lco erAartlrec ruilt r pouroe, HacroF u_lee tA 6y4yulee

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lco erAartlrec ruilt r pouroe, HacroF u_lee tA 6y4yulee
lco erAartlrec
ruiltapTpr,{T:
r pouroe, HacroF
u_lee
tA6y4yulee
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paccMarpvBar'tce KaK PA y na4ileHTa c ncopila3oM. Wright V onucar oco6brlt BapilaHr
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peBMaronoroB (ACR) BnepBbte onpeflenilfla
flcA rar orgenbHyo KnilHil.{ecKyo $opvy e
1964 roAy, BKflloel4Bero B rnaccrQrKallytro
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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
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llcA ras u6orur-uofi peBMaroLlAHofr 6olesHyr"
ocHoBaHoHa [uhpoKoM cneKTpe ennAeMnonorrqecKrx, TeHerilqecK[x, vopQonorilt{ecKrx,
mMMyHOnOrh qec Krlx v KnvHVKo- peHTre Ho nof tALrecKrlxgauHurx(1 ).
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49
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pasHoo6pa3tAeKflrHrvecKilx nponBneawh (2).
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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)
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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).
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erilx
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6roraropoe, aHTnMaflffpnfiHurxnpenaparoB,
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auQQepeHuilaumo, nponNQepaumo KreroK,
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K n poqeccbr anonro3a). llyrev aKrvBaL1Avr
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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
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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
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rorcrr B ncopilarilLrecKrx nanynax u 6nnw<ax.
peMoAenilpoeaHrn (52) :
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(56).
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c l
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armnilqHoMncopha3e - peBMarorgonoAo6Hurfr
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HO COnOCTaBfleHile
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- 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 ,
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