The article presents the consensus materials of the European Society of Cardiology on the use of diuretics in chronic heart failure (CHF). Diuretics represent an important class of drugs for the treatment of heart failure from the perspective of evidence based medicine. Much attention in the consensus s paid to the algorithm of using diuretics, in particular loop diuretics, in acute decompensation of CHF. Clinical and pharmacological advantages and disadvantages of the main drugs of loop diuretics (furosemide, torasemide, bumetanide) in CHF are discussed. There was analyzed the effectiveness of low and high doses of loop diuretics, the method of administration (bolus or continuous infusion) in terms of effective diuretic therapy and prevention of tolerance to diuretics, as well as the impact on the prognosis of survival during decompensation of heart failure. It also discusses modern approaches to the diagnostic criteria for assessing the effectiveness of diuretic therapy in acute decompensation of CHF, and shows the possibility of determination the level of excretion of Na⁺ ions in the urine as a surrogate marker of the effectiveness of diuretic therapy to optimize the dosage regimen of diuretics. An algorithm of diuretic therapy is proposed (the choice of dosages and regimens for using loop diuretics) for patients with acute decompensation of heart failure, including intravenous use of loop diuretics in an optimal increasing dose for the first 24 hours before stopping stagnation with a further transition to a maintenance dose of loop diuretic for euvolemia status and combined diuretic therapy with thiazides to obtain synergism. The recommendations for correction of electrolyte disturbances against the background of diuretic therapy is considered.

Loop diuretics are recommended for CHF to prevent signs and symptoms of congestion: this is the only group of drugs with a level of recommendation as class I in patients with heart failure with a reduced or preserved ejection fraction.

Cardiovascular diseases (CVD) is the most frequent cause of death in diabetes mellitus (DM) patients, and diabetes, in turn, significantly increases the risk of cardiovascular pathology, and therefore the implementation of measures for primary and secondary prevention of complications in patients with DM and CVD is a topical direction of modern medicine. In case of diabetes, CVDs occur 2-5 times more frequently than in persons without this pathology. There is also a high risk of developing conditions such as coronary heart disease (CHD), myocardial infarction (MI), arterial hypertension (AH), acute cerebrovascular disease (ACVD). Thus, 69% of patients with DM have dyslipidemia, 80% - AH, 50-75% - diastolic dysfunction, 12-22% - chronic heart failure (CHF). Mortality from MI among patients with DM is 1.5-2 times higher than among people who do not suffer from this disease, both in the acute stage of MI, and in prolonged observation. Therefore, it is necessary to work out a common approach to this problem on behalf of both cardiologists and endocrinologists, and patients, which will improve the quality of treatment and prevent the development of DM complications.

Intensive control of glycemia in patients is essential to prevent the development and progression of DM complications, which is proved by a number of fundamental studies presented in this article. Regular and competent self-control by patients allows maintaining normal or close to normal blood glucose levels. It is a reliable, convenient and patient-friendly way to prevent the development of diabetic complications.

Chronic stable angina (CCS) is the most prevalent symptom of ischaemic heart disease and its management is a priority. CCS are defined by the different evolutionary phases of CAD, excluding situations in which an acute coronary artery thrombosis dominates the clinical presentation (i.e ACS).

The most frequently encountered clinical scenarios in patients with suspected or established CCS are: 1) CAD patients with suspected CAD and ''stable'' anginal symptoms, and/or dyspnoea; 2) patients with new onset of heart failure or left ventricular dysfunction and suspected CAD;3) asymptomatic and symptomatic patients with stabilized symptoms <1 year after ASC or patients with recent revascularization;4) asymptomatic and symptomatic patients > 1 year after initial diagnosis or revascularization; 5) patients with angina and suspected vasospastic or microvascular disease; 6) and asymptomatic subjects in whom CAD is screening.

Тhе new technologies improve the results of treatment of these patients. Authors used determinants of the clinical likelihood of obstructive coronary artery disease and suggested stepwise strategy for long-term anti-ischemic drug therapy in patients with CCS and specific baseline characteristics.

Current guidelines recommend pharmacological therapy with drugs classified as being first line (beta blockers, calcium channel blockers, short acting nitrates) or second line (long-acting nitrate, ivabradine, nicorandil, ranolazine and trimetazidine). Second line drugs are indicated for patients who have contraindications to first line agents, do not tolerante them or remain symptomatic. Patients with angina pectoris due coronary artery disease should also detreated with low dose aspirin and a statin. The demonstrated effect of the drugs include disease clinical manifestation, reduction and decrease of cardiovascular incidence and mortality rates.

Introduction. The neurocirculatory asthenia often meets at young men of military age, making 75% in structure of diseases of a cardiovascular system. The condition of microcirculation at patients with neurocirculatory asthenia depending on the nature of vegetative disturbances is insufficiently studied.

The purpose of the real research was studying of a condition of microcirculation according to a thermovision research at young men of military age with neurocirculatory asthenia depending on the nature of vegetative dysfunction.

Materials and methods of a research. 169 young men aged from 17 till 21 year with neurocirculatory asthenia of primary genesis are examined. The control group was made by 60 almost healthy young men of the same age. At young men of military age with a neurocirculatory asthenia according to a thermovision research the condition of microcirculation is studied and 3 degrees of disturbance of the thermal drawing are established. The method of cardiointervalographia was used to study a functional condition of the autonomic nervous system. The following parameters were studied: type of vegetative regulation, reactivity of departments of the autonomic nervous system and vegetative provision of cardiac activity.

Results of a research and discussion. Frequency of disturbances of microcirculation according to a thermovision research at young men of military age with neurocirculatory asthenia depending on type of vegetative regulation is studied. Frequency of disturbances of thermal drawing of III degree was authentically higher at young men with sympathetic type of vegetative regulation in comparison with normotonic type (р < 0.05). The assessment of frequency of disturbances of microcirculation according to a thermovision research at young men of military age with neurocirculatory asthenia depending on type of vegetative regulation and vegetative provision of cardiac activity is carried out. At disadaptation of vegetative provision of cardiac activity in all groups the III degree of disturbance of the thermal drawing is defined authentically more often (p < 0.01-0.05).

Conclusions. At young men of military age the III degree of disturbance of the thermal drawing in most cases decides on sympathetic type of vegetative regulation at disadaptation of vegetative provision of cardiac activity.

Cardiovascular disease (CVD) is a major cause of death among patients with diabetes. Antiplatelet therapy is an important part of the treatment and prevention of CVD and acetylsalicylic acid (ASA) is the main medication. This review describes modern approaches to the primary prevention of cardiovascular events in patients with diabetes. Until now, no concerted strategy on this issue has been developed by the global medical communities. The approaches used in the guidelines were heterogeneous and did not cover most of the risk factors, which were often associated with the underlying disease. The risk assessment for CVD with a view to developing risk factor stratification is often difficult due to the variety of manifestations and complications of the disease, as well as the specificity of factors used as independent predictors of atherosclerotic vascular disease for the diabetes population. Only cardiovascular risk analysis in an individual patient can make it possible to choose the best method for prevention. Therefore, the most important objective is to introduce the adopted CVD risk stratification criteria for patients with diabetes into clinical practice, which will enhance the preventive treatment and personalize the therapeutic approaches.

The adopted standardized cardiovascular risk analysis system for patients with diabetes, for now, has been implemented in the 2019 European clinical guidelines.

The consensus regarding use of ASA adopted by the European Society of Cardiology (ESC) in collaboration with the European Association for the Study of Diabetes (EASD) in 2019 has been based on meta-analyses with a high degree of evidence. They advise to use low-dose ASA in patients with diabetes, if they are at «high» and «very high» risk of CVD and have no obvious contraindications.

It allowed clinicians to use low-dose ASA (in combination with proton pump inhibitors) as one of the most important methods for primary prevention. Such modern approaches will surely improve the cardiovascular morbidity and mortality rates in the diabetes population.

AH and diabetes mellitus are comorbid diseases and are interconnected by general pathophysiological mechanisms of development, similar to cardiovascular complications. The presence of a close relationship between AH and diabetes mellitus is due to the importance of activation of the renin-angiotensin-aldosterone system, which underlies the remodeling of the cardiovascular sys­tem and the development of complications. According to modern clinical guidelines, ACE inhibitors are the drugs of choice in the treatment of AH in combination with diabetes mellitus. The use of ACE inhibitors in patients with AH and diabetes mellitus is accompanied by a reduction in the relative risk of cardiovascular outcomes and mortality. A scientific review of major clinical stud­ies with the results of efficacy of ACE inhibitor ramipril in patients with AH and diabetes mellitus is presented. Ramipril has a high affinity for ACE-1 and kinase II enzymes, pronounced clinical and organoprotective effects, proven to influence the prognosis. The HOPE study showed a 22% reduction in cardiovascular outcomes and mortality in high-risk patients treated with Ramipril (p < 0.001), and a 25% reduction in a subgroup of patients with diabetes mellitus. In a large retrospective cohort analysis, ramipril had a lower risk of mortality in patients with AH and diabetes mellitus compared to other ACE inhibitors (captopril, enalapril, fosinopril). In a number of studies (ATLANTIS, MICRO-HOPE, DIABHYCAR) in patients with diabetes mellitus and MAU, ramipril contributed to a significant slowdown of MAU progression and a significant regression of MAU, reducing the risk of diabetic nephropathy by 22%. This confirms the pronounced nephroprotective effect for primary and secondary nephropathy prevention. Several studies (AASK, HOPE, DREAM, ADaPT) using ramipril have shown a 17-36% reduction in the risk of the development of new cases of type 2 diabetes mellitus.

Thus, the evidence on the efficacy of ramipril has allowed to expand indications for its use not only for cardiovascular diseases (AH, chronic heart failure, MI), but also for diabetes mellitus and diabetic nephropathy, which significantly differs the drug from other ACE inhibitors.

Back pain is often considered under the diagnostic heading “nonspecific pain” because of difficulties in identifying the primary source of pain in everyday clinical practice. However, despite the difficulties in identifying the specific etiology of chronic low back pain, diagnostic procedures can identify its source in 90% of patients. We report a clinical case of typical discogenic pain.

The 6-week pain, which developed after barbell exercising in a 42-year-old man, resulted in the loss of professional employment. The pain was localized to the midline of the lower back (axial pain) and intensified in a sitting position. Computed tomography images demonstrated subchondral changes in L5-S1 vertebral bodies (Modic-1). A holistic diagnostic approach, including a vibration test, made it possible to diagnose the degenerative disc disease (L5-S1 intervertebral disk disease) with subacute discogenic pain. The patient received Dexalgin®25 at a dose of 25 mg x 3 times a day in combination with omeprazole 20 mg per day for 5 days, then the patient was switched to Nimesil 200 mg per day in two divided doses. A complex drug of the SYSADOA group containing glucosamine and chondroitin was used as adjuvant therapy. Pain intensity was reduced by 70 % at 6 weeks (2 points on VAS scale, which corresponds to the level of mild pain syndrome) as compared to the baseline level.

This clinical case stresses the importance of accurate diagnosis of back pain and demonstrates the potential for successful combination non-surgical treatment of discogenic pain in primary outpatient settings.

The article discusses one of the leading problems of modern angioneurology - chronic cerebral ischemia. The main etiological factors playing a significant role in the development of chronic cerebral ischemia, among which atherosclerosis, hypertension, myocardial diseases, diabetes mellitus, etc. play a major role. The main clinical manifestations of this disease are described. The emphasis is on the fact that the main nucleus of the clinical picture of chronic cerebral ischemia is cognitive impairment, which in most cases determines the severity of patients. The development of cognitive impairment is associated with focal or diffuse brain lesions, resulting in the impairment of one or more cognitive functions. Vascular cognitive deficits are the result of acute or chronic cerebrovascular processes. The main causes and mechanisms of vascular cognitive impairment development are presented. It is shown that depending on the mechanism and the cause, the rate of cognitive impairment development may vary. The clinical picture of cognitive impairments developing as a result of the lesion of small brain vessels is described. The peculiarities of vascular cognitive disorders occurring against the background of cerebral hypoperfusion are described. The modern criteria of diagnosis are given. The main diagnostic methods are listed. The main approaches in treatment of patients with chronic cerebral ischemia depending on the disease stage are described. In-depth attention is given to neuroprotection with a more detailed description of the mechanisms of action and clinical efficacy of drugs with active substances - citicoline and ethylmethylhydroxypyridine succinate.

Allergic rhinitis (AR) is found in the practice of doctors of various specialties, but making the correct diagnosis and prescribing adequate therapy can take many months and sometimes years. Currently, the problem of AR remains relevant, due to the extreme prevalence of AR, late diagnosis, underestimation of the possible risks of disease progression, complications, and the addition of such a formidable pathology as bronchial asthma. The path of the patient presented in the clinical case is quite typical for many patients with AR and concomitant pathology of nose. A young patient with allergic rhinitis received conservative treatment, and was later operated, but the effect was incomplete and short-lived. Only after 4 years, the patient was first examined by an allergist. Symptoms of AR indicate that the patient has an atopic status that promotes the involvement of various organs and systems in the inflammatory process.

To verify the diagnosis and clarify the entire spectrum of “guilty” allergens, a specific allergological examination was carried out, which included skin testing and determination of specific IgE antibodies. The main participants in allergic inflammation are mast cells, eosinophils, lymphocytes, epithelial and endothelial cells. The effect of mediators on vascular endothelial cells and neuroreceptors of the nasal mucosa leads to the formation of allergic inflammation and the onset of clinical symptoms of AR. One of the main mediators released upon repeated contact with an allergen in a sensitized body is histamine, therefore antihistamines are first-line drugs at any stage of AR therapy. In our clinical case, taking into account complaints, medical history, clinical manifestations, results of laboratory (specific, nonspecific) and instrumental methods, the patient needs treatment of the corresponding first stage of therapy based on symptom control. The effectiveness of 2nd generation H1-antihistamines in the management of symptoms such as pruritus, sneezing, and rhinorrhea is due to histamine-mediated development of the early phase of the allergic reaction, which in turn leads to the onset of the late phase and the chronic co Bilastine can be considered as the drug that most fully meets the requirements of ARIA experts for 2nd generation H1-antihistamines : selective blockade of H1 receptors, high antiallergic effect, rapid onset of clinical effect, duration of action 24 hours, lack of tachyphylaxis and good tolerance. The results of the studies and their analysis show that bilastine is the preferred choice for monotherapy of allergic rhinitis.urse of allergic inflammation in the nasal mucosa.

Prevention of recurrent ARVI is an urgent medical and social problem, especially in children. In children of this group, an imbalance of the intestinal flora was detected, which can be leveled by oral administration of probiotics, which cause immunomodulatory effects.

Normal micro-flora performs important physiological functions and are active against pathogenic and conditionally pathogenic microflora. The microbiota (a collection of microbes that colonize the human body) is affected by the environment, often leading to the development of SARS. In this case, the normal microflora has an antagonistic activity in relation to the pathogenic one. Useful bacteria are called probiotics (lactobacilli and bifidobacteria) and represent a treatment option for chronic respiratory diseases.

During the recurrence of acute respiratory infections (ROIDP), intestinal flora dysbiosis is detected, which can be improved by the use of probiotics.

Known diseases that disrupt the function of normal microflora, causing dysbiosis.

There are microorganisms that violate the permeability of the epithelial barrier of the mucous membrane. Dysbiosis can be regulated by probiotics that are administered both orally and nasally. They can have various immunomodulatory effects. Prebiotics are an indigestible form of fiber. A combination of Pro-and prebiotics is a synbiotic that has a synergistic effect in the treatment of many diseases and reduces the frequency of all infectious diseases.

New synbiotic dietary supplement contributes to the improvement of immunological mechanisms, mucosal immunity, enhancement of antiviral immunity, etc. It contains 5 probiotics and one prebiotic and is approved for use in children from the first month of life. This supplement has a positive effect on several immune system indicators in the treatment of sickly children. It may be recommended for dysbiosis, diabetes, coeliac disease and for the prevention of influenza and flu-like syndromes.

Introduction. Antibiotic resistance is a topic that is currently causing concern for all of humanity in the world. Experts at the World Health Organization consider it a global threat. Irrational and uncontrolled use of antibacterial drugs, the low level of prevention of bacterial and viral infections have led to an increase in mutations and the emergence of new resistant strains of microorganisms. The growth of antimicrobial resistance dictates the search for alternatives to systemic antibiotic therapy. In this connection, the search for an alternative to systemic antibiotic therapy is relevant.

Goal of research. This article discusses the use of a topical antibacterial drug tiamphenicol glycinate acetylcysteinate, which is a combination of a broad-spectrum antibiotic and a mucolytic.

Materials and methods. A literature review was conducted with an analysis of scientific research data on the effectiveness of the topical antibacterial drug tiamphenicol glycinate acetylcysteinate.

Results. In the practice of an otorhinolaryngologist topical use of tiamphenicol glycinate acetylcysteinate, including inhalation, helps to improve the course and prognosis of the disease, reduce the recovery time, and in some cases, reduce the systemic antibiotic use.

Conclusion. The obtained data allow us to recommend topical antibacterial drug tiamphenicol glycinate acetylcysteinate for use in otorhinolaryngological practice.

Introduction. In almost all diseases of the gastrointestinal tract, the inflammatory process plays an important pathogenetic role and affects the course of the disease and the determination of treatment tactics. The most physiological way to prevent and treat inflammatory diseases of the gastrointestinal tract, of course, is dietary nutrition.

Purpose: To study the anti- inflammatory effect of a specialized product specialized therapeutic and dietary prophylaxis nutrition «Vegetable soup with oatmeal herbs» based on a study of clinical and laboratory parameters and dynamics of inflammatory markers.

Materials and methods. An open single-center prospective observational study was conducted in parallel groups. The main group and the comparison group were 14 and 10 patients with gastrointestinal diseases, respectively. Only patients of the main group received a specialized product «Vegetable Soup with herbs and oatmeal». All participants were assessed the dynamics of clinical blood analysis indicators (hemoglobin, white blood cells, red blood cells, leukocyte formula indicators) and the dynamics of proteinogram indicators (total protein and protein fractions-albumins and globulins) and C-reactive protein (CRP).

Results. The anti-inflammatory effect after administration of the specialized product occurs in 14 days and is expressed in a reliable reduction of leukocytosis, blood sedimentation rate (BSR), CRP. After 2 months after the start of the product intake, the BSR values decreased significantly by 35%, the CRP by 51% from the baseline and the leukocyte content decreased by 14.5%. Against the background of a dietotherapy in 14 days levels α1-глобулина, α2-глобулина and γ-globulin began to decrease, and in 2 months level a1-globulins decreased by 40% of initial level to the reference values. The level of α2-globulins and γ-globulin also decreased significantly, while the albumin concentration in the blood increased significantly. In the comparison group, changes in these parameters did not reach a reliable degree of significance.

Conclusions: the specialized product «Vegetable Soup with herbs and oatmeal» has an anti-inflammatory effect, characterized by a decrease in anti-inflammatory laboratory parameters, which manifests itself after 14 days of administration, can be recommended for inclusion in the diets of patients with gastrointestinal diseases during exacerbation and during remissions as well.

Abdominal pain is a frequent reason to see a doctor. At the same time, it is very important in the first stage of diagnosis to determine the degree of pain risk, as in some diseases such as acute ulcer, myocardial infarction, acute pancreatitis, the urgency of medical care is directly related to the survival of patients or the development of related complications. The most typical clinical manifestations of abdominal pain are pain of varying intensity, signs of peritoneal irritation and disturbance of intestinal motility. In some cases, the clinical picture may be accompanied by fever, nausea and vomiting, signs of pain or toxic shock, etc. The diagnosis of abdominal pain is based on a thorough analysis of the examination results, which includes not only laboratory examinations of blood, urine and feces, but also echography of abdominal organs, endoscopic (esophagogastroduodenoscopy, colonoscopy) and, if necessary, methods of radiation diagnostics (in particular, computer tomography, magnetic resonance imaging).

The article presents the classification and mechanisms of development of abdominal pain. The main attention is paid to inflammatory intestinal diseases (Crohn's disease and ulcerative colitis) for which etiology, pathogenesis, clinical signs, diagnostics and treatment are considered, taking into account modern trends in clinical practice. The main diagnostic measures to determine inflammatory bowel diseases are given, based on the analysis of the clinical picture and the results of laboratory, radiological and endoscopic examinations. It is emphasized that the results of the study, its diagnostic accuracy and therapeutic safety largely depend on the quality of patients' preparation for diagnostic activities. The main drugs used to prepare the intestines for research are solutions based on polyethylene glycol. The choice of medication therapy depends on the degree, location and severity of the disease. The same medications may be prescribed for different diagnoses - ulcerative colitis and Crohn's disease.

The data given in the article is in accordance with the latest recommendations of ESCEO years 2016, 2019 in regard to possibilities of the sympthom-modifying and structure-modifying action of chondroitin sulfate in the treatment of patients with osteoarthritis. There is the data on the therapy effect when treating patients with osteoarthritis and with periarticular tissues damage with chondroitin sulfate injections (Alflutop, Biotehnos) having strong evidence base, including randomized placebo-controlled studies. In the randomized study it is shown reliably high effectiveness of Alflutop against placebo in regard to main clinical manifestations of the desease as well as possibility to slow down progress of the destructive processes at osteoarthritis of the knee-joint. The data given on estimation of effectiveness and safety of alternate introduction of Alflutop at osteoarthritis 2 ml intramuscularly every other day (10 injections) compared with a standard mode of use of Alflutop 1 ml intramuscularly every day for 20 days. Equal effectiveness of the two modes of Alflutop introduction is demonstrated subject to good tolerance of the drug. Ability of Alflutop to supress the mediators of inflammation, such as interleukins 6 and 8, and degradations at osteoarthritis, as well as to stimulate the proliferation and renewal of chondrocytes is shown according to the results of an international experimental study, explaining its ability to cause a quick analgesic and anti-inflammatory effect. Alflutop inhibits in vitro extracellular release of the pro-inflammatory cytokine interleukin 6 (IL-6) for 16 per cent and chemokine IL-8 for 35 per cent, inhibits pro-angiogenic factor VEGF for 56 per cent, has an antioxidant effect, which contributes to the synthesis of cartilage macromolecules, a decrease in the activity of matrix metalloproteases (MMPs), a decrease in the concentration of prostaglandins and leukotrienes, and a decrease in chondrocyte apoptosis. The data on the effectiveness of the Alflutop injection course in case of damage to the periaticular tissues in the shoulder, elbow, knee joint is given. The data on the gastroprotective effect of the drug, demonstrated in experimental and clinical studies is given.

Currently, there is a significant increase in the incidence of gout, which is often combined with diabetes, hypertension, obesity, and atherosclerosis, being pathogenetically closely related to them. The increase in the incidence of gout seems to be associated with an increase in the number of patients with hyperuricemia, which is the main factor leading to the development of the disease. Knowledge of risk factors for gout, its clinical manifestations, methods of diagnosis and treatment is very important for a primary outpatient physician, since early diagnosis and adequate therapy of the disease, as well as concomitant pathology, prevents the development of severe cardiovascular complications and complications of gout itself. Currently, both international and national guidelines for the management of gout patients have been developed. The recommendations reflect the main symptoms of gout, features of the course of acute gouty arthritis depending on the patient's gender, as well as changes in the kidneys associated with hyperuricemia. The issues of diagnostics, prevention of the progression of the pathological process, and competent administration of anti-inflammatory and urat-lowering therapy are covered in detail. The article presents the risk factors for the development of gout. Much attention is paid to the description of the main clinical manifestations of gout both in the early stages of its development (acute gouty arthritis) and later (chronic tofus gout). The article presents diagnostic criteria for gout developed by ACR/EULAR, as well as methods of laboratory and instrumental diagnosis of the disease available to the primary outpatient physician. Gout therapy (non-drug and medication) is also multi-purpose. Its main directions (relief of an acute attack, prevention of relapses, urate-lowering therapy and indications for it) are reflected in the article in accordance with current national and international recommendations.

Diabetic autonomic neuropathy is the second most common form of damage to the nervous system in diabetes mellitus as a result of disorders of the central and/or peripheral parts of the autonomic nervous system. On average, its frequency of occurrence is about 40%, and 60% or more with an increase in the duration of diabetes over than 10 years. Diabetic autonomic neuropathy is characterized by polysyndromism of clinical manifestations. In this regard, a number of forms of diabetic autonomic neuropathy are distinguished both in the form of an isolated violation of the function of organs and systems, and with their combined defeat. In the pathogenesis of autonomic neuropathy, vascular and metabolic changes common to the development of diabetic polyneuropathy play an important role. The most significant risk factors for the development of diabetic autonomic neuropathy are the patient's age, duration of diabetes mellitus, and a higher average HbA1c. The development and progression of diabetic autonomic neuropathy depends on glycemic control, but its forms such as gastrointestinal and impaired recognition of hypoglycemia (asymptomatic hypoglycemia) can cause poor compensation for diabetes. This article discusses the various clinical manifestations of gastrointestinal autonomic neuropathy. Attention is drawn to the fact that the clinical picture is often nonspecific and asymptomatic, which complicates timely diagnosis. The gastrointestinal form of diabetic autonomic neuropathy leads to limited performance, social maladaptation of patients, dramatically reduces the quality of life of patients with diabetes mellitus. In clinical practice, the doctor must remember that it can significantly affect the achievement of glycemic control, as a result of a violation of the digestion and passage of food, as well as a violation of the pharmacokinetics of hypoglycemic drugs. Impaired recognition of hypoglycemia also makes it difficult to compensate well. These complications require a personalized approach to the patient from the doctor, and strict and frequent self-control of glycemia with the help of a modern glucometer from the patient to maintain optimal glycemic control and prevent possible hypoglycemic conditions.

Currently, with osteoarthritis (OA), numerous over-the-counter and prescription drugs are used, as well as biologically active additives (BAA). Significant market share in Russia are: chondroitin sulfate, glycosaminoglycan-peptide complex and Alflutop.

The purpose of the article is to compare the clinical recommendations of the professional communities of doctors of the Russian Federation, countries of Europe, Great Britain, the USA, Canada, Australia on approaches to chondroprotective therapy/SYSADOA for osteoarthritis using the example of chondroitin sulfate, glycosamine glycan-peptide complex and Alflutop.

Materials and methods: The analysis included 11 clinical recommendations (guideline) from 2008 to 2019 on the management of patients with OA.

Results: The glycosaminoglycan-peptide complex (Rumalon) and Alflutop were recommended by the Russian Scientific Medical Society of Therapists (RNMOT), but are not mentioned in the recommendations of several Russian professional communities. In the European recommendations, the glycosaminoglycan-peptide complex and the drug Alflutop are not considered. Chondroitin sulfate to reduce the symptoms of OA is recommended by 5 professional guideline. With the exception of Russian recommendations, the listed professional communities recommend the use of chondroitin sulfate only as a “pharmaceutical quality drug”.

Conclusion: It is advisable to agree on Russian recommendations on the use of the drugs in question. At the level of foreign and Russian professional communities, particular attention is required to analysis of data on the use of chondroitin sulfate, taking into account the quality of production, the composition of active substances and bioavailability, the quantitative content of active substances and the quality of substances. It is necessary to systematize the products with a separate assessment of the effectiveness of registered medicines, biologically active additives of pharmaceutical quality and low-quality products with minimal bioavailability. 

The term placebo is defined as a substance with no therapeutic effect that improves health by convincing the patient that the substance is effective. The term comes from the Latin “placere”, meaning “I will delight” or “do good”. Placebo is a universal tool for evaluating non-medical effects in randomized controlled trials to determine the true pharmacological effect of a drug. Examples of placebo action can be found in any field of medicine, but there is no conceptual basis that integrates it into everyday clinical practice, nor is there a corresponding medical education programme. Three main mechanisms of placebo effect are considered: the expectation model, reflective causality and the neurotransmitter model; it is necessary to take into account that these hypotheses may complement each other.

Nocebo is defined as a substance that has no therapeutic effect, but worsens the condition of the person receiving it because of the negative beliefs and expectations of the person. Nocebo effect, according to several studies, can be modulated by cholecystokinin. There is evidence that cholecystokininin induces hyperalgesia, “turning” anxiety into pain. According to the negative expectation model, nocebo induces hypothalamic-pituitary-adrenal axis, which increases plasma concentrations of adrenocorticotropic hormone and cortisol. Interest in nocebo has increased in recent years due to the introduction of immunobiological biosimilars in clinical practice. There are reports of a higher frequency of drug withdrawal by patients switching from original drugs to biosimilars in open trials compared to blind ones, suggesting a nocebo effect. The conceptual basis of personalized psychopharmacotherapy is to maximize placebo effect and minimize nocebo effect in order to improve treatment outcomes.