Фармакологическая гастропротекция: показания, возможности и риски

Статья представляет собой аналитический обзор концепции фармакологической гастропротекции. Авторы подчеркивают, что целостность слизистой оболочки желудка поддерживается за счет сложного баланса между факторами агрессии (соляная кислота, пепсин, НПВП, H. pylori) и защиты (слизь, бикарбонаты, простагландины, адекватная микроциркуляция, регенерация слизистой оболочки). Перечислены основные механизмы повреждения слизистой оболочки желудка и приведена классификация факторов защиты. Рассмотрены термины «цитопротекция» и «гастропротекция». Обосновано, что истинная гастропротекция определяется как фармакологическое усиление именно защитных свойств слизистой, а не подавление кислотной агрессии. В связи с этим ингибиторы протонной помпы (ИПП), остающиеся золотым стандартом для профилактики опасных осложнений (кровотечений, перфораций), не относятся к истинным гастропротекторам, поскольку действуют на фактор агрессии. Приведены критерии оценки риска желудочно-кишечного кровотечения и подход к назначению гастропротекторов. К истинным препаратам с доказанными гастропротективными свойствами авторы относят препараты висмута, мизопростол и ребамипид. Однако каждый из них имеет серьезные ограничения: риск кумуляции висмута при длительном приеме, выраженные побочные эффекты мизопростола (диарея, абортивное действие) и недостаточно мощную доказательную базу у ребамипида для широкого применения. Ключевой проблемой клинической практики является низкая частота применения гастропротекции даже среди пациентов высокого риска (пожилой возраст, прием антикоагулянтов и НПВП, язвенный анамнез), которым она показана в первую очередь. Основной вывод работы заключается в том, что классическая гастропротекция уступила место антисекреторной терапии не из-за неэффективности, а из-за простоты, предсказуемости и мощной доказательной базы ИПП в предотвращении жизнеугрожающих осложнений. Смещение парадигмы потребует создания нового препарата с неоспоримыми преимуществами перед существующей стандартной терапией.

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