Современные возможности тройной фармакотерапии инфекции Helicobacter pylori

Инфекция Helicobacter pylori представляет глобальную проблему здравоохранения, поскольку патоген ассоциирована с развитием язвенной болезни желудка и двенадцатиперстной кишки, гастритом, аденокарциномой желудка и MALT-лимфомой. Эффективность эрадикационной терапии снижается вследствие нарастающей антибиотикорезистентности, что требует пересмотра терапевтических стратегий. В статье представлены механизмы выживания H. pylori в агрессивной среде желудка, его факторы патогенности, современные данные о механизмах действия основных антибактериальных препаратов, применяемых при лечении инфекции в России и мире: кларитромицина, метронидазола, амоксициллина, тетрациклина, левофлоксацина, рифабутина, висмута трикалия дицитрата, а также механизмы формирования резистентности для них. Детально рассмотрены однофазные и двухфазные схемы эрадикационной терапии согласно российским клиническим рекомендациям 2022 г. и консенсусу Маастрихт VI, включая схемы первой линии: стандартную тройную терапию, усиленную и неусиленную препаратами висмута, конкоминантную, последовательную, гибридную, обратную гибридную, квадротерапию с препаратами висмута, двойную высокодозовую, вонопразановую двойную терапию. Для терапии второй линии рассмотрены схемы, включающие левофлоксацин, рифабутин, изложены принципы индивидуализированной терапии. Дана краткая клинико-фармакологическая характеристика каждого препарата. Также проанализированы причины неудач в поиске оптимальной схемы эрадикации H. pylori. Упомянуто изменение отношения Всемирной организации здравоохранения к H. pylori как к возбудителю, требующему разработки новых антибактериальных препаратов. Рассмотрены понятия «постантибиотическая эра» и «ренессанс антибиотиков». В заключительной части рассмотрены риски, связанные с выбором схемы терапии первой линии и препаратов, входящих в них. Сделано заключение, что при надлежащей оценке резистентности H. pylori тройная фармакотерапия с висмутом или без него является сравнительно эффективной и безопасной схемой эрадикации для регионов Российской Федерации. Учет особенностей метаболизма кларитромицина, нежелательных лекарственных реакций препаратов позволяет сделать рациональный выбор терапии первой линии, учитывающей физиологические и клинические особенности пациентов с инфекцией H. pylori.

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