medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-16-38-44medsovet-6458Research ArticleАКТУАЛЬНОЕ В ПУЛЬМОНОЛОГИИФармакотерапевтическая стратегия ведения больных ХОБЛ: фокус на «двойные» бронходилататорыPharmacotherapeutic strategy for COPD patients: focus on dual bronchodilatorshttps://orcid.org/0000-0002-1990-2042СинопальниковА. И.SinopalnikovA. I.

Синопальников Александр Игоревич, д.м.н., профессор, заведующий кафедрой пульмонологии

Россия, Москва, ул. Баррикадная, д. 2/1, стр. 1

Alexander I. Sinopalnikov, Dr. Sci. (Med.), Professor, Head of the Department of Pulmonology

2/1, Bldg. 1, Barrikadnaya St., Moscow, 125993, Russia

aisyn@list.ruРоссийская медицинская академия непрерывного профессионального образованияРоссияRussian Medical Academy of Continuous Professional EducationRussian Federation2021291020210163844Copyright © Синопальников А.И., 20212021Синопальников А.И.Sinopalnikov A.I.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/6458

В качестве приоритетного направления фармакотерапевтической стратегии ХОБЛ инициативой GOLD в течение двух десятилетий неизменно указывается применение бронходилататоров. Авторы международных и национальных клинических рекомендаций рассматривают фиксированные комбинации длительно действующих β2-агонистов (ДДБА) и длительно действующих холиноблокаторов (ДДХБ) как препараты «первой линии» у большинства пациентов с ХОБЛ. Многочисленные клинические исследования показали, что фиксированные комбинации ДДБА/ДДХБ обеспечивают оптимальную бронходилатацию и играют первостепенную роль в предотвращении обострений ХОБЛ. Превосходя плацебо и активный контроль, ДДБА, ДДХБ, ингаляционные глюкокортикостероиды (ИГКС/ДДБА), комбинированные бронходилататоры могут отличаться по своему терапевтическому потенциалу. Имеющаяся доказательная база в настоящее время не позволяет сделать однозначный выбор в пользу той или иной фиксированной комбинации ДДБА/ДДХБ. С появлением на фармацевтическом рынке «тройных» комбинаций (ИГКС/ДДБА/ДДХБ) с особой остротой встал вопрос об их сравнении с «двойными» бронходилататорами. Имеющиеся на сегодняшний день данные позволяют утверждать, что применение «тройной» терапии не рассматривается в качестве стартового варианта лечения ХОБЛ и целесообразно только в подгруппе пациентов с более высоким исходным риском обострения заболевания: при наличии анамнестических указаний на перенесенные обострения ≥ 1, потребовавшие назначения системных антибиотиков и/или глюкокортикостероидов, или обусловившие необходимость госпитализации в течение предыдущего года. Таким образом, ИГКС-содержащая терапия оправдана лишь в случаях повторных обострений ХОБЛ средней степени тяжести или единичных эпизодов тяжелого обострения, несмотря на продолжающийся прием ДДБА/ДДХБ, а также у отдельных категорий больных, воспалительный профиль которых предполагает «ответ» на ИГКС.

For two decades, the GOLD Initiative has consistently identified the use of bronchodilators as a priority in the pharmacotherapeutic strategy for COPD. The authors of international and national clinical guidelines consider fixed combinations of long-acting beta2-agonists (LABAs) and long-acting muscarinic receptor antagonists (LAMAs) as “first-line” drugs in most patients with COPD. Numerous clinical studies have shown that fixed LABAs/LAMAs combinations provide optimal bronchodilation and play a paramount role in preventing exacerbations of COPD. Outperforming placebo and active controls, LABAs, LAMAs, inhaled glucocorticosteroids (ICS)/LABAs combination bronchodilators may differ in their therapeutic potential. The available evidence base currently does not allow to make an unambiguous choice in favor of one or another fixed LABAs/ LAMAs combination. With the appearance of “triple” combinations (ICS/LABAs/LAMAs) on the pharmaceutical market, the issue of their comparison with “dual” bronchodilators has become particularly acute. Currently available data suggest that the use of “triple” therapy is not considered as a starting treatment option for COPD and is appropriate only in a subgroup of patients with a higher baseline risk of exacerbations: in the presence of a history of exacerbations ≥ 1, which required prescription of systemic antibiotics and/or glucocorticosteroids, or necessitated hospitalization during the previous year. Thus, ICS-containing therapy is justified only in cases of recurrent exacerbations of moderate COPD or single episodes of severe exacerbations, despite the continued administration of LABAs/LAMAs, as well as in certain categories of patients whose inflammatory profile suggests a “response” to ICS.

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The authors declare that there are no conflicts of interest present.