AaHHbte, oHh noKa3aHbl
npr f1cA, He conpoBoxrqaoqeMcn nopaxeHileM no3BoHoqHilKahnH KpecTlloBo-noAB3AotUHbrxcoqnenennil (41).
Merorpercar qBflflercn npenaparoM eur6op a c p e g h E n B n . O H e n e p e u r e6 u r r n p i l M e H e H
e 1951 rogy Aflq neqeHhfl rnxerbtx Qopvr AepMarosa r flcA (33). npoBeAeHbt3 vHoroqeHTpoBbtx Lt HecKonbKoKfll4Hrt{ecKilxilccfleAoBaHVil, a Koropbtx 6urla AoKa3aHaero BbtcoKaq
eQSerrreHocrb r xopouafl nepeHocnMocrb.
flprzrl-lcA MerorpeKcar Moxer npilMeHflTbcn B
Lxr4poKoM
Ailana3oHe .qo3 ot 7,5 Ao 3Ovr/Heg.
(35). npn peQparrepHbtx gopvax flcA u/vnv
Tqxel blx tAntA aTtAnt4tl
Hbtx Bap h aHTax AepM aTo ga AoKa3aHaeQQerrilBHocrb LlHTeHcrBHofi
repanntA BbtcoKrMl4Ao3aMil MerorpeKcara (100
vr e/e) B coqeraHnu c 250 Mr MerilJtnpeAHn3onoHa (36). floroxhrefibHoe BrtaqHile MerorpeKcara Ha cycraBHofrcru4poM cBn3btBaor c
HblX npenapaToB B 3aBilCl4MOCTl,{
OT BeAyU-tl/X ero cnoco6Hocruo HaKannrBarbce e aurcorofr
Knr HhqecKrx n ponBnewnil.
KoHLleHTpaLIAt KaKB ctAHolnanunoil xLlAKocrN,
MoHorepanmq HfIBC noKa3aHaronbKo npr
raKV B KOprilKaflbHOM
CnOeKOCTLI,
B BOCnareH<Mflf-KoM> Tet{eHilu ga6ofl eBauun 6es BbtpaxeH HblxeHre3ax (22). florasaHrAMn MA Ha3HaqeHbfx BocnarilTeflbHbtxnponBnennil, HanphMep HtAe MeTOTpeKCaTaCnyxar: reHepaflil3oBaHonnroaprptATvntAm3onrpoBaHHoeTetleHileapHuril aprphr c eKccygarrBHbtM KoMnoHeHToM,
TpilTa EhcrarbH urx vexQaraH roBbtx cycraBoB. Tqxecrb reqeHilq c 6urcrputM nporpeccllpoOguaro Aaxe npr orHocilTenbHo cnoKofiHoM BaHreM AecTpyKt_ltAucycTaBoB, BbtpaxeHHbte
TeqeHril ea6oneaaHVA ox.vtqaru croftroro eQcilcTeMHbte npoqBneHuF, 3noKaqecTBeHHafl
roJtbKoHnBC He npflxo- Qopva, BbrcoKaela6oparopHaff aKrilBHocrb,
Qe<ra or Ha3HaqeHVfl
Kar npaeuro, y nauileHToBytMeerMec- aTilnrLrHbte npoFBJ]eHrq AepMaTo3a, Hu3Kaq
rqNTbcR.
ro crofrrrfr 6oneeoh cungpoM, orpaHilqeHl4e eQQerrrzreHocrbHnBn, IKC, gpyrnx EflBC.
ABuxeHiln, vro rpe6yer pacuupeHrfl TepaneBflpnveHeure
cynuQaca nasvHa oKasbtBaer
TZqecKLlx Me po n pil et ttth'.no<anbHoe BBeAeHhe yMepeHHbrfieQQerr npr nopaxeHrtA cycraBoB
rn oKoKo prll Kocrepor'tAo B, Ha3HaqeHre 5 l-lB l-l.
tA KOXLA,HO He BnVAeT Ha nopaxeHLle no3BoCrcrevHoe npil MeHeHile rfloKoKoprt4Kocre- HorlHmKan nporpeccrlpoBaHVe aprptfia (24,pol46oB npr l-lcA noKa3aHo npil reHepanil3o- 32). HasHaqaercfl B cyroqHorZAose 2-3 r/cy:r.,
BaHHoMnepNQepmqecKoMaprpmre, aurcoroil xopor.xo nepeHocrrce naLlNeHTaMr.[1o gaua KTil BHo cr r ea 6 ol e BaHtAfl, HamA.vtAlAC
r cre MHblx Hurv B B SaAorraHa(2OOS)
cynuSacara3nH nonponereurfr vnn HeeQQerrhBHocrt4 H|1BC. noxilTerbHo Bnrner He ronbKo Ha cycraeHoil,
KoHrponrpyeMbtx t4ccneAoBauwh eQQerlaeHo r Ha roxHurfi cilH4poMbt.
Hocrl4 HilBC n l-KC npr,r[1cA He npoBo4l4flocb.
K noragaHtA+M lnq Ha3HaqeHilF cynu$acaVpoaeHuAoKa3arerbHocrl4ocHoBaHTorbKo Ha nagvHa orHeceHbt onilroaprprrilLtec<uh gvtcMHeHrr SKCnepTOBtAnv onvcaHt tA orAeflbHbtx ranuHuril v nonvaprprrTtqecKuil eapuaurur flcA
KnmHil lec rNx Ha6l lo Aeuttth.
c yMepeHHoilnnu MnHrManbHofiarrileHocrblo,
Cpe4n SnBn oQrqranuHo pa3perxeHbt K a TaKXe HenepeHocr4MocTb MeToTpeKCaTa.
nphMeHeHilo npil flcA verorpeKcar, cyruQaB 2005 rogy OapMaKororrqecKLtM KoMilre5B
roM PocctAiACKofA
Oeaepaquu6un pa3perxeH K
hcnofi b3oBaHiltonpm flcA reQryHovng.
Cpe.qil paeHoo6pa3HbrxMexaHil3Moe .qeficrern neQnyHaMmganpr,rflcA oco6oe 3HaqeHre
ilMeer 6no<aga eKcnpecchl4 MoreKyn KfleroLrHoil aArestAtA,gaMe4reHne xeMoraKcuca neilrpoQrnoe, cHrxeHile eKcnpeccrzt'i'MarpLlqHbrx
MeTannonpoTehHa3,qTo B coBoKynHocTr4Moxer cnoco6creoaarb yMeHbueH14roAerpaAal-lr/l/ xpnu4a tA Kocrtt, T.e. Bo3geltcrBoBarb Ha
KocrHyroAecrpyKUno (38). Kpoue eroro, oco6euHocruro neQnyn aMVtAa fl Bflflercn BnvAHVe
Ha nponNQepallilro enrgepMaflbHbrx KneroK
6narogapq ropMoxeHho crHre3a p53-peryflgTopa KfleTOtlHOr-O
4ilKfla, qTOBaXHOAJ]FnCOpila3a, conpoBoxAatoulerocq rrnepnponrzQepaqrefi enN.qepMrca (34).
f1o 4aHHurM orKpbrrbtx t4ccreAoeanuh fleQnloHaMilA o6ragaer repaneBTrqecroil aKrrBHocrbo npm ncopfia3e ra llcA (37) a Ao3e
10-30vr/cyr. B geofiHov cnenoM nnarle6oKoHrpornpyeMoM
l4ccneAoBaHWt (TOPAS
- Treatment of Psoriatic Arthritis Study), AnvBueMCff 24 uegenu, reQnoHaMuF, noKa3an BbrpaxeHHyro repaneBTilqecKyro e$QerrreHocrb
no AaHHbrMAilHaMilKLrOCHOBHOT-O
KpilTepilrr
eQQe<rmaHocrrl npoBoALrMoilrepanrr - PsARC (Psoriatic Arthritis Response Criteria), rrcfio nallileHToB,orBerrB[uvx Ha repanmlo neQnyHaMilAoMoKa3anocu e 2 pa3a 6onuure, qev
B rpynne, nonyLraou1rxnnaqe6o (37). Becuva
mHrepecHofi ffBnnerce pa6ora Cuchacovich
and Sato 2002 (24), e <oropoil noKa3aHo BnveHre neQnoHaMhAa Ha reMnbf peHTreHororrqecKor-o nporpeccnpoBaHt/.e N peMoAynrrllilro
Kocrl4. err gaHubre noATBepx4aor Bo3MoxHocrb neQnoHauntra ropMo3Trrb KocrHyro 14
xpnuleByto AecrpyK4l/o npm flcA. I-lplreM npenapaTa MoxeT conpoBoxAaTbcs Ao3o3aBrcilMblMr no6oqHsrN/r eQQerraMil, pa3BtABaauJttqaule B nepBbreMecrr4brHa3HaqeHuq.Wx
MTACA
MoxHo he6exaru nyreM cBoeBpeMeHHofir<oppeKllr4r/ cyrosHoil Ao3bt, tAntAorKagoM or Ha3HaqeHileHacbrulaouleftAosst npenapara (100
Mr exeAHeBHoB reqeHile 3 gHefi).
Hecvorpn Ha y4oBnerBopilrenuHuril eQQerr
or Ha3HaqeHnAKnaccilqecrrx SflBf'|, ocraercn
p F r 4H e p e u e H H b r B
x o n p o c o BB r e q e H r r A a H H o r o
sa6oneaanmc. KnaccilqecKhe SnBn He 3aMeAA R S M E D I C AN S s( 1 5 )
flqoT peHTreHofloTl4qecKoronporpeccmpoBaHrfl, noqrn He Bnvator Ha KocrHyropeeop64uro,
He ocTaHaBrr Balor n porpeccrl poBaHre apTpt4Ta il cnoHEnnvra, qro AilKTyer Heo6xoAurMocrb
noilcKa Apyrrx npenaparoB. B HecKolbKnx
rccneAoBatzex 6urno noKa3aHo, vro npm l-lcA
HapeAy c gnc6anaHcoM npo- 14nporLrBoBocnanhTenbHbrxr_lr4ToKl4HoB,
ilMeeT MecTo noBbtLxeHHoeHaKonneHraeOHO-q B Ko)Ke, ctAHoBtAanuHoil xllAKocrl4, B TKaHnx. OHO-a ilrpaer
KnoqeByo ponb B pa3BilTLilABocnannTenbHoro
npouecca He ronbKo npr PA, Ho n npil ncopl/ase, ncA. OH o6na4aer r.rkrpoKllMcneKrpoM
6vonorw.aecKTrxeQQerroe, o6ecneqilBatoulnx
BOCnafirlTenbHyro w 14MMyHoperyflqTopHyro
aKTmBHocrb.BaxHofi oco6ennocrbto AeilcrerrrqOHO-a npm flcA qenqerce eFo yqacrme B
peMOAenhpOBaHril 3a CqeTyCVneHVn
KOCTHOM
RANKL-saBrcrMoro ocreoKracroreHe3a, Bo3MOXHO Bbr3brBatoqero pa3Bl1Tile BHyTpr/CyCTaBHoroocreoflr3a y nauileHroe (9,1 3).
flprsHaHNe eaxFroftponr OHO-d BpasBnrrzrrr
r4MMyHoBocnarilTenbHbrx3a6oneBaHnf4 npilBer|O K CO3AaHilCIMOHOKflOHaflbHbTX
aHTilTefl,
yrHeraroulnx AaHHbth 4uro<wH. C 2005 roAa
ncopila3 tA llcA cerqorcrr noKa3aHileM Anq
Ha3HaL{eH
nn 6uonorrqecrofi Tepanw. f1poeepaHAOMl43l4pOBaHHbrx
nnalleAeHO HeCKOfibKO
6o-rcoHrponnpyeMbrxrlccneAoBanwittc npilMeHeHileM MOHOKflOHanbHbtx
aHTilTeI pa3firr]Hbrx
KraccoB (50). B ilccneAoBaHnv IMPACT (The
Infliximab Multinational Psoriatic Arthritis Controlled Trial), oueHNBanacbeSQerrreHocrb npenapara y 104 6oruHux BbrcoKoaKrmeuurna
f1cA,
He orBermBr.rr,rM
Ha fietreHile xorfl 6ur o4Hrv me
SnBn Q0). AntarenbHocrb retreHilq cocraBntna 50 HeAeru. Tepanrn unQnu<crMa6oM e
Aoge 5 vr/rr Bbr3Bana3HaqilTenbHoeyMeHb[xeHne cHMnroMoB aprprra, neneuwh AaKrt rlvra,
eHTegilTa, KoxHbrx npoqBneHnk. locttttrHyroe
ynyqueHile coxpaHFnocb no BceM KoHTponilpyeMbrMToqKaMB reqeHne 50 negenu na6notrelrt+. flepeHocmMocrb unSnu<cuva6a y Bcex
6onuHurx 6ana xopourefr, qacrora noclaHQy3l4oHHblxpear4mil, HexefiareflbHbrx ABneHwil,
rpe6youlr/x npeKpauleHiln fleqeHrfl, 6urna conocraBrMoh e o6eux rpynnax (20).
B orrpurrov 2-x aerHeM taccfleAoBaHltv, no
oLleHKe eQQerra uuQnu<ctava6a Ha pa3nilq-
59
nc o Pl/ATt/I1=cKt/n
n=tpttlt
/ svlvu_lEE
r-r
PolirroE,HACTOF
r_uEE
Hbre napaMerpbr BocnafirreflbHoro npollecca
y 6onuHurx[1cA, ernoqae peHTreHofiorl4t{ecKoe
nporpeccilpoBaHile y 6oruur,rHCrBa 6onuHstx
He ua6noAanocb npilpocra eposttfr vnn nporpeccLrpoBaHnfl cyxeHiln cycraenofi qeflil.
AHanormqHbrepe3ynbrarbr 6unu nonyqeHbt B
ilccne,qoBaHtAtAIMPACT ll. Ta<rv o6paeov,
uuSnu<ctn a6 Aora3an cBoto eQQerrreHocrb
y 6onuHurxc |1cA KaK npn KparKoBpeMeHHoM,
TaK w nptA AnvreflbHoM npilMeHeHilvt. l-loragaHilq K npilMeHeHua wa|nurcmva6a npr flcA
cneAytou-lile: MaKchMafibHaq aKTHBHocrs sa6oneBaHtAAHa nporflxeHuv 3 rrr6onee MeceqeB,
HeeQQerrrBHocrb rnil HenepeHochMocrb He
MeHee 2 -x 5l-lB fl, nor maprpnrvrqecKrfr, ocreonuttqecrufA
nnv
cnoHAilnoaprpnrutlec<nil
BapilaHTbr cycraBHoro cilHApoMa, 6utcrponporpeccilpyroulee reqeHile, peQparrepuutil
K Tepantah roxHuril cnHApoM tArv ero rflxerbre
Qopvrur.
flpr,r flcA Haunr npilMeHeHNe pa3nilLtHbre
wnru6vttopur OHO-a, BKflloqar v nofiHocrbro
qenoBeqecKile perov6raHaHTHbte MoHoKnoHaflbHbre aHTLrrefla. 3aperucrpNpoBaH Anc
npilMeHeHVA npv llcA a.4anrrrvyva6. K 2005
roAy 3aKoHrrilflocbAeoilHoe cnenoe nnarle6oKOHTpOnilpyeMOeilCcneAoBaHrle, B KOTOpOM
npoAeMoHCrp14poBaHaBbtcoKas eQQerrreHocrb aAanilMyMa6a npu flcA. Uenbo rccne.qoBaHhff ADEPT (ADalimumab Effectivenss
in Psoriatic Arthritis), 6urna oLleHKarepaneBTilqecKoro BnvAHVtAaAanilMyMa6a na Bbtpavt TeMnbl peHTreHoxeHHocTb cilMnToMaTVKlA
rorilqecKor-o nporpecctApoBaHVA npoLlecca
y 6oruHurx rcxeflbrM l4 cperqHerqxeflbtw flcA
(43).lAarcpec K aAanilMyMa6y npn ['lcA autcor,
rlTo AoKa3btBaeTcqMHoroqilcIeHHblMTl l4ccfleAoBaHrFMn. HegaeHo 3aKoHqilnocbMHorolleHTpoBoe, orKpbrroe ilccnegoBaHne STEREO,
rge noKa3aH nonoxmrenuHutfreQQerr npenapara y 442 1ontHbrx c aKThBHoreryulttv f1cA,
pe3hcreHrHbrMK oAHoMy unu 6onee SflBfl nrm
6tAonoru,tecKilMareHTaM (55). Ha ocHoBaHnil
pFAa pa6or MoxHo c.qefiarb 3aKnotleHile, qro
cnMnroMoB v Bnt4nHheHa peHTreHofiorhqecKoe nporpeccilpoBaHre ea6oneBaHt A (30,42)
B cecgr c ermM aganilMyMa6 uoNer rcnofib3OBaTbCcKaK B COqeTaHilVC ApyrtAltt 5[lB[],
TaK v Br.qe MoHorepanhil. flpe4nonaraercg,
qro ero nprMeHeHVe nptt paHHeM llcA vroxer
He rofl bKo n peAoTBparvrb n porpeccLl poBaHile
6onesHn, Ho m cnoco6creoearu croilroil peMt cctAtA
aa6oneaaHilq.
AHanNenpyq Bbr[xecKa3aHHoe,MoxHo cAe.rro l-lcA qBnqerce pacnponarb 3aKnroqeHr,re,
crpaHeHHurusa6oneBaHileM, nopaKaoull4M, B
o c H o B H o M ,T p y g o c n o c o 6 H o e H a c e a e H r e . 3 a 6oneeaHhe, ilMeoulee pa3nilLrHbteBapnaHTbl
TeqeHnF, qacTo Tqxelbre, vHBantA4tA3l4pylorqile, rpe6youlee .qnrreabHoro KoMnneKCHoFo neqeHilq, B ToM rrvrcne u u6agucuoro". flcA
3arparaM c PA u
cpaBHrM no eKoHoMl4qecKLlM
X'lASHtnaUileHTaKXe BflHgeTKaKHa KaLTeCTBO
nporHoe.
Ta, TaKil Ha er-oxr43HeHHbrfr
'Il4TEPATYPA:
1 . 5 a 4 o < r a HB . B . K e o n p o c y o K r a c c u Q w < a 1 v n
ncopharnqecKoro aprpma/ /Knua. peBMar o n . - 1 9 9 5 . - N e 1 .- C . 5 3 - 5 6 .
2.F,atro<ttrHB.B. flcopnarrqecrnfr aprpl/r l/
ncopila3: npo6neva B3ailMocBAgtAvt B3anAvoo6ycnoBJreHHocrw. We6paHHbte neKlq:.i'Vl
no KnvHv.recrofi peBMaronorvlA. floA peg.
B . A . H a c o H o e o i lr H . B . E y H r y r a . M . , M e g r rlvHa,2001, 82-90
3. SaAorrrrH B.B, f"lcoprarr.recKilil aprpt4T
(rnunu<a, AnarHocrvKa, neseHNe). AeropeQepar.4oKr frwcc. M., 2003.
4 . E , a t r o < u HB . B . C o e p e v e H H a n r e p a n r q n c o pilarrqecKoro aprprta, Consilium Medicu m , 2 0 0 5 , T . 7 . N s3 , C 1 8 1 - 1 8 8
5. Sagorr,rH B.B. Cycraeuofi cuHApoM tA ctAcreMHbre npoqBneHilF ncopilarrqecKoTo
aprpilra. /l1oco6ue AnF Bpaqefi. PocMAl - l O ,M o c r e a , 2 0 0 6 , 3 8 c .
6. EaI,o<ran B.B. IeQnronaMilA - Hoeutil 6astActlttiA n porl4 BoBocnan rreruH urfi npenapar B repaniln ncopuarnqecKoro aprpnra/ /
P M X , 2 0 0 6 , T . 14 ( 5 8 3 - 5 8 7 )
a4anilMyMa6 rveer cyulecrBeHHbte ornveve
or SflBl-l no eQQeKrLrBHocrLtrepannv. Pe- 7 . E a 4 o < u u B . B . A u r u q r r o K r H o B a q r e p a n r e
ncopilarmqecKor-o aprpma// PMX, 2006,
3yn braroM n pilMeHeHilq n penap ana6unn6utcrpo Hacrynaoullrfr repaneBrv\ecKvtil eQQerl
T . 1 4( 6 0 5 - 6 0 9 )
onpeAenqevutfr no AtiHaMNKe KrLlHtl..tecKltx B . S a A o r r a H8 . B . , K o p c a r o e a l O . I . l z l H r e H c t a s 60
Hafl repan vq ncoptAarilqecKofo apTptAra./ /
peBMaronortAA,
Hayuuo-npaKTilqecKac
2006, Ns4, C64-79
9. Ea4orraH B.B. Tepanrn aAarhMyMa6ov
ncopilarfiqecKoro
aptpma.//HayrHopeBMaronorv+, 2008, Ns4, C
npaKTilL{ecKae
41-47
10. Senoea E.B. SypraHcraq E.A.,Karrypcrrfi
11.8. vt coaBT. Krmurro-vrop$oron4LrecKhe
npoqBneHilfl nopaxe{Vfl cepALIa npil ncop r a s e . K a p 4 r a o n o r n n .1 9 9 5 , 3 5 , 5 : 6 2 - 6 6
1 ' 1. K o p u r y H o eH . H . , . [ , o p v r r r L o H T oEB. H . ,I x y p ro T.lO. Knrurro-exoKapAmorpaQrvec<an
xapaKreptAorvKa nopaxeHilq cep.q4a npn
CepOHeraTilBHblxCnoHArnoaprprrrrax (6Ore3Hr Peilrepa, 6onesHil Sexrepeea. ncop i l a r i l q e c K o M a p r p r , r r e ) .T e p . A p x r z e , 1 9 9 1 ,
65, 5: 41-45.
12. KoreprraH H.l-. flcoprzras r,r llcopmarilqec < u h a p t p n r / n e K L p A +M M A w l i . W . M . C e q e H o B a -p e n p i l H r . 2 0 0 6 . c . 2 - 1 1
13. HacoHoe E.r| l,4HQnrarcur'ta6npil cnoHEilnoapTponaTnFx il ncopvaTnLrecKoMapr p i l T e : H o B b r en o K a 3 a H i l q .P M X , 2 0 0 5 , T . 1 8
(232)
1 4 . H a c o u o e B . r | n p m M e H e H n eT H Q T A K C V M a 6 a n p w p e B M a r i l q e c K r xg a 6 o r e e a H r n x . M . ,
2005, 56c.
1 5 . f l a H a c o r H . H . , M y x m HH . A . , B a p u r a e c < u h
B.A., tA Ap. KnrHnro-MopQonorrqecKile
oco6eHuocrn ncopltarilqecroft HeQponar u v . T e p . A p x r e , 1 9 9 0 ,6 : 9 9 - 1 0 3 .
1 6 . P e e M a r o n o r t a n/ / K n u H n q e c K i l e p e K o M . ,
Mocrea, ..IeOTAP-Megra,, 2008, c, 92-98
1 7 . L l l n o n o e B . l - . ,C e r c r y H o e 7 1 . B . ,L L l e e v e H r o
T.lA., l-yvrauoecran M.I. l-larororNfl cepAeLfHo-cocygwctoi,t ckrcreMbr y 6onuHurx
ncopila3oM. Kaptrnonolan, 1990, 2:118-
120.
18. Abbott Laboratoriesinternal data: PowerP o i n t fi l e n P s AC l i n i calD ata., A ugust 20,
2004.
1 9 . A l e n i u sG . M . , S t e g m a y r8 . G . , D a h l q u i s t
S.R . R e n a l a b n o rm a l i ti esi n popul ati onof
patients with psoriatic arthritis. Scand. J.
R h e u m a t o l2. 0 0 1 ,3 0 , 5 : 2 7 1 - 7 4 .
2 0 . A n to n iC . E., K a v a n aughA ., K i rkhanB . et
a l . S u s ta i n e db e n e fi tsof Infl i xi mamtherapy
fo r d e rma to l o g i ca n d arti cul armani festati A R SM E D I C A
N S s( 1 5 )
ons of psori ati carthri ti s.A rthri ti sRheum . ,
2 0 0 5 ,V o l .5 2 , 4 , 1 2 2 7 - 1 2 3 6
2 1 . B a k e rH , G o l d i n gD . N . , T h o m p s o nM . P s ori asi sand arthri ti s.A nn InternMe d 1963;
58:909-25
22. B ol ognaC ., E ndoL.,A nayaL.M. et al. M ethotrexateconcentrationsin synovialmembrane and trabecul arand corti cal bone in
rheumatoi darthri ti spati ents.A rthr.Rheum .
1 9 9 4 , 3 7 ,1 7 7 0 - 1 7 7 3 .
2 3 . C o h e n M . R . , R e d e D . Y . ,C l e g g D . O . B a s el i ne rel ati onshi psbetw een psori asisand
psori ati carthri ti s:anal ysi sof 221 pat ient s
w i th acti vepsori ati carthri ti s.J. R heum at ol.
1999,26, B :1752-1756.
24. CuchacovichM, Sato L. leflunomidedecreasesjoint erosionsand inducesreparative
changesi n a pati entw i th psori ati car t hr it is.
A n n .R h e u mD i s 2 0 0 2 ; 1 4 6 : 3 3 5 - 3 3 6
25. Farr M., K i tas G.D ., W aterhouseL. et al.
i n psori ati carthri ti s:b lind,plS ul fasal asi ne
acebo, control l edstudy.J. R heumat ol. l990,29:1427-34.
2 6 . G e l f a n dJ . , G l a d m a nD . , M e a s e P . e t a l .
E pi demi ol ogy
of psori ati carthri ti si n t he popul ati onof the U ni tedS tates.J. A m . Acad.
D ermatol .,2005,53, 573
27. GladmanD.D., FarevellV.T.,Wong K. etal/
Mortal i tystudi esi n psori ati carthri tis:r esults from a si ngl eoutpati entcente P ro gnost ic
i ndi catorsfor death.A rthri ti sR heum. ,1998,
4 1 ( 6 ) : 1 1 0 3 - 1 .01
28. Gl admanD ., R ahmanP .P sori ati ca r t hr it is/
C hapter71. l n: K el l y' sTextbookof Rheum atol ogy.6th E d. W .B . S aundersC om pany:
P hi l adel phi a,
2001, 107 1- 1079.
2 9 . G l a d m a nD . ,A n t o n iC . , M e a s eP .e t a l . P s o ri ati carthri ti s:epi demi ol ogy,
cl i ni ca fl eat ur e s , c o u r s e ,a n d o u t c o m e A
. n n . R h e u m .D i s .
2 0 0 5 ,V .6 4 , ( s u p p l l.l ) ,M a r c h , 1 1 1 4 - 1 1 1 7 .
30. GenoveseM. C ., MeaseP .J.,Thmp sonG . T.
et al. Saffetyand efficacyof adalimumabin
treatmentof patientswith psoriaticarthritis
w hy had fai l ed di seasemodi fyi ngant ir heumati c drug therapy.J. R heumato l.2007,
,
34, 1040-1050.
3 1 . M c G o n a l dD . , C o n a g h a nP . ,E m e r yP . P s ori ati c arthri ti s.A rthr. R heum.. 19 99. 42.
10 8 0 -10 8 6 .
O I
NCO PI/ATIAI=CKI/INA?TPI/T
nPoLUnoE,HACTOFUJEE
l/ svAvUEE
r e s e i v i n ga d a l i m u m a bA
. n n . R h e u m .D i s . ,
3 2 . G u p t aA . K . , G r o b e rJ . S . , H a m i l t o nT . A .e t
2 0 0 8 ,6 7 , s u p p l .l l , 5 2 8
a l . S u l fa s a l a s i nth
e e rapyfor psori ati carthri , l a d m a nD . D . ,R i t c h l i nC . T . e t
ti s : a d o u b l eb l i n d ,p l acebo,control l edtri al . 4 3 . M e a s eP . J . G
l .9 9 5 , 2 2: 894-8.
al . A dal i mumabfor the treatmentof pat ient s
J . R h e u m a to 1
with moderatelyto severelyactive psoriatic
3 3 . G u b n e rR . , A u g u s tS . , G i m b e r gV . T h e r a p arthri ti s.A rthri ti s.R heum.,2005, 52, 3279eutic suppressionin tissue reactivity.ll/ Etfe c t o f a m i n o p te ri nin rheumatoi darthri ti s
3289
a n d p s o r i a s i sA.m . J . M e d .S c i . , ' 1 9 5 1 , 2 2 1 , 44. Mol l J.M.H ., W ri ght V . P sori asisar t hr it is.
1 7 6 -1 8 2 .
S e m i n .A r t h r i t i sR h e u m .1 9 7 3 , 3 ,1 : 5 5 - 7 8 .
3 4 . H e r r m a n nM . , F r a n g o uC . G . ,K i r s c h b a u m . 45. Ory P .A .,Gl admanD .D ., MeaseP. J.Psor i. n n .R h e u m .D i s . ,
B C e l l c y c l e c o n tro lo f the de novo pyri mi da t i ca r t h r i t i sa n d i m a g i n gA
2 0 0 5 ,6 4 ( s u p p l l.l ) , 11 5 5 - ' 1 5 7 .
i n e s y n th e s i sIn h i b i torl efl unomi dethe p53
and p21 WAF-1 pathways (Association of 46. PitzalisC. Skin and joint diseasein psoriaR h e u m a to l o g yH e a l th P rofessi onal s32nd
ti c arthri ti s:w hat i s the l i nk?B ri t.J. Rheum N a ti o n a Sc
l i e n ti fi cMeeti ng,B -N ov1997)
a t o l .1 9 9 8 ,3 7 , 5 : 4 8 0 - 3 .
3 5 . J o n e s G ., C ro ttyM ., B rooksP .Interventi o- 47. R ahmanP .,N guyenE .,C heungC et al. Compari sonof radi ol ogi cal
severi tyi n psor iat ic
us for psoriaticarthritis.CochraneDatabas e S y s t.R e v .2 0 0 0 ,3 , C D 0002" 12.
arthri ti sand rheumatoi darthri ti s.J. Rheum 3 6 . J o n e s G ., C ro tty M . , B rooksP . Interventi atol .2001, 28, 1041-1044
ons for treating psoriaticarthritis(Cochran 4 8 . R a h m a nP . , E l d e rJ . G e n e t i ce p i d e m i o l o gy of psori asi sand psori ati carthr it is.Ann,
Review).In: The CochranLibrary,iss Oxford
R h e u m .D i s . 2 0 0 5 ,V . 6 4 , s u p p l . l l , M a r c h ,
U
p
d
a
t
e
2
0
0
1
,
1
1
8
.
S
o
f
t
w
a
r
e
,
11371
- 139.
3 7 . K a l tw a s s e Jr .P. N a sh P .,Gl admanD .D . et
al. Efficacyand safety of leflunomidein the 49. R i tchl i nC . T. The pathogenesi sof psor iatreatmentof psoriaticarthritisand psoriassi s and psori ati carthri ti s.N ew applicat ions
i s .A r t h r i t i sR h e u m . 2 0 0 4 , 5 0( 6 ) : 1 9 3 9 - 5 0 .
f o r T N F i n h i b i t i o nl.m m u n e x ,P h i l a d e l p h i a ,
2000,9-20.
3 8 . K r a a nM . C . , R e e c eR . J . ,B a r g E . C . e t a l .
s psor iat ic
T a k Mo d u l a ti o no f i n fl ammati onand meta- 50. R i tchl i nC . T.The pathogenesi of
l l o p ro te i n a s ee x p re s si oni n synovi alti ssue
a r t h r i t i sC
. u r r .O p i n . R h e u m a t o l . , 2 0 0 51, 7 ,
406-412.
b y l e fl u n o mi d ea n d methotrexatei n pati ent
a c ti v erh e u ma to i da rt hri ti s.A rthri ti sR heum. 51. S al varaniC ., Lo S cocco G., Ma cchioniP.
2 0 0 0 , 4 3 :1 8 2 0 -1 8 3 0.
Prevalenceof psoriaticarthritisin ltalianps3 9 . K ru e g e rG ., Bo w c o ckA . P sori asi spathopori ati cpati ents.J. R heumatol .,1995. - vol.
h y s i o l o g y c: u rre n tc o nceptsof pathogene2 2 : 1 4 9 9 -15 0 3 .
s i s .A n n . .D i s .2 0 0 5 ,V . 6 4 , S u p p l .l l , M a r c h , 52. S eki K ., TakahashiR ., N okamu r aT. Psor 11 3 0 - 1 3 6 .
iatic arthritis associatedwith chondrolysis
4 0 . L a n g l e yR ., K ru e g e rG., Gri ffi thsC . P sorand osteol i si s.R heumatol ogy,1999, 38,
i a s i s : e p i d e mi o l o g y,cl i ni calfeatures,and
1:86-9.
q u a l i tyo f l i fe .An n . R h eum.D i s.2005,V .64, 5 3 . S o k o l lK . 8 . , H e l l i w e lP
l . S .C o m p a r i s o no f
s u p p l .l l , M a r c h ,1 11 B -1 1 2 3 .
di sabi l i tyand qual i tyof l i fe i n rheum at oid
4 1 . M a d e r R . , G l a d m a nD . D . , L o n g J . e t a l .
arthri ti sand psori ati carthri ti s.J . Rheum .
Does injectablegold retard radiologicevid2 O O 1 , 2 81: 8 4 2 - 6 .
e n c e o f j o i n t d a ma ge i n psori ati carthri ti s? 54. Tayl orW ., Gl admanD .D ., H el l i wellP.et al.
. e d . 1 9 9 5 ,1 B : 1 3 9 - 4 3 .
C l i n .I n v e s tM
CASPARStudy Group Developmentof New
4 2 . Ma n g e r8 ., L o re n zH .M.,S pl ekel erR . et al .
Criteria From a Large InternationalStudy.
A d a l i m u m a b( H u m i r a )i m p r o v e st h e s i g n s
A rthri ti sR heum.,2006,54 (8):2665- 2673
a n d s y m p to m so f j o i nt, ski n and nai l mani - 5 5 . V a n d e r B o s c h F . , M a n g e rB . , G o u p i l l eP .
fe s ta i ti o n so f p s o ri a t i carthri ti s(P sA ):resuet al " C l i ni calremi ssi onon j oi ntsa nd skin in
patientswith psoriaticarthritistreated with
Its from a Germandatabaseof PsA patiens
62
A d a l i m u m a b(H u mi ra )- resul tsof the S TE - 58. W i l l i amsonL., D al bethN ., D ockertyJ. L. et
R E Ot r i a l .A n n . R h e u m .D i s . ,2 0 0 8 ,6 7 , s u p al. Extendedreport: naildiseasein psoriatic
p l .l l ,5 3 3 .
arthritis-clinically im portant, potentially tre5 6 . Ve a l eD ., R i tc h l i nC ., F i tzGeral d.
l mmunopatableand often overlooked.Rheumatology
(Oxford).2004,Jun.:43(6): 690-1.
athologyof psoriasisand psoriaticarthritis.
A n n .R h e u m .D i s . 2 0 0 5 V
, .6 4 , S u p p l .l l , M a - 59. W ong K ., Gl admanD ., H ustedJ et al. M or r c h , 1 1 2 6 -1 1 2 9 .
tality studies in psoriaticarthritis.L Causes
5 7 . Wri g h tV . R h e u m a ti s ma nd psori asi s;a rea n d d e a t h .A r t h r .F | h e u m . , 1 9 9 7 , 4 01, 8 6 8 e v a l u a ti o nAm.
.
1872.
J M e d 1 959.27:454-62
A R SM E D I C A
N S s( 1 5 )
63