Mawonekedwe a dyslipidemia mu mtundu 2 shuga

Mtundu wachiwiri wa matenda ashuga a shuga, kusala kudya kwa hyperglycemia ndipo chakudya chikangokhala chofunikira sichodziwikiratu kuti chimayambitsa matenda a mtima, koma zotsatira za dyslipidemia pachiwopsezo cha matenda a mtima m'magawo onse a zinthu zoopsa zimawoneka kuti zikukulamulira.

Malinga ndi 3rd National Health and Nutrition Study ku USA, 69% ya odwala matenda a shuga ali ndi vuto la lipid metabolism (V.

Pali umboni wokuwonjezereka kwa kuphatikiza kwa maselo othandiza magazi kuundana mukakumana ndi glycated LDL.

Zotsatira za hyperglycemia pa atherogenesis mu khoma la mtima zimadziwika kudzera mu kupezeka kwa kupindika kwa mtima kosagwirizana ndi kuchuluka kwa kupsinjika kwa oxidative (F Cerielo et al., 1997). Maonekedwe a mphamvu ya kudziphatika kwa magazi monocytes kwa mtima endothelium ndi imodzi mwazomwe zimayambitsa kupangika kwa zotupa za atherosselotic khoma la mtima. Zifukwa zazikulu zakuchulukirachulukira kwa kusokonekera kwa monocyte-endothelial mu mtundu 2 wa shuga ndi kupsinjika kwa oxidative ndikuwonjezereka kwa kuchuluka kwa mankhwala omaliza a glycated metabolic. Kuchulukitsa kwa lipid peroxidation sikungakhale chifukwa, koma kuwonetsa kukhalapo kwa yaying'ono- ndi macroangiopathies.

Chifukwa cha kuchuluka kwa dyslipidemia pakukula kwa matenda a shuga- ndi macroangiopathies mu shuga mellitus, akatswiri a European Diabetes Policy Group mu 1998 adafotokozera zoopsa zokhudzana ndi matenda a mtima ndi odwala omwe ali ndi matenda a shuga a 2 malinga ndi kuchuluka kwa dyslipidemia (Table 5).

Ubwenzi pakati pa digiri ya dyslipoproteinemia mwa odwala matenda a shuga a 2 komanso chiopsezo chokhala ndi matenda amtima.

American Diabetes Association kwa odwala omwe ali ndi matenda ashuga, koma popanda kuwonetsa kwa matenda a coronary atherosulinosis, amafanana ndi odwala omwe ali ndi matenda amitsempha yamagazi poyambira chiopsezo cha zovuta zamtima.

Zolemba pa ntchito ya sayansi pamutu wakuti "Mbali za chithandizo cha dyslipidemia mwa odwala omwe ali ndi matenda a shuga a 2"

S.A. URAZGILDEEVA 1 3, MD, O.F. MALYGINA 2, Ph.D.

1 Sayansi-Clinical and Educational Center "Cardiology", Faculty of Medicine, St. Petersburg State University

2 North-West State Medical University. I.I. Mechnikov, St. Petersburg

3 Center for Atherosulinosis and Lipid Diserals of Clinical Hospital No. 122 otchedwa L.G. Sokolova, St. Petersburg

NKHANI ZA KUTENGA KWA DYSLIPIDEMIA

MWAVUTA NDI 2 TYPE DIABETES MELLITUS

Kuwunikiraku kumathandizira kudziwa zina mwa matenda ndi matenda a dyslipidemia mwa odwala omwe ali ndi matenda a shuga 2 pofuna kupewa zovuta zamtima.

chandamale lipid

chitetezo cha lipid-kutsitsa mankhwala

Matenda a shuga mellitus (DM) ndi matenda opita patsogolo omwe amatenga zaka za XXI. kugawa miliri. Malinga ndi International Diabetes Federation, kuchuluka kwa matendawa padziko lapansi pofika chaka cha 2015 kufika anthu 415 miliyoni. Pofika chaka cha 2040, kuchuluka kwa odwala kufika pa 682 miliyoni akuyembekezeredwa, ndiye kuti, matendawa amatha kupezeka mwa munthu aliyense khumi padziko lapansi. Chifukwa chake, shuga imasokoneza kwambiri chitukuko chokhazikika cha anthu. Zinthu ku Russia zibwereza zomwe zikuchitika padziko lonse lapansi. Chifukwa chake, malinga ndi State Register of Patients ndi matenda a shuga, mu Januware 2015 muli anthu pafupifupi 4.1 miliyoni ku Russian Federation ndipo opitilira 90% amadwala matenda a shuga 2 - mamiliyoni 3.7 Pakali pano, zotsatira zaulamuliro ndi matenda obwera omwe adachitika FSBI "Endocrinological Sayansi Center" ya Unduna wa Zaumoyo ku Russian Federation munthawi ya 2002 mpaka 2010, idawonetsa kuti chiwerengero chenicheni cha odwala matenda ashuga ku Russia ndichulukirachulukirachile 3% kuposa omwe adalembetsedwa ndikufika pa 9 miliyoni miliyoni, omwe ndi 7% ya anthu. Malinga ndi International Diabetes Federation, ku Russia kuli odwala pafupifupi 12.1 miliyoni omwe ali ndi matenda ashuga ndipo dziko lathu lili pachigawo chachisanu malinga ndi kuchuluka kwa matendawa, kusiya China, India, United States ndi Brazil patsogolo. Kuchuluka kwa vuto la mtima wamatenda a shuga, omwe ndi chimodzi mwazomwe zimayambitsa kulemala ndi kufa kwa odwala, kukulanso.

KUGWIRITSA NTCHITO ZA ZIWEREWERE NDI ZINTHAZO ZA CARDIOVASCULAR

Matenda oopsa a hyperglycemia mu shuga amaphatikizidwa ndi kuwonongeka kwa thupi ndi ziwalo zosiyanasiyana (makamaka maso, impso ndi mitsempha), chifukwa cha kusinthika kwakanthawi kochepa mu microvasculature kapena microangiopathy. Micro ndi macroangiopathies zimayambitsa kuwonjezeka kwa kufa kwa mtima ndi odwala omwe ali ndi matenda a shuga a 2, omwe ndi okwanira 4-5 kuposa chizindikiro ichi mwa ambiri. 80% ya imfa ya odwala omwe ali ndi matenda a shuga a 2 amaphatikizidwa ndi chiwonetsero cha atherosulinosis, ndipo% yawo imayambitsa matenda a mtima (CHD). Kuposa 75% ya hospitalizations a odwala omwe ali ndi matenda ashuga amathandizidwanso ndi chiwonetsero cha atherosulinosis chimodzi kapena chinzake. Chifukwa chake, 50-70% ya zotupa zonse zomwe sizili zowawa zam'munsi zimawerengeredwa ndi odwala matenda a shuga.

Micro ndi macroangiopathies zimayambitsa kuwonjezeka kwa kufa kwa mtima ndi odwala omwe ali ndi matenda a shuga a 2, omwe ndi okwanira 4-5 kuposa chizindikiro ichi mwa ambiri

Ena a endocrinologists amawona atherosulinosis ngati vuto la shuga chifukwa cha zotsatira zoyipa za hyperglycemia komanso majini pazinthu zamitsempha. Poyerekeza ndi michere ya microvascular: matenda ashuga retinopathy ndi nephropathy - atherosulinosis imatchedwa macrovascular complication. Nthawi yomweyo, ndizodziwikiratu kwa akatswiri a mtima kuti atherosulinosis odwala omwe ali ndi matenda amtundu wa 2 ndi matenda odziyimira pawokha, pomwe shuga imakhala imodzi mwazofunikira kwambiri pakukula kwa atherosulinosis. Chifukwa chake, kafukufuku wamkulu kwambiri wamatenda, INTRHEART, omwe adachitika mu 2000-2004, adawonetsa kuti matenda ashuga ndi chinthu chachitatu chofunikira kwambiri pakukula kwa matenda oopsa a myocardial infarction (AMI) mwa amuna azaka zapakati

Pambuyo kuphwanya lipid kagayidwe ndi kusuta, ngakhale asanakhale ochepa matenda oopsa.

Amadziwikanso kuti matenda ashuga amakulitsa kwambiri kuchuluka kwa matenda a mtima komanso kumawonjezera chiopsezo cha zovuta zazikulu ndi kufa kwa chitukuko cha zochitika zapamtima. IHD mwa odwala matenda ashuga ali ndi zinthu zomwe amazidziwa bwino. Angina pectoris nthawi zambiri amakhala atypical, ndipo ngakhale kuphwanya kwakukulu kwamitsempha yamagazi kungakhale kosagwirizana ndi kupweteka. Nthawi zina, ngakhale AMI imatha kukhala yopanda tanthauzo mwachilengedwe ndipo imapezeka pokhapokha pojambulitsa ECG. Njira ya AMI imadziwika ndi kutsika pang'ono pakukonza, komwe kumatha kuyambitsa mapangidwe a aneurysm ammunsi ventricle nthawi zambiri kuposa mwa anthu omwe ali ndi shuga. Kuphatikiza apo, chidwi chamtima cha arrhythmias ndikuwonetsa kulephera kwa mtima kulembedwa, njira yomwe imadwalitsa kwambiri shuga.

Monga kuwunika mwachidule kwa mayeso azachipatala a 11 T1MI omwe adachitika kuyambira 1997 mpaka 2006 adawonetsa, mwa odwala 62,000, 17.1% ya odwala omwe ali ndi matenda a shuga. Kwa odwala awa, chiwerengero chaimfa cha masiku 30 ndi 8.5% ndikukula kwa AMI ndikutukuka kwa gawo la BT ndi 2.1% yokhala ndi AMI popanda chiwopsezo cha gawo la BT, lomwe limakhala lalitali pafupifupi 2 kuposa la odwala omwe ali ndi matenda a shuga. Olemba bukuli amaona kuti mfundo imeneyi ndi yofunika kudziwa njira zoyendetsera odwala omwe amafunikira chithandizo chokhwima kwambiri, ngakhale “champhamvu”, kuphatikizapo kutsika kwa lipid. Coronary angiography nthawi zambiri imawulula za distalary matenda am'mitsempha, zomwe zimapangitsa kukhala kovuta kuchitanso opareshoni ya myocardium. Odwala amadziwikanso ndi chotupa chachikulu cha mafupa ambiri a mtima, kuphatikiza mitsempha yamtundu wamtundu, ndimakonda kukulitsa mitsempha ya mitsempha komanso kuwonongeka kwa mapepala ndi mapangidwe a thrombosis. Dziwani kuti njira ya atherosselotic mu shuga imayamba kale kwambiri kuposa anthu omwe alibe matendawa. Chowonadi cha kukhalapo kwa zovuta zazikulu za lipid metabolism mwa odwala omwe ali ndi matenda ashuga zimathandiza kwambiri pamenepa.

Zambiri za dyslipidemia mu shuga mellitus

Malinga ndi tanthauzo la matenda omwe akufotokozedwa mu ma algorithms a chithandizo chapadera cha odwala omwe ali ndi matenda a shuga, matenda a shuga ndi gulu la matenda a metabolic (metabolic) omwe amadziwika ndi matenda a hyperglycemia, omwe ndi chifukwa chophwanya insulin, insulin, kapena zina mwazinthu izi. Inde, gawo lalikulu la insulin m'thupi la munthu ndikuwonetsetsa kuti glucose amalowerera m'maselo ndikugwiritsa ntchito kwake ngati mphamvu yothamanga. Komabe, insulin ya mahomoni ili ndi mawonekedwe ambiri

zochita, kukopa mitundu ina ya kusinthana. Insulin yochulukirapo, yomwe imalephereka pamaso pa insulin kukaniza odwala omwe ali ndi matenda a shuga a 2, imayambitsa kukulitsa zotsatira zingapo zomwe zitha kuganiziridwa atherogenic. Insulin yochulukirapo imawonjezera mphamvu zomatira za monocytes, imalimbikitsa kuchuluka kwa mitsempha ya HMC, imayambitsa kukanika kwa ntchito komanso kuwonjezeka kwa ntchito yolumikizana ndi zinthu za m'magazi.

Nthawi zambiri, ndi mtundu wachiwiri wa matenda ashuga, dyslipidemia (DLP) amakula, womwe umakhala wachilengedwe. Nthawi zina, kupezeka kwa DLP koteroko kungayambitse kudziwitsidwa kwa zovuta za carbohydrate metabolism ndipo kumakhala maziko a kuyesa kwa glucose.

Kafukufuku. INTRHEART idawonetsa kuti matenda ashuga ndi gawo lachitatu lofunikira kwambiri pakulowerera kwa pachimake myocardial infarction kwa amuna azaka zapakati pambuyo pa metabolidi ya metabolidi ndi kusuta, ngakhale patsogolo pake.

Makhalidwe akulu a DLP mu mtundu wa 2 shuga ndiwonjezere mu triglycerides (TG) mu kapangidwe ka lipoproteins otsika kwambiri (VLDL) komanso kuchepa kwa msana wa lipoprotein cholesterol (HDL cholesterol) yayikulu.

Monga choyambitsa chitukuko cha matenda oopsa a hypertriglyceridemia (GTG) mu mtundu 2 wa shuga, chidwi chochepa cha visceral adipose minofu ya antilipolytic zotsatira za insulin imatha kutchedwa, zomwe zimapangitsa kuti lipolysis iwonjezeke, kulowa kwa kuchuluka kwamafuta acids mumtunda wamagazi ndipo, chifukwa chake, onjezani kapangidwe ka TG ndi VLDL ndi chiwindi. Kuphatikiza apo, ndi hyperglycemia, ntchito ya endothelial lipoprotein lipase (LPL), yomwe imayambitsa matenda a TG ndi VLDL, yafupika, yomwe imakulitsa kuphwanya kumeneku. Kutsika kwa cholesterol ya HDL mu mtundu wa 2 shuga kwachitika chifukwa cha kuchuluka kwa ntchito ya hepatic LPL komanso kuthamanga kwa catabolism ya HDL. Kuchuluka kwa cholesterol mu low-density lipoproteins (LDL) mwa odwala matenda ashuga nthawi zambiri sikuwonjezereka, komabe, odwala ambiri amapezeka ndi DLP yophatikizika kapena yosakanikirana, makamaka ngati matenda ashuga amayamba chifukwa cha maziko a DLP yoyamba, omwe adakonzedweratu. Nthawi yomweyo, ngakhale ndi otsika a LDL cholesterol, odwala omwe ali ndi matenda a shuga a 2 amadziwika ndi predominance ya kachigawo kakang'ono ka LDL kakang'ono kwambiri ndi atherogenicity chifukwa cha kuthekera kwakukulu kwa oxidize ndi glycosylate. Nawonso, glycosylation ndi makutidwe ndi okosijeni a HDL kumapangitsa kutsika kwawo kwa antiatherogenic. Kukula kwa diabetesic nephropathy mwa odwala kumachulukitsa kuchuluka komwe kulipo kale mu TG komanso kuchepa kwa cholesterol ya HDL. Zosintha zochulukirapo pazowoneka za lipid zimatha kudzipatula, koma nthawi zambiri zimaphatikizidwa ndipo zimatchedwa diabetesic lipid triad 6, 7.

Laboratory matenda a diabetesic DLP akhoza kudziwika zovuta ngati kutsimikiza mwachindunji kuchuluka kwa LDL cholesterol sichinachitike. Fomywald yodziwika komanso yogwiritsidwa ntchito kwambiri pakuwerengera kuchuluka kwa cholesterol ya LDL siyingagwiritsidwe ntchito mwa odwala omwe ali ndi matenda ashuga, chifukwa kuchuluka kwambiri kwa TG komanso zotsika za cholesterol ya HDL kumabweretsa zosokoneza kwambiri zotsatira zake. Pa mulingo wa TG wa b,5,5 mmol / L, kuwerengeka kwa mulingo wa cholesterol wa LDL wogwiritsa ntchito fomayi sikulondola. Kutsimikiza kwachindunji cha kuchuluka kwa cholesterol ya LDL kungachitidwe kutali ndi ma labotore onse. Malinga ndi malingaliro a EAB 2011 ndi NOA / RKO 2012, tikulimbikitsidwa kuti anthu omwe ali ndi mlingo wa TG wa $ 2.3 mmol / l adziwe kuchuluka kwa cholesterol yosagwirizana ndi HDL (cholesterol-non-HDL). Chizindikiritsochi chimawerengeredwa mophweka - kuchokera muyezo wa cholesterol yathunthu, ndikofunikira kuchotsa gawo la HDL cholesterol 8, 9.

Makhalidwe akulu a DLP

ndi mtundu wa 2 matenda a shuga ndizochulukirapo

triglycerides, lipoproteins

kachulukidwe kochepa kwambiri komanso kosachepera

high lipoprotein cholesterol

Mu ma labid apadera a lipid, ndizotheka kudziwa zowonjezera zomwe zimakhala ndi matenda ashuga a DLP ndikugwiritsa ntchito njira yolondola komanso yoyambirira yotsimikizirira atherogenicity ya seramu yamagazi: zomwe zili ndi mapuloteni ang'onoang'ono a LDL ndi protein ya apoV. Nthawi zina mayeserowa amakupatsirani chisankho chakufunika kwa kukonza mankhwala a DLP, ngakhale odwala omwe ali ndi matenda a shuga a 2, makamaka, ndi odwala omwe ali ndi chiwopsezo chachikulu cha mtima (SS), chomwe chimafuna chithandizo chogwira ntchito cha lipid.

MITU YA 2 YOPHUNZITSA Odwala - OLEMBEDWA NDI ATSOGOLO KWAMBIRI KWAMBIRI

Kuwunikira gulu langozi CC ndikofunikira kwambiri pakupanga kasamalidwe koyenera ka odwala komanso kusankha chithandizo chokwanira chomwe chitha kukhalabe ndi cholesterol chokwanira. Malinga ndi zomwe amapereka pamavomerezo a ESC / EASD okhudzana ndi matenda ashuga, prediabetes ndi CVD, yomwe idakhazikitsidwa mu 2014, odwala matenda ashuga ayenera kuonedwa ngati gulu lowopsa kwambiri komanso loopsa kwambiri la zovuta za CC: odwala matenda a shuga komanso vuto limodzi la SS Matenda kapena kuwonongeka kwa ziwalo zomwe zikuyang'aniridwa ziyenera kuonedwa ngati gulu lowopsa kwambiri, komanso odwala ena onse omwe ali ndi matenda ashuga monga gulu lowopsa. Odwala omwe ali ndi matenda amtundu wa 2 kapena matenda a shuga a 1 omwe ali ndi zowonongeka kwa ziwalo zoberekera ndi microalbuminuria amadziwikanso pachiwopsezo chachikulu cha CC malinga ndi zomwe amapereka pakuwongolera dyslipidemia NLA / RKO 2012 ndi EAS 2011 ., pamodzi ndi odwala omwe akudwala matenda a coronary arteryial and / kapena peripheral arterial atherosclerosis, ischemic stroke, omwe ali ndi matenda a impso kapena osakhazikika, komanso odwala omwe ngozi ya zaka 10 ya CC-kufa ndi SCORE £ 10% (Gome 1). Nthawi yomweyo, chiopsezo chotenga zovuta za CC kwa odwala omwe ali ndi matenda ashuga ndizokwera kwambiri kuposa anthu opanda matendawa, ndipo mwa amayi ndiwokwera maulendo 5, mwa amuna 3 katatu 8, 9. Chifukwa chake, ngati chiwopsezo chazotsatira zakayikidwa malinga ndi kuchuluka kwa SCORE, , mwachitsanzo, mu 5%, kwa amayi ndi abambo omwe ali ndi matenda a shuga ndi 25 ndi 15%, motere, ndiye kuti, odwala oterewa amawatcha kuti ali pachiwopsezo chachikulu cha zovuta za CC.

ZOPHUNZITSA ZA KUTETEZA KWA HYPOLIPIDEMIC KWA AZITI NDI TYPE 2 DIABETES MellITUS

Gome 1. Zida za cholesterol yotsika kwambiri (LDL cholesterol) yotsika kwa odwala omwe ali ndi magulu osiyanasiyana a mtima (CV) pachiwopsezo 8, 9

Gulu la chiopsezo cha SSL chandamale cha LDL cholesterol, mmol / l

Ngozi yayikulu kwambiri a) odwala omwe ali ndi matenda amitsempha yamagazi ndi / kapena zotumphukira kwamatumbo, ischemic stroke, yotsimikiziridwa ndi njira zodziwira b) odwala omwe ali ndi matenda amtundu wa 2 kapena mtundu wa 1 omwe ali ndi chiwopsezo cha ziwalo zam'magazi komanso microalbuminuria c) odwala omwe ali ndi pakati kapena kwambiri matenda a impso - glomerular filtration rate (GFR) sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

Kuopsa kwambiri a) kuwonjezeka kwakukulu mu chimodzi mwazinthu zowopsa, mwachitsanzo, HCS yayikulu kapena AH yayikulu b) yokhala ndi chiopsezo cha SCORE cha SCORE - ¿5% ndipo sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

ASPEN 505 Atorvastatin 10 mg / placebo 18%

CARE 586 Pravastatin 40 mg / placebo 25% (p = 0.05)

LIPID 1077 Pravastatin 40 mg / placebo 21 °% (p sindikutha kupeza zomwe mukufuna? Yesani ntchito yosankha.

phindu lawo lalikulu ndikuchepa kwa TG ndi 20-50%, zomwe mafuta am'mafuta a cholesterol ndi LDL amachepetsa ndi 10-25% pansi pa michere. Tiyenera kudziwa kuti chifukwa cha mankhwala omwe ali ndi ma fibrate, pali kuwonjezeka kwakukulu kwa cholesterol ya HDL (mwa 10-25%).Kuphatikiza pa lipid-kutsitsa kwenikweni, michere, makamaka fenofibrate, imakhala ndi anti-yotupa yowonjezera ndikuchepetsa mulingo wa uric acid mu plasma. Mmodzi mwa maphunziro oyamba a mankhwala a kalasi la fibrate, hemphibrozil, HHS, odwala 135 omwe ali ndi matenda amtundu wa 2 adatenga nawo gawo. Mu gulu la othandizira, kuchuluka kwa zochitika za SS kunali 60% kochepera mu gulu la placebo, koma chifukwa cha kukula kochepa kakulidwe, kusiyana kwake sikunali kofunika pazotsatira. Kafukufuku wa VA-HIT anali ndi odwala omwe ali ndi otsika a cholesterol ya LDL, odwala 769 anali ndi matenda a shuga a 2, omwe amakhala pafupifupi gawo limodzi mwa magawo atatu aanthu onse odwala (anthu 2,531). Mu gululi, kusiyana kwa kuchuluka kwa zochitika za SS pakati pa omwe amalandila gemfibrozil ndi placebo kunali 24% ndipo kunali kofunikira kwambiri p p. 0.05).

Kafukufuku wa FIELD ndi ACCORD omwe ali ndi fenofibrate atsimikizira kuti kuwongolera kwakukulu mu chiwopsezo cha zovuta za CC kungayembekezeredwe kokha pagulu la anthu omwe ali ndi THG yayikulu komanso otsika HDL cholesterol. Anaona kuchepa kwakukulu kwa zovuta zazikuluzikulu za m'magazi komanso matenda a shuga. Mwachitsanzo, mu kafukufuku wa FIELD, panali kuchepa kwakukulu (79%) kwa kupitirira kwa retinopathy kwa retina pagulu lachipatala chogwira, ndipo kufunika kwa laser coagulation kutsika ndi 37%. Kusintha kofananako kunawonedwa mu diabetesic nephropathy ndi neuropathy. Chiwopsezo chotenga matenda a shuga a nephropathy amatsika ndi 18%, ndi kupita patsogolo kwa proteinuria ndi 14%. Mothandizidwa ndi mankhwala a fenofibrate, kusinthasintha kosanenepetsa chifukwa cha phazi la matenda ashuga kumatsika ndi 47%. Tiyenera kudziwa kuti kuchepa kwa pafupipafupi kwa zovuta zonse za shuga kumawonedwa mosasamala kanthu ka kayendedwe ka glycemic, kuchuluka kwa kuthamanga kwa magazi kapena mbiri ya lipid. Kupanga kwa izi kungakhale chifukwa cha anti-yotupa ndi antioxidant katundu wa fenofibrate ndipo kumafunanso kuti apitirize kuphunzira. Chifukwa chake, kugwiritsa ntchito mafupa, limodzi ndi kugwiritsa ntchito ma statins, kuli koyenera kuthandizira DLP kwa odwala omwe ali ndi matenda a shuga a 2.

Pa mulingo wa TG osapitirira 4.5 mmol / L, mankhwala a statin amawonetsedwa ngati mankhwala oyamba, ndipo akukhalabe kutchulidwa THG (pamwambapa 2.3 mmol / L), mankhwala achiwiri, fenofibrate, amawonjezeredwa pamankhwala. Ngati mulingo wa TG uposa 4.5 mmol / l, makonzedwe apakati a statin ndi fenofibrate 17, 18 akhoza kukhala olongosoka. Mwachilengedwe, kugwiritsa ntchito mankhwala ophatikizira a lipid kumapangitsa maudindo ena kwa adotolo pakuwunika kawirikawiri chitetezo chamankhwala. Pamene statin ndi fibrate zimagwiritsidwa ntchito limodzi, kuwongolera kwa ntchito ya creatine phosphokinase

(CPK) imachitidwa miyezi itatu iliyonse. chaka choyamba cha mankhwala, ngakhale wodwalayo ali ndi zodandaula za kupweteka kwa minofu ndi kufooka. Ziyeneranso kukhala miyezi isanu ndi umodzi. yang'anani ntchito za alanine aminotransferase (ALT) ndi milingo ya creatinine. Pankhani imeneyi, ndikufuna kudziwa kuti ntchito za ALT ndi CPK ziyenera kuwunikira isanayambike mankhwala othandizira lipid, komabe, ndizowona kwa odwala aliwonse, osati odwala matenda ashuga okha. Kuphatikiza apo, ziyenera kukumbukiridwa kuti kugwiritsidwa ntchito kwa gemfibrosil ndi ma statins kuli koletsedwa chifukwa cha chiwopsezo chachikulu chokhudzana ndi zovuta chifukwa chazovuta za pharmacokinetics a mankhwalawa 8, 9.

Ma algorithms popereka chithandizo chapadera chamankhwala kwa odwala omwe ali ndi matenda ashuga amalemba mankhwala kwa odwala omwe ali ndi matenda amtundu wa 2 pamaso pa chiwopsezo chachikulu kapena ngati chandamale cha LDL ndi TG cholesterol sichikwaniritsidwa

Poganizira za kufunika koperewera kwa mankhwala ochepetsa mphamvu ya lipid kuti muchepetse chiwopsezo cha zochitika za SS kwa odwala matenda ashuga a 2, ndikufuna kudziwa kuti mayesero akulu omwe adachitika mwachisawawa atsimikizira kufunika kwa

glycemic control pochepetsa chiopsezo cha kusokonezeka kwa mtima wamagulu ali m'gulu lino la odwala 19, 20, 21.

Odwala omwe ali ndi matenda a shuga a mtundu wachiwiri nthawi zambiri amayenera kutchulidwa ngati chiwopsezo cha mtima kwambiri.

Dyslipidemia yachiwiri kwa odwala omwe ali ndi matenda ashuga ali ndi mawonekedwe ake: kuchuluka kwambiri kwa triglycerides ndi otsika a cholesterol ya HDL, komanso zowonjezera zazingwe zazing'ono zamkati LDL.

Monga momwe mankhwalawa amathandizira dyslipidemia mwa odwala omwe ali ndi matenda a shuga 2, kuphatikiza kuchuluka kwa cholesterol ya LDL, index ya non-HDL-C ingagwiritsidwe ntchito.

Gulu lalikulu la mankhwala omwe amalimbikitsidwa kuti agwiritsidwe ntchito kwa odwala omwe ali ndi matenda a shuga 2 ndi ma statins, makamaka atorvastatin ndi rose-wideatin.

Kuphatikiza pa ma statins, eetimibe cholesterol mayamwidwe angagwiritsidwe ntchito, ndipo fenofibrate ingagwiritsidwe ntchito kuchepetsa triglycerides komanso kupewa zovuta za microvascular odwala omwe ali ndi matenda a shuga a 2. f

1. IDF Diabetes Atlas, 7th Edition, 2015. http // www. diabetesatlas.org/resource/2015-atlas.html.

2. Malangizo azachipatala: "Ma aligorms othandizira odwala mwapadera odwala matenda a shuga", kope la 7, 2015, lolemba ndi II. Dedova, M.V. Asanu ndi chimodzi.

3. Yusuf S, Hawken S, Ounpuu S et al. Ofufuza Phunziro la INTERHEART. Zotsatira zakuwoneka zomwe zingasinthidwe zomwe zingachitike chifukwa cholumikizidwa ndi myocardial infarction mu 52 coutries (Phunziro la INTERHEART): kafukufuku wowongolera milandu. Lancet, 2004, 364 (9438): 937-952.

4. Donahoe SM, Atewart GC, McCabe CY et al. Matenda a shuga ndi kufa potsatira ma syndroms acute. LAMA, 2007, 298 (7): 765-775.

5. Krasilnikova E.I., Wokondedwa Y. V., Shlyakhto E.V. Udindo wa insulini pakukula kwa atherosulinosis. M'buku. Atherosulinosis Mavuto a pathogenesis ndi mankhwala. SPb. 2006: 137-163.

6. Glinkina I.V. Chithandizo cha lipid kagayidwe kachakudya matenda a 2 shuga. Dokotala wopita, 2002, 6: 6-8.

7. Sniderman AD, Lamarche B, Tilley J et al. Hypertriglyceridemic hyperapoB mu mtundu 2 shuga. Chisamaliro cha Mashuga, 2002, 25 (3): 579-582.

8. Maupangiri a ESC / EAS oyang'anira ma dyslipidemias. Ntchito Yoyang'anira dyslipidemias wa European Society of Cardiology (ESC) ndi European

Atherosulinosis Society (EAS). Atherosulinosis. 2011, 217: S1-S44.

9. Kuzindikira ndikusintha kwa matenda a lipid metabolism popewa komanso kuchiza matenda a atherosulinosis. Atherosclerosis ndi dyslipidemia, 2012, 4.

10. Malangizo a matenda ashuga, prediabetes ndi mtima. European Society of Cardiology (ESC) Diabetes, Prediabetes ndi Cardiovascular Disease Working Gulu mothandizana ndi European Association for the Study of Diabetes (EASD). Russian Journal of Cardiology, 2014, 3 (107): 7-61.

11. Kwiterovich PO. Dyslipidemia M'magulu Apadera. Dyslipidemia, 2010: 124.

Chitsogozo cha 12,2013 ACC / AHA pakuthandizira kwa cholesterol yamagazi kuti achepetse chiopsezo cha mtima ndi matenda a mtima mwa akulu: lipoti la American College of Cardiology / American Heart Association Task Force on Practice Guidlines. Zozungulira, 2014, 129, 25 (Suppl. 2): 1-45.

13. Jones PH, Davidson MH, Stein EA et al. Kuyerekeza mphamvu ndi chitetezo cha rosuv-astatin motsutsana ndi atorvastatin, simvastin ndi pravastatin kudutsa Mlingo (STELLAR mayeso). Amer. J. Cardiol., 2003, 92 (2): 152-160.

14. Urazgildeeva S.A. Hypolipidemic mankhwala muzochita za katswiri wazachipatala pamalopo. Upangiri wachipatala kuchipatala. 2013, 6: 56-64.

15. Warraich HL, Wong ND, Rana JS. Ntchito yophatikiza ndi matenda ashuga a dyslipidemia. Curr. Cardiol. Rep, 2015, 17 (5): 32.

16. Keech A, Simes RJ, Barter P et al. Zotsatira zakuchiza kwa fenofibrate kwa nthawi yayitali pazochitika zamtima mu 9795 anthu omwe ali ndi mtundu wa 2 matenda a shuga (kafukufuku wa FIELD): kuyesedwa kosasankhidwa kwachinsinsi. Lancet, 2005, 366 (9500): 1849-1861.

17. Home P, Mant, Diaz J, Turner C. Gulu la Maupangiri a Maupangiri. Kuwongolera matenda a shuga 2: chidule cha kuwongolera kwa Nice. BMJ, 2008, 336 (7656): 1306-1308.

18. Lembani matenda a shuga a 2 mwa akulu: kasamalidwe. Malangizo a Nice Wolemba: 2 Disembala 2015. zabwino. org.uk/guidance/ng28.

19. Gulu la UK Prospential Diabetes Study (UKPDS) Gulu. Kusintha kwamphamvu kwa shuga m'magazi ndi sulphonylure-kapena kapena insulini poyerekeza ndi chithandizo chamwadzidzidzi komanso chiopsezo cha zovuta kwa odwala omwe ali ndi matenda ashuga a 2 (UKPDS). Lancet, 1998, 352 (9178): 837-853.

20. Khaw KT, Wareham N et al. Association of hemoglobin A1C omwe ali ndi matenda amtima komanso kufa kwa akuluakulu: European Prospective Investigation in Cancer ku Norfolk. Ann. Mkati. Med, 2004, 141 (6): 413-420.

21. Hardy DS, Hoelscher DM, Aragaki C et al., Association of glycemic index ndi glycemic katundu wokhala ndi chiopsezo cha matenda amtima wamkati mwa azungu komanso anthu aku America omwe alibe ndi mtundu 2 wa matenda ashuga: chiwopsezo cha Atherosulinosis mu Communities Study. Ann. Epidemiol., 2010, 20 (8): 610-616.

HMG-COA reductase inhibitors (ma statins)

Monga kalasi, mankhwalawa amalekeredwa mosavuta ndipo amagwira bwino ntchito pakuchepetsa cholesterol ya LDL, chifukwa chake masiku ano ndiwodziwika kwambiri pakuthandizira hyperlipidemia.
Lovastatin, simvastatin ndi pravastatin ndi metabolites a bowa kapena zotumphukira za metabolites izi. Ngakhale fluvastatin, atorvastatin ndi rosuvastatin ndi zinthu zopangidwa mokwanira. Lovastatin ndi simvastatin ndi "mankhwala osokoneza bongo", popeza amayamba kukhala ndi mankhwala osokoneza bongo pambuyo pa hydrolysis m'chiwindi. Mankhwala omwe atsalawo akuperekedwa kale kale.
Njira yamachitidwe. HMG-CoA reductase inhibitors, kupondereza enzyme ofunikira kwa cholesterol synthesis, HMG-CoA reductase, kumathandizanso kuchepa kwa kupanga kwa BB komwe kumakhala ndi lipoproteins ndikuthandizira ma LDL receptors. Zotsatira zake, zinthu za m'magazi a LDL cholesterol ndi VLDL triglycerides zimatsika kwambiri, makamaka kwa odwala omwe ali ndi matenda a shuga a 2.
Pharmacokinetics Kutumphukira kwa m'mimba mwa mankhwalawa kumasiyana 30% (atorvastatin) mpaka> 90% (fluvastatin). Ma statins onse amapangidwa mu chiwindi mkati mwa 50% (pravastatin) - 79% (simvastatin). Ma Statin amawachotsa makamaka mu mawonekedwe omangidwa ndi mapuloteni (> 80%), kupatula pravastatin, yemwe zomanga zake zomanga thupi zimakhala zosakwana 50%. Lovastatin, simvastatin ndi atorvastatin zimapangidwa mu dongosolo la cytochrome P450 lolembetsedwa ndi CYP3A4 enzyme, ndipo fluvastatin ndi rosuvastatin ndi magawo a enzyme ya CYP2C29, ngakhale rosuvastatin imachotsedwera makamaka osasinthika. Chilolezo cha Pravastatin chimachitika kudzera mu sulfonation komanso kudzera mu mapuloteni enaake a anionic a chiwonetsero cha chiwindi, omwe amachititsa kuti ma statins agwire. Chiwindi ndi malo akuluakulu ochotsera ma statins. Kuchulukitsa kwakukulu ndi impso kumangokhala kokha kwa pravastatin, koma ndi kulephera kwa aimpso, kuchuluka kwa pravastatin m'magazi sikokwanira, popeza kumakhala ndi chiwindi chochuluka kwambiri mu chiwindi. Zambiri za lovastatin ndi rosuvastatin zimawonjezeka mwa odwala a uremic. Popeza chotsika kwambiri chaimpso ndichizindikiro cha atorvastatin (70 mg%).

Zotsatira zoyipa kwambiri za ma statins ndi myositis, zomwe sizimayamba.

1 kesi / 2000 odwala. Ngakhale ma statin sakhala a mankhwala a hepatotoxic, kuwonjezeka kwapakati pa mayeso a hepatic kumatha kuwonedwa motsutsana ndi maziko awo, chifukwa chake, ntchito ya chiwindi iyenera kupendedwa musanapereke mankhwala. Ma Statin samakhudza kagayidwe kazakudya.
Ma Statist ndi contraindified pa mimba ndi yoyamwitsa. Mu okalamba, chithandizo chikuyenera kuchitika kuyambira ndi Mlingo wocheperako, chifukwa ndizotheka kuwonjezera chidwi chawo.
Zotsatira zoyipa. Zotsatira zake zoyipa zimaphatikizapo arthralgia, dyspepsia, kudzimbidwa, komanso kupweteka kwam'mimba. Zotsatira zochepa za myopathy kwambiri ndi rhabdomyolysis, zomwe zimatsatiridwa ndi kupweteka kwambiri kwa minofu, zimafotokozedwa. Nthawi zambiri, hepatotoxicity imawoneka nthawi ya mankhwala a statin.

Otsatira a bile acid

Ma Resine omwe bile mu matumbo bile acid, omwe amatchedwa sequestrants of bile acids (SCFA), amachititsa kuchepa kwa LDL-C ndi 15-30% ndipo nthawi yomweyo amakhudza ndende ya HDL. Ma SCFA amatha kuwonjezera triglycerides. American Diabetes Association yazindikira SCFA ngati chithandizo chofunikira kwambiri cha dyslipidemia kwa odwala omwe ali ndi matenda a shuga, ndipo kutsitsa kwawo kwa HDL kumakhala kogwirizana ndi HMG-CoA reductase inhibitors (ma statins) akagwiritsidwa ntchito palimodzi. Mankhwala a Colesevelam omwe amtunduwu amathandizanso kuchepetsa HHAlc mu T2DM - 0,5% kuposa placebo. Pamenepa, mu Januware 2008, Wheel idavomerezeka ndi FDA ngati mankhwala ena othandizira odwala matenda ashuga.
Njira yamachitidwe. SKHK imamanga ma bile acid m'matumbo, kutsekeka kwawo. Kuchepa kwa ndende ya bile acid kumalimbitsa hepatic enzyme 7-alpha-hydroxylase, womwe umapangitsa kutembenuka kwa cholesterol kukhala bile acid. Kuwonjezeka kwa kusintha kwa cholesterol mu bile acid kumapangitsa, LDL receptors, yomwe imakulitsa chilolezo cha LDL kuchokera m'magazi. Zotsatira zake, SCFA imachepetsa cholesterol yathunthu, LDL, apolipoprotein B ndikuwonjezera kuchuluka kwa HDL-C. Makina omwe amachititsa kuchepa kwa glycemia motsogozedwa ndi SCFA sakudziwika.
Pharmacokinetics SKHK imatengedwa pamlingo wochepa ndikuwonetsa mphamvu zawo pamatumbo. Zotsatira zochizira zimadalira kuchuluka kwa cholesterol yotsika ndikuwonekera patatha milungu ingapo.
Zochita Zamankhwala. SKHK imakhudza mayamwidwe ndi kuchuluka kwa mankhwala ambiri, kuphatikizapo sulfonamides, anticonvulsants, antiarrhythmic ndi pakamwa kulera. Mulimonsemo, ngati mankhwalawa ali ndi "chithandizo chochepa", ayenera kutengedwa maola 4 musanatenge SCFA kapena maola 4 mutatha kumwa SCFA.
Kuthandiza kwamankhwala othandizira, kufooka ndi zotsatira zoyipa. SKHK amagwiritsidwa ntchito kuti athetse hypercholesterolemia, koma popeza amatha kuyambitsa kuchuluka kwa triglycerides, chizindikiro ichi cha mafuta kagayidwe chiyenera kuyang'aniridwa mopitilira. Pazifukwa zomwezo, SCLC sayenera kutumizidwa kwa odwala omwe ali ndi hyper-triglyceridemia. Chifukwa cha kudzimbidwa kwa odwala omwe akulandira SCFA, izi zimatha kukhala vuto linalake kwa odwala matenda a shuga. Chifukwa cha kutsimikizika kwa vuto la hypoglycemic, ndikofunikira kuti ma Wheelworm apange shuga yachiwiri. Kuchepetsa nthawi - kupewa kumwa ndi sulfonamides ndi mankhwala ena, kuyang'ana pakumalizika kwa ola limodzi ndi maola 6 mutatha kutenga SCFA, imatha kukhala vuto kwa ambiri.
Zotsatira zoyipa zazikulu za SCFA ndi kudzimbidwa ndi dyspepsia. Myalgia, kapamba, kukhathamiritsa kwa zotupa, kutumphuka ndi kuchuluka kwa michere ya chiwindi kunawonedwanso.
Contraindators ndi malire. SKHK amalekanitsidwa ndi odwala omwe ali ndi miyala mu ndulu, ndikulimbana kwathunthu kapena kutsekeka kwa m'mimba, ndipo chisamaliro chapadera chiyenera kutengedwa mwa odwala omwe ali ndi triglycerides okwera m'magazi.

Fibric acid derivatives (fenofibrate ndi heme-fibrosyl) ndi a PPAR alpha agonists ndipo ali ndi tanthauzo pa metabolidi ya lipid, kuchepetsa chiopsezo cha zochitika zamtima. Amalimbikitsidwa pa matenda a dyslipidemia mwa odwala matenda a shuga. Mwambiri, mwa odwala matenda ashuga, ma fibrate amachepetsa triglycerides ndi 35-50%, LDL-C ndi 5-20% ndikuwonjezera HDL-C ndi 10-20%. Fenofibrate imawerengedwa kuti ndi njira yofunika kwambiri pochizira odwala LDL-C odwala omwe ali ndi matenda ashuga omwe ma statins sangathe kupereka chandamale cha lipid ndipo amakhala ndi chiyanjano chogwiritsidwa ntchito limodzi ndi ma statins.

Njira yamachitidwe. Mwa kuyambitsa PPAR-a, fibrate amasintha kagayidwe kazitsulo motere:

kuwonjezera lipoprotein lipase synthesis,
onjezani kapangidwe ka apo A-I ndi apo A-P, omwe ndiye mapuloteni akuluakulu a HDL,
onjezerani kaphatikizidwe ka ABC-A1, kamene kamathandizira kuti mafuta a cholesterol ayambe kuyenda pomwe A-1 akuchita HDL biogenesis,
sinthani apo A-C, choletsa wa lipoprotein lipase ndikuchulukitsa apo A-V, kapangidwe kake komwe kamachepetsa mulingo wa lipoprotein wolemera mu TG,
sinthani kufotokozera kwamapuloteni oyamwa a cholesterol (Nieman-Pick C1-1).

Kuphatikiza pazotsatira zomwe tatchulazi, ma fi-m'bale amachepetsa hepatic lipogenesis pomangiriza ku hepatic X receptor (PCR), kuletsa PCR-mediated lipogenesis. Kuphatikiza apo, pakuwongolera kagayidwe ka lipid, ma fiber amatha kukhala ndi antiatherogenic pogwiritsa ntchito njira zotsatirazi:

fenofibrate amachepetsa kuchuluka kwa mapuloteni a C-reactive, interleukin 6 ndi lipoprotein ogwirizana ndi phospholipase A2, malo atatu otupa,
fenofibrate imachepetsa ntchito ya matrix chitsulo proteinase ndipo imatha kupititsa bata,
fenofibrate, koma mwina si ena omwe amapezeka ndi phibric acid, amalimbikitsa kapangidwe ka mtima endothelial N0 synthetase,
zotumphukira za fibrinic zimachepetsa kuchuluka kwa mtundu wa 1 plasminogen activator inhibitor womwe umalimbikitsidwa ndi insulin, womwe umapangitsa ntchito ya fibrinolytic ku T2DM, yomwe imadziwika ndi hyperinsulinemia.

Fenofibrate imakhala yothandiza kwambiri kuposa gemfibrozil, imachepetsa mulingo wa LDL-C mwa odwala omwe ali ndi kuchuluka kwambiri kwa LDL ndikuchepetsa kuchuluka kwa cholesterol yomwe sili m'gulu la HDL-C odwala omwe ali ndi hypertriglyceridemia. Fenofibrate ikhoza kukhala yothandiza pakuchepetsa milingo ya LDL mwa odwala omwe ali ndi TG yotsika pomwe ma statins, nicotinic acid, ndi SCFA adapezeka kuti alibe ntchito. Fenofibrate amachepetsa mulingo wa uric acid, ndikuwonjezera kuchulukana kwa ura-tov.
Kuchita ndi mankhwala ena. Pazonse, ma fiber ayenera kugwiritsidwa ntchito mosamala ndi ma statins, chifukwa izi zimawonjezera chiopsezo cha myopathy ndi rhabdo-myolysis. Popeza michere imamangidwa kwambiri ku albumin, imawonjezera mphamvu ya warfarin.
Kuthandiza kwamankhwala othandizira, kufooka ndi zotsatira zoyipa. Kuchita bwino kwamankhwala kwa fibrate kwaphunziridwa mu maphunziro osiyanasiyana azachipatala. Kutengera ndi zomwe zapezeka m'mawuwo, mfundo zotsatirazi zitha kufikiridwa:

kuwunikanso kwa deta ya NNT (Helsinky Heart Trial, gemfibrozil) kuwonetsa kuti zabwino zazikulu kwambiri za gemfibrozil zili m'gulu loopsa: omwe nthawi yomweyo amakhala ndi cholesterol-LDL / cholesterol-HDL (> 5) komanso mulingo wa TG> 200 mg%. Mu gululi mudapangitsa kutsika kwa 71% pachiwopsezo cha PRS,
mu kafukufuku wa VA-HIT (Veteran Affears HDL Intertin Trial), panthawi imodzimodzi, mphamvu yapamwamba ya gemfibrozil idawonetsedwa kwa magawo osiyanasiyana a metabolism ya carbohydrate - kuyambira kulekerera kosalekeza kuti azidutsa matenda a shuga,
mu kafukufuku wa DIAS (Diabetes Aterosulinosis Diabetes Study) fenofibrate kwa odwala omwe ali ndi matenda a shuga a 2 adapangitsa kuti pang'onopang'ono matenda a atherosulinosis, omwe akuwonetsedwa angiographical,

Kutengera ndi zomwe zapezedwa, kuthekera kochiritsa odwala omwe ali ndi matenda a shuga a 2 omwe ali ndi ma fiber kumawerengedwa. Masiku ano, matenda a shuga ndi chisankho choyamba. Fibates iyenera kuperekedwa kwa odwala omwe samaloleza ma statins, kapena ngati gawo limodzi la odwala omwe ali ndi vuto lalikulu la osakanikirana a LDL-C. Kuphatikiza apo, kuphatikiza, mwayi pakati pa ma fiber amapatsidwa fenofibrate.
Ma Fibrate (makamaka fenofibrate) amathanso kugwiritsidwa ntchito kutsitsa kuchuluka kwa LDL mwa odwala omwe ali ndi magulu ochepa kwambiri a TG, koma pachifukwa ichi, zokonda zimaperekedwa kwa mankhwala amakalasi ena - ma statins, nicotinic acid ndi SCFA.
Kuti mukwaniritse kwambiri, mankhwalawa ndi ma fibrate mpaka miyezi 3-6 amafunikira.
Popeza ma fibrate amawonjezera chiopsezo chokhala ndi cholelithiasis, sayenera kutumizidwa kwa odwala matenda a shuga omwe ali ndi vuto la mtima wamitsempha chifukwa cha matenda ashuga othana ndi vuto la matenda ashuga.
Ma fimu amachotsedwa makamaka ndi impso, chifukwa chake chidwi chachikulu chimayenera kulipiridwa mpaka pakukula kwa odwala omwe ali ndi matenda a nephropathy, komanso odwala okalamba. Filates sinafotokozedwenso kwa amayi apakati komanso pakubala.
Kupweteka kwam'mimba ndizomwe zimachitika kwambiri pakulimbana ndi michere ndipo zimaphatikizapo dyspepsia, nseru, kusanza, kudzimbidwa kapena kutsegula m'mimba, kupweteka kwam'mimba komanso kuwonjezeka kwa kupanga kwa mpweya. Mu 2-3% ya odwala, zotupa za pakhungu zimawonekera. Zotsatira zoyipa zamagetsi, monga chizungulire, kugona, kusawona bwino, zotumphukira, kupsinjika, kusokonezeka kwa libido, komanso kukanika kwa erectile, kukulira limodzi ndi chithandizo ndi gemfibrozil.

NICOTIC ACID (Niacin)

Niacin (niacin, nicotinamide) ndi vitamini (B3, PP) ndipo wagwiritsidwa ntchito pochiza matenda oopsa (hyperlipidemia) zaka 50 zapitazi. Mlingo waukulu, wopitilira muyeso wa tsiku ndi tsiku, niacin amachepetsa ma plasma a VLDL ndi LDL, mbali imodzi, ndikukulitsa mulingo wa HDL, mbali inayo. Ichi ndiye mankhwala okhawo a gi-polypidemic omwe amatsitsa muloprotein (a). Komabe, zovuta zingapo zoyipa zimapangitsa kuti zikhale zovuta kugwiritsa ntchito.
Niacin akulimbikitsidwa ngati mzere woyamba wa chithandizo cha hypertriglyceridemia ndi / kapena LDL-C wokhala ndi magawo otsika a HDL-C. Mwanjira iyi, niacin ikhoza kuphatikizidwa ndi ma statins, SCFA kapena ezetimibe.
Njira yamachitidwe. Niacin amakhudza kagayidwe ka apo-lipoprotein B (apo B wokhala ndi lipoproteins), komanso HDL. Pogwiritsa ntchito GPR109A receptor mu adipocyte, niacin imayambitsa kuchepa kwa cAMP, komwe kumayambitsanso kutsika kwa msase wa lipase yokhala ndi mahomoni okhala ndi minyewa ya adipose. Zotsatira zake, hydrolysis ya TG ndi kusakanikirana kwa mafuta acids kuchokera ku minofu ya adipose amachepa. Izi zimachepetsa kukhathamiritsa kwamafuta acid (FFAs) mu chiwindi, komwe ndi kiyi yopangira TG ku LDL. Kuphatikiza apo, niacin amachepetsa misempha ya TG poletsa ntchito ya digricerol acyl transferase 2, yofunika kwambiri mu syntigantceride.
Dziwani kuti beta-hydroxybutyrate ndi gawo lachilengedwe la GPR109A, chifukwa chake kutsegula kwa GPR109A kumawonjezera kukana kwa thupi pakukula kwa ketoacidosis.
Zotsatira za apo zopangidwa ndi lipoproteins ya B zimapangidwa kudzera mu nicotinic acid pa kapangidwe ka kapangidwe ka VLDL. Niacin amachepetsa kupanga kwa chiwopsezo cha VLDL, chomwe chimalumikizidwa kwambiri ndi kuchepa kwa magazi a FFA kuchokera ku minofu ya adipose kupita ku chiwindi. Kuphatikiza apo, niacin imalepheretsa kuphatikizika kwa TG ndikuwonjezera kuchepa kwa chinyengo cha apo B mu hepatocytes. M'maphunziro azachipatala, kuchepa kwa milingo ya VLDL kumawonedwa pokhapokha kusala TG kumachepa. Popeza LDL ndi metabolite wa VLDL, chifukwa chake, kuchepa pakupanga VLDL kumayendetsedwa ndi kuchepa kwa mulingo wa LDL m'magazi.
Kuphatikiza apo, kudzera mu makina a prostaglandin-Mediated, nicotinic acid imakulitsa kapangidwe ka CD macrophage receptor yapakompyuta, yomwe imakhudzidwa ndi oxidation wa LDL.
Niacin amachulukitsa mulingo wa HDL-C kwambiri kuposa mankhwala ena osinthira lipid, ndipo izi zikuchitika chifukwa cha kuchepa kwa chilolezo cha HDL, chomwe, pambuyo pake, chingakhale chifukwa chakuchepa kwa TG m'magazi.
Niacin imathandizira kaphatikizidwe wa ABC-A1, kiyi yofunika kwambiri yoyendetsa gawo loyambirira la mayendedwe a cholesterol osinthika.
Ndiye niacin:

amaletsa kumasulidwa kwa FFA kuchokera ku minofu ya adipose,
kumawonjezera ntchito ya lipoprotein lipase,
amachepetsa kapangidwe ka triglyceride,
Imachepetsa kuyendetsa kwa ma triglycerides a VLDL,
linalake ndipo tikulephera lipolysis.

Pharmacokinetics Niacin amatha msanga komanso kukhathamira m'mimba ndi matumbo aang'ono. Chiwonetsero chazikulu m'magazi chimawonedwa pambuyo pakupita kwa mphindi 45, ndikukula kwa nthawi yayitali - maola 4-5 pambuyo pa kuperekedwa. Vasodilation imachitika mphindi 20 mutatenga niacin osatenga nthawi yayitali ndipo umatha pafupifupi ola limodzi. Pafupifupi 12% ya niacin imachotsedwa mu mkodzo, koma ngati muyezo umaposa 1000 mg / tsiku, kagayidwe kake ka niacin m'thupi kamadzaza ndipo amakayikira mkodzo kwambiri. Niacin amadziunjikira makamaka m'chiwindi, ndulu ndi adipose.
Zochita Zamankhwala. Rhabdo-myolysis samakonda kupangidwa pamene niacin amatengedwa ndi ma statins. Popeza niacin amagwirizanitsidwa ndi SCFA, nthawi pakati pa niacin ndi SCFA iyenera kukhala ola limodzi isanakwane ndi maola 4-6 mutatenga SCFA. Popeza niacin amachepetsa mitsempha ya magazi, imatha kukhala ndi vuto la mankhwala omwe amakulitsa mitsempha yamagazi - nitrate ndi calcium blockers.

Mankhwala, Mlingo ndi ma regimens othandizira
NICOTINAMIDE (NICOTINAMIDE) - mlingo woyambirira ndi 100 mg 2 kawiri pa tsiku, kuwonjezeka kwa sabata kwa 100 mg, mpaka mlingo umafika 500 mg 2 kawiri pa tsiku. Kenako, mlingo umaperekedwa kwa 500 mg kuti akwaniritse zomwe mukufuna. Mlingo umatha kufikira 4 g / tsiku, koma nthawi zambiri 1500 mg / tsiku ndi lokwanira. kuthetsa hypertriglyceridemia. Ngati khungu layamba kupangika, ndiye kuti 1 ora musanayambe kumwa niacin, aspirin ndi mankhwala ochepa.
Niacin wokhala ndi nthawi yayitali amakhala ndi mapiritsi a 500, 750 ndi 1000 mg. Mlingo woyambirira ndi 500 mg, womwe umatuluka ndi 500 mg sabata iliyonse iliyonse. Njira yokonza ndi 1-2 g patsiku. Kutalika kwake ndi 2 g / tsiku.

Mphamvu zamankhwala. Pa mlingo wa 3-4 g patsiku, nicotinic acid amakhudza kuchuluka kwa lipoprotein motere:

amachepetsa mulingo wa LDL-C ndi 20-30%,
amachepetsa mulingo wa TG ndi 20-50%,
kuchuluka kwa HDL-C ndi 25-50%,
amachepetsa lipoprotein (a) mwa 30%.

Ponena za kufala kwamankhwala, komwe kumatsimikiziridwa ndi zomwe amadziwika kuti ndizotsatira za atherosulinosis, nicotinic acid imachepetsa:

kufa kwathunthu
matenda amtima,
pafupipafupi infaration yopanda tanthauzo.

Zotsatira zoyipa, contraindication. Mpaka 30% ya odwala sangathe kulekerera niacin chifukwa cha zovuta zake: redness, dryness, ichthyosis ndi kuyabwa kwa khungu, khungu la khungu lamankhwala am'mimba, gastritis, zilonda zam'mimba, hepatitis, kupweteka pamimba, kuchuluka kwa uric acid, gout, insulin, hyperglycemia, hypotension ndi kutaya chikumbumtima (osati kawirikawiri), athistrogia (osadziwika), komanso amblyopia woopsa (kawirikawiri).
Kuchepa kwa khungu kumatha kuchepetsedwa mwa kutenga Mlingo wa aspirin kapena choletsa chilichonse cha prostaglandin (ibuprofen 200 mg), womwe umapangidwa mphindi 30 musanafike niacin. Zotsatira zoyipa zimatha kuchepetsedwa ngati chithandizo chikuyamba ndi mulingo wochepa, mankhwalawa amatengedwa ndi chakudya, koma osati ndi zakumwa zotentha. Kuphatikiza apo, tikulimbikitsidwa kuti muyambe kulandira chithandizo chamankhwala osagwiritsa ntchito nthawi yayitali ndikusinthira kwa nthawi yayitali pokhapokha ngati rednessyo singagonje ndipo sangathetse mwa kutenga praglandin inhibitor. Poyerekeza ndi momwe mankhwalawo amathandizira ndi nicotinic acid, kuyamba kwa redness kumakhala kosadziwika, nthawi zambiri kumakhala kupweteka kwam'mimba kapena chiwindi.
Odwala omwe ali ndi vuto loyambirira la chakudya chambiri (kudya hyperglycemia, NTG) amatha kuyamba kudwala matenda a shuga panthawi ya mankhwala a niacin, ndipo odwala omwe ali ndi matenda osokoneza bongo amatha kufuna kuchuluka kwa mankhwala ochepetsa shuga, ngakhale HbAlc sikukula kwambiri. Kuphatikiza apo, kuchuluka kwa glycemia sikukhudzana ndikuchepa kwa pafupipafupi zochitika zamkati mothandizidwa ndi niacin.
Niacin amadziwikiratu odwala omwe amaphwanya kwambiri chiwindi, kugwira ntchito kwa zilonda zam'mimba, panthawi yomwe ali ndi pakati komanso mkaka wa m`mawere, mpaka zaka 16 ndi vuto laimpso.

OMEGA-3 FATTY ACIDS
Mankhwala a gululi amakhala ndi ma omega-3 fatty acids (EFAs) - eicosopentaenoic acid (EPA) ndi docosahexaenoic acid (DHA) - ndipo amagwiritsidwa ntchito pochepetsa hypertriglyceridemia. Komabe, phindu lawo silimangokhala pazotsatira za triglycerides, ndipo zidakhazikika kuti ali ndi anti-atherogenic zotsatira komanso amachepetsa mwayi wokhala ndi matenda a mtima ndi kufa kwa arrhythmogenic mosayembekezereka. Zotsatira zake, American Association of Cardiology inalimbikitsa kuti anthu omwe ali ndi matenda amtima amatenga 1 g patsiku la EPA kuphatikiza DHA. Zinapezekanso kuti ma asidi awa amalepheretsa kukalamba kwa minofu, kuchepa kwa magazi, komanso kumakhala ndi zotsatira zabwino m'mikhalidwe yovuta.
Mu shuga mellitus, amalimbikitsidwa pochiza matenda osagwirizana ndi hypertriglyceridemia ndipo amagwiritsidwa ntchito kwambiri ngati chithandizo chowonjezera cha ma statins, chifukwa amachepetsa triglycerides ndi insulin kukana kwa T2DM.
Limagwirira zake kuchitapo kanthu ndi matenda ogwira. Amakhulupirira kuti ma WFAs amakhudza kapangidwe ka VLDL ndi triglycerides m'chiwindi. Kuphatikiza apo, zimakhudza triglycerides kwakukulu, ndipo motsutsana ndi mtundu wa 3-6 g patsiku, mulingo wa TG umachepa ndi 25-50%. Monga gemfibrozil, WFA imatha kuwonjezera LDL ndi cholesterol yathunthu ndi 10%, makamaka mwa anthu omwe ali ndi dyslipidemia yosakanikirana. HDL OZHK siyinakhudzidwe. Phindu la WFA pakuwapanikizika kwa systolic mwa anthu omwe ali ndi matenda oopsa akufotokozedwa.
Ndi T2DM, panali kuwonjezeka kwapakati pa LDL ndi cholesterol yathunthu. Mu T2DM, OZHK nthawi zambiri amagwiritsidwa ntchito ngati adjunct statin pothandizira kuthana ndi hypertriglyceridemia komanso kuchepetsa insulin.
Pharmacokinetics OZHK imatengeka msanga pambuyo pa kayendetsedwe ndipo imafalitsidwa m'thupi. Mafuta acids amachotsedwa pa metabolic oxidation kupita ku CO2 ndi madzi.
Kuchita ndi mankhwala ena. Popeza WFAs imapondereza kuphatikizana kwa maselo othandiza magazi kuundana, chisamaliro chapadera chimayenera kuthandizidwa popereka mankhwala othandizira, ma thrombolytics, ndi mapuloteni othandizira. Kukula kwakukhalirana kwa kudalirana kumeneku sikudziwika.
Kukonzekera, Mlingo ndi regimens chithandizo. Mulingo wamba wa WFA wopezeka m'mapiritsi ndi 4 ga patsiku, omwe amatengedwa kamodzi kapena kawiri pa tsiku. Mankhwala atha kuchotsedwa ngati njira zochizira zofunika sizikwaniritsidwa miyezi iwiri.
Zotsatira zoyipa ndi contraindication. Halitosis, kusintha kwa kulawa, kusokonezeka m'matumbo, kupweteka kumbuyo, zizindikiro zonga chimfine, chizolowezi chowonjezeka cha matenda, komanso kuwonjezeka kwa kugunda kwa angina ndizofala kwambiri panthawi yamankhwala ndi OZHK. Panali kuwonjezeka kwa kuchuluka kwa mayeso a chiwindi - ALT ndi ACT, omwe amayenera kuyang'aniridwa pochiza OZHK.
Mankhwala a OZHK sayenera kulembedwa kwa amayi apakati komanso oyamwitsa, komanso omwe asakwanitse zaka 18. Sizikudziwika ngati WFA imakhudza ntchito ya chiwindi ndi impso.

Malangizo a lipid-kuchepetsa mankhwala ochizira matenda ashuga

Kutsitsa LDL-C:

makamaka ma statin
mankhwala ena akuphatikizapo SCFA, ezetimibe, fenofibrate, kapena niacin.

Kuti muwonjezere HDL-C:

nicotinic acid kapena ma fiber. Kutsitsa triglycerides:
fibrate (fenofibrate, gemfibrozil), niacin, milingo yayikulu ya ma statins (kwa odwala omwe adakweza LDL-C).

Ndi yophatikiza Hyperlipidemia:

chisankho choyamba: Mlingo waukulu wama statins,
kusankha kwachiwiri: ma statin osakanikirana ndi ma fibrate,
kusankha kwachitatu: ma statins osakanikirana ndi niacin.

Pali zifukwa zisanu zomwe zimapangitsa kuti lipatsidwe mankhwala ochepetsa lipid:

kulitsa kuchepa kwa LDL-C,
onjezani kuchepetsedwa kwa cholesterol-VLDL,
sinthani mavuto obwera chifukwa chogwiritsa ntchito mankhwalawa.
luso logwiritsa ntchito SCFA kwa odwala omwe ali ndi hypertriglyceridemia ndi kukwezedwa kwa LDL-C,
kuthetseratu kuchuluka kwa LDL-C komwe kwachitika chifukwa chochiza matenda oopsa a hypertriglyceridemia

Zowongolera zolimba - chithandizo cha matenda a dyslipidemia a 2 matenda a shuga

Kutsitsa LDL - Cholinga choyambirira, ndipo nthawi zambiri msinkhu wawo umakhala wokwezeka ngakhale ndikuwongolera kwa shuga. ADA imalimbikitsa kuyambitsa zakudya komanso zakudya zamankhwala kwa odwala omwe ali ndi matenda amtundu wa 2 omwe ali ndi zolondola zolondola za LDL.

Malangizo NCEP (AT III) nawonso ali pafupi. M'magawo onse awiri, mulingo wa LDL Mankhwala omwe amakhudza metabolop liprotein

Zimachitika kafukufuku ndi ma statins atsopano, omwe ali ndi mphamvu zambiri pa lipids ndi lipoproteins, chifukwa chake kusankha kwakukulu kukuyembekezeka zaka zikubwerazi.

Ma Static amathanso kukhala opindulitsa zotsatira komanso pamlingo wa TG ndi HDL plasma. Mwakutero, kugwiritsa ntchito kwawo kwa metabolic syndrome ndi matenda a shuga a 2 kumakhala koyenera, pomwe mulingo wa TG umachulukitsidwa nthawi zambiri ndipo mulingo wa HDL umatsitsidwa. Umboni wotsimikizika womwe unakweza TG ndikuchepetsa HDL ndizoopsa pamtima pazomwe zimayambitsa kufunikira kwa kukwaniritsa magawo a zomwe zikuwonetsa.

Kuphatikiza apo, nkhani yofunsira michere Kuchepetsa chiopsezo cha mtima mwa odwala omwe ali ndi matenda a shuga a 2 omwe ali ndi dyslipidemia, pomwe zokambirana zidachitika kale, yankho labwino tsopano lalandiridwa malinga ndi maphunziro azachipatala a multicenter. Monga LDL, kuwongolera glycemic kwambiri kumatha kukonza TG ndi / kapena HDL, koma sikufikira gawo lenileni, ngakhale kusintha kwakukulu m'moyo komanso kuphatikiza mankhwala a hypoglycemic.

About chandamale Makhalidwe a TG Pali zosiyana pakati pa ADA ndi NCEP (ATP III). NCEP (ATP III) imakhala m'magulu a TG motere:
500mg yabwinobwino

ADA Ndikugwirizana ndi magulu awiri oyamba komanso mulingo wa TG Kukonzekera kwa pharmacological kusintha milingo ya lipid / lipoprotein

NCEP (APR III) ikuwonetsa kuti zopangidwa ndi VLDLP - "zidutswa zofunikira" - "zotsalira" - ndi atherogenic. Muzochita zamankhwala, VLDL imayesedwa ndi mulingo wa lipoproteins wotsalira. Mwa anthu omwe ali ndi TG yayikulu (> 200 mg%), kusiyana pakati pa cholesterol yathunthu ndi HDL (yosakhala HDL) ndi cholinga chachiwiri chothandizira. Chizindikiro cha matenda a shuga a 2 chiyenera kukhala chochepera 130 mg%.

Njira Zowonera Lipid / Lipoprotein Control mu Type 2 Shuga

1. Ma sampuli amwazi kuti mupeze kuchuluka kwa cholesterol, TG, HDL, LDL amatengedwa pamimba yopanda kanthu, atatha kudya kwa maola 8.
2. Kuwongolera kwakukulu kwa glycemic kuzungulira maziko azakudya, kuchepa thupi komanso mankhwalawa ndikofunikira kuti mulingo wokhazikika wa HbAlc wa 45 mg% kwa amuna ndi> 55 mg% kwa akazi.

4. Ngati zomwe akufuna kuchita pa cholesterol ndi LDL sizikwaniritsidwa, ndikofunikira kupereka mankhwala a statin ndikuwonjezera mlingo wawo kotala katatu kuti mukwaniritse cholinga chamankhwala.
5. Ngati TG sinafike pamlingo wotsutsa motsutsana ndi maziko a LDL Makhalidwe abwino a lipid sipekitiramu oyambitsa zakudya komanso njira zamankhwala zamankhwala odwala akulu omwe ali ndi matenda ashuga

Mfundo zazikuluzikulu: Zoyeserera kuchokera pachiyeso chosasinthika pakulamulira kwa dyslipidemia kwa odwala omwe ali ndi matenda a shuga a 2

- Kuwongolera glycemic kumakongoletsa mawonekedwe a lipid mwa odwala omwe ali ndi matenda a shuga a 2 omwe amakhala ndi dyslipidemia, koma samakonda kubwereranso mwanjira zawo.
- Kafukufuku atatu pa kupewa koyambira awonetsa kuti kuchepa kwa 25-30% m'magawo a LDL ndi mankhwala a statin mwa odwala omwe ali ndi matenda amtundu wa 2 amachepetsa chiopsezo cha zochitika zapamtima ndi 34-37%.
- Kafukufuku awiri wokhudzana ndi kupewa kwachiwiri adawonetsanso kuchepetsedwa kwakukulu kwa chiwopsezo cha zochitika zam'mimba panthawi ya mankhwala a statin mwa odwala omwe ali ndi matenda a shuga a 2 omwe ali ndi matenda amitsempha yamagazi.

- Kafukufuku atatu woyembekezeredwa, makamaka pa prophylaxis yachiwiri, adawonetsa kuti kuchepa kwa TG kuchuluka kwa 27-31% ndi kuchuluka kwa HDL ndi 5-6% panthawi yamankhwala othandizira ndi fibrate kumachepetsa chiwopsezo cha zochitika za coronary kapena kupititsa patsogolo kwa coronary arteriomatosis malinga ndi angiography mwa odwala omwe ali ndi matenda a shuga a 2 mtundu.
- Kuti muthane ndi mawonekedwe a lipid, mankhwala a kalasi 4 amagwiritsidwa ntchito: ma statins, othandizira a bile acids, nicotinic acid, fibrate.
- Njira zamphamvu zakuwongolera kwa lipids / lipoproteins a mtundu 2 a shuga zimafotokozedwa.
- Kuwongolera kudzipereka ndikofunikira kwambiri pakukwaniritsa bwino pulogalamu.

Zambiri kwa akatswiri

Mankhwala -
Mabuku -
Endocrinology -
Zochitika pakukonzekera kwa dyslipidemia mu mtundu 2 shuga

Chidziwitsochi chimapangidwira akatswiri azaumoyo ndipo sangathe kugwiritsidwa ntchito ndi anthu ena, kuphatikizanso kukambirana ndi dokotala komanso kusankha momwe angagwiritsire ntchito mankhwalawa!