Comparison with drug therapy and. And pharmacotherapy

»» №1 2000 CHAIR PROFESSOR G.B. FEDOSEEV
HEAD OF THE DEPARTMENT OF HOSPITAL THERAPY, ST. PETERSBURG STATE MEDICAL UNIVERSITY NAMED AFTER N. ACADEMIC I.P. PAVLOVA, CORRESPONDING MEMBER OF RAMS
K.N. KRYAKUNOV,
ASSOCIATE PROFESSOR

In the 20th century, humanity experienced a "pharmacological explosion" that did not bypass Russia. After a long (until 1991) drug shortage, there was an abundance that gave rise to new problems. In the Vidal directory "Medicines in Russia" for 1999, 3929 drugs from 315 companies are presented. Added to this is the information explosion in the field of clinical pharmacology, which has been rapidly developing in the last 50 years. In this regard, the concerns of Academician B.E. Votchala: "Involuntarily it becomes scary for a doctor who can lose his bearings in this sea of ​​\u200b\u200bfunds." When choosing the means of treatment, the doctor must constantly remember the four most important principles of pharmacotherapy (safety, rationality, controllability and individualization), carefully consider the prescription (not forgetting the saying "Measure seven times, cut once"). At the same time, it seems to us, he must clearly imagine the answers to 5 questions: what should be assigned?, to whom? (one of the fundamental principles of domestic medicine is to treat not the disease, but the patient), when? (remembering the postulate of B.E. Votchal: "It is necessary to treat with drugs when it is impossible not to treat"), how? (considering the variety of routes of administration of drugs) and, finally, for what purpose? Each of them gives rise to many other specific questions.

1. Question "WHAT"?

The correct choice of the drug often decides the success of the treatment. It is necessary to find the best means for each patient, separating the wheat from the chaff.

The main guideline for selection is the clinical diagnosis. Medical therapy not always needed: so, there is no need to prescribe it for mild forms of SARS, skin-articular hemorrhagic vasculitis, acute glomerulonephritis, infectious mononucleosis, extrasystoles, etc. D. Lawrence's rule should be followed: "If in doubt about prescribing a drug to a person who can do without it, treatment should be avoided."

In rare cases, the only remedy is used for treatment - the drug of choice, for example, normosang in acute intermittent porphyria (M.M. Podberezkin et al., 1996), more often when choosing a treatment, options are possible.

Are carefully weighed indications and contraindications. at the same time, "taking into account contraindications is often more important than indications" (V.P. Pomerantsev, 1991). Sometimes a drug that was considered contraindicated for a certain disease later enters the arsenal of its treatment (for example, it happened with beta-blockers and thyroid hormones in heart failure).

Initially, the choice of the drug can be empirical (for example, the appointment of antibiotics for pneumonia, infective endocarditis), and then, if the pathogen is detected, a correction is carried out. Sometimes you have to resort to trial and error. about which B.E. Votchal wrote: "The obscene method of trial and error is still better than persistence in mistakes."

Choice of drug may be based on results special tests: such are acute drug tests in the selection of antiarrhythmic drugs, the use of bicycle ergometric control in the development of IHD therapy, etc.

It is preferable to prescribe drugs that allow you to kill two or three birds with one stone (for example, beta-blockers with a combination of coronary heart disease, arterial hypertension and arrhythmias or calcium antagonists in patients with hypertension, chronic bronchitis and cor pulmonale).

The schemes, standards, and treatment algorithms developed for many diseases, in which first-line, second-line and reserve funds are allocated, also help in choosing a drug.

Unreasonable prescriptions should be avoided (more often these are anabolics prescribed "for the company", digestive enzyme preparations, vitamins, so-called metabolic agents, etc.), as well as the use of outdated, ineffective means(anathematized, in the words of Professor Zimssen).

As a rule, drugs should not be prescribed for unknown diagnosis, analgesics and drugs for unexplained abdominal pain, corticosteroids for unexplained fever or nephrotic syndrome of unspecified origin, etc.

With the current level of examinations, ex juvantibus therapy is used less and less.

When choosing a drug, its cost is taken into account. The problem was also relevant in the 19th century: then the Pharmacopoeia for the Poor was specially published (the last edition was published in 1860), and Gogol’s Zemlyanika said: “We don’t use expensive medicines. recover, then he will recover." In parallel, however, there was also the "Court Pharmacopoeia".

A similar picture is observed now: the concept of "elitist pharmacology" (for the elite) has come into life, and many poor people cannot afford to purchase necessary medicines. In 1996, each resident of Russia spent only 5-10 dollars on health (of which 4.5 dollars was spent on medicines). Patients' refusal to purchase expensive drugs often leads to a decrease in the quality of treatment, an unfavorable course of the disease (E.E. Loskutova, 1996). The title of the work of Aaron and Schwartz (USA) is indicative: "A recipe written with pain" (we are talking about recipes for cheaper and less effective means for low-income patients); this feeling is familiar to Russian doctors. It can be reconciled with the fact that not all patients with coronary artery disease can afford treatment with neoton, ticlid, preductal, and patients with bronchial asthma can afford treatment with thiled and accolate. But due to the high cost of drugs, they are practically inaccessible to most Russian citizens hypocholesterolemic therapy (unfortunately, garlic cannot replace statins), complex treatment peptic ulcer with Hp eradication, treatment of prostate adenoma, osteoporosis, lysis of gallstones, use of modern antidepressants, etc.

Combination therapy is unavoidable in the treatment of many patients, or polypharmacotherapy(arguments for and against it are discussed in the work of Professor V.P. Pomerantsev, published by the journal "In the world of medicines" in No. 1, 1999). Polypharmacotherapy should not be confused with polypharmacy (overtreatment, "overfeeding patients with drugs", in the words of Professor F.G. Yanovsky). Overtreatment is noted in 80% of patients. The appointment of the "drug armada" provokes "an additional iatrogenic pathology, a violation of the internal ecological environment of the organism" (L.G. Belov et al., 1996). Polypharmacy is "useless, but not harmful" (Z.I. Yanushkevichus et al., 1976), and "more" in treatment does not always mean "better" (V.P. Pomerantsev).

Risk medicinal iatrogenic small if the patient receives no more than 3 drugs. When using 4-6 drugs, it increases by 20 times. The maximum risk of complications is observed if more than 10 drugs are used simultaneously. True, the situation can be mitigated if the instinct of self-preservation works in patients and they do not take part of the medicines, or (like many poor pensioners) they begin to save up hospital pills "for a rainy day."

The polymorbidity of a modern therapeutic patient (especially the elderly) initiates polypharmacy. But one should not forget the recommendation of N.V. Elshtein: "It is not necessary to treat all diseases at once. It is necessary to highlight the priority direction in therapy."

When prescribing polypharmacotherapy, it is very important to take into account the possible interaction of drugs. This section clinical pharmacotherapy devoted to an extensive literature. "The number of clinically important interactions is so great that any attempt to remember them does not make sense," D. Lawrence argued. That's why great importance for institutions of practical healthcare could have the introduction of reference computer programs on all aspects of interdrug interaction.

2. The question "WHO?"

The most important feature of the modern patient - the Russian end XX century - is life in extremely unfavorable socio-demographic conditions. Since 1992, there has been a continuous natural decline in the population (in 1999 it decreased by another 700,000 people). The number of orphans is 2.5 times more than it was in 1945, immediately after the war. The number of drug addicts and substance abusers is already about 10 million people. Died 3.5 times from alcohol poisoning in 1997 more people than in 1990. Mortality from tuberculosis has risen by 40%; annually, about 13,000 tuberculosis patients are released from places of detention. In 1998, more than 300 thousand patients with syphilis were identified, the epidemic of which continues. Occupational morbidity has increased by 40% over the past 5 years.

Psychiatrists write about a "mental epidemic" in Russia with an increase in the frequency of self-destructive behaviors (alcoholism, drug addiction, substance abuse, suicides). Low material security, malnutrition also contribute negatively to the incidence rate.

When choosing therapy, the doctor must take into account a large number of factors that characterize each individual patient.

The gender of the patient is taken into account (the frequency of drug intolerance in women is 2.4 times higher than in men) and his age. The therapist needs to be familiar with the main provisions of geriatric pharmacology, as well as the pharmacology of the reproductive period (for example, in the treatment of arterial hypertension in young men, one should take into account the negative effect on sexual function of clonidine, rauwolfia, nifedipine, anaprilin and give preference to beta-blockers: prazosin, etc. ).

Attention is drawn to the profession of the patient: persons whose work is related to the concentration of attention should be prescribed sedatives with great care; contact with certain substances in the workplace can affect the metabolism of drugs, etc.

Body weight is important for choosing the dose of the drug. Excessive body weight reduces the effect of antihypertensive drugs. Obesity is often accompanied by hepatic steatosis, which affects on the drug metabolism.

A special chapter of clinical pharmacology is drug treatment. pregnant and lactating women. The features of pharmacotherapy are also being studied. menopause - narrowing of contraindications to hormone replacement therapy should be taken into account ( International Symposium for perimenopause, Switzerland, 1995).

Needs no comment on the importance of careful collection allergic history- taking into account, in particular, cross-allergic reactions, for example, in the group of novocaine - lidocaine - novocainamide - sulfonamides - PAS.

Alcohol abuse is taken into account. Ethanol activates the metabolism of aminophylline, rifampicin, diphenin, weakening their effect, but enhances the effect of tranquilizers, indirect anticoagulants, some antihypertensive drugs, increases the risk of erosive and ulcerative lesions of the gastrointestinal tract in the treatment of non-steroidal anti-inflammatory drugs and glucocorticoids. Alcohol increases the hepatotoxicity of anabolics, isoniazid. Taking certain medications (trichopolum, furazolidone, cephalosporins) worsens alcohol tolerance (teturam-like effect).

When smoking, the hepatic metabolism of eufillin, anaprilin increases with a weakening of the therapeutic effect.

Should be considered accompanying illnesses. In arterial hypertension in combination with diabetes mellitus, β-blockers and saluretics are not indicated; when combined with COPD, β-blockers are not recommended, caution is required ACE inhibitors(cough provocation) and more calcium antagonists are indicated; when combined with prostate adenoma, the drug of choice is prazosin, which reduces urethral obstruction. special attention requires concomitant pathology of the kidneys, liver, and intestines (especially with oral therapy).

Pay attention to the level whey protein: if it is reduced, the proportion of freely circulating drug may increase, which increases the risk of side effects.

Knowledge matters a lot genetically determined features reactions to drugs, first of all, the rate of their acetylation in the microsomal system of the liver. "Fast acetylators", which are especially numerous among the Eskimos, Japanese, Latin Americans, metabolize many drugs faster, and "slow" ones (there are more of them among the Egyptians, Swedes, British) - 2-3 times slower. All this is important for the choice of doses and treatment regimen. In "slow acetylators" hydralazine and novocainamide often cause drug-induced SLE, isoniazid - peripheral neuropathy. Methods for diagnosing the rate of acetylation (according to Evans) have not yet entered into wide practice.

Pathological reactions to drugs are possible with a deficiency of enzymes such as glucose-6-FDG (hemolysis), pseudocholinesterase (breathing is not restored during mechanical ventilation with muscle relaxants), methemoglobin reductase (methemoglobinemia in the treatment of sulfonamides, nitrates). Genetically determined resistance to indirect anticoagulants has been described.

In the course of treatment, various attitude of patients to drug therapy. Pharmacophiles justify the opinion of W. Osler: "Homo sapiens differs from other mammalian species in its passion for drugs." Their home "grandmother's" first-aid kits are full of medicines, including expired ones and those that cannot be identified (Lawrence). Pharmacophobes resolutely refuse any "chemistry" and try to get by with only natural therapy, forgetting that poisons and toxins are by no means rare in the natural environment. Sick "dictators" assertively dictate to the doctor how they want to be treated, and continuously conflict with him.

In the process of treatment, the so-called compliance patient (from compliance - consent, cooperation of the patient with the doctor). It is known that only 25-30% of patients strictly follow medical prescriptions. Lack of cooperation may be the fault of the doctor if he does not provide the necessary explanations about the treatment course or if the treatment regimen is overly complicated. Sometimes the patient does not feel the doctor's confidence in right choice therapy (V.A. Manassein pointed out that when prescribing medicines, the doctor "in most cases should act as if he is no less confident than the Pope in his infallibility"). The low cultural level of the doctor, the frequent change of attending doctors, etc. negatively affect the "consent".

The lack of "cooperation" due to the fault of the patient may be associated with old age (decrease in intelligence, hearing, memory), mental disorders, alcoholism, drug addiction, and such psychological features, as an excessively high level of claims and self-esteem, aggressiveness of character. Often the disease itself is "to blame": a latent course, a rapid improvement or, conversely, no effect, the appearance adverse reactions etc. (V.P. Pomerantsev).

3. The question "HOW?"

Must choose optimal route of drug administration, although many patients insist on injections and drip infusions (the famous expression: "I can take pills at home"). Heparin is not administered intramuscularly because of the risk of hematomas, but they forget that for the same reason, it is undesirable to administer other drugs intramuscularly during the period of heparin treatment. The rectal route of drug administration, proposed back in the 2nd century BC by the ancient Greek physician Soranus, avoids stomach irritation and the effect of the drug passing through the liver.

The sublingual and buccal routes of administration of drugs such as nitrates, relief agents have their advantages. hypertensive crisis, glycine, etc. Ascolong (a buccal form of aspirin) provides a deaggregant effect at a dose of 12.5 mg, as it bypasses the liver and does not have an ulcerogenic effect on the stomach.

In many cases, it is important to tell the patient when to take the drug. in relation to receiving write. Before meals, it is better to take antibiotics, as food impairs their absorption, choleretic, pancreatic enzymes, oral hypoglycemic drugs, angiotensin receptor antagonist valsartan (diovan), etc.

Food improves the absorption of anaprilin. Sometimes it is important what to take with medicines: iron preparations should not be taken with tea, coffee, milk, ampicillin - acidic fruit juices: their absorption worsens (VG Kukes et al., 1997).

The distribution of the daily dose of the drug is preferably made taking into account daily biorhythms. When taken in the morning, glucocorticoids, non-steroidal anti-inflammatory drugs are most effective, and in the evening - antihistamines, drugs, cardiac glycosides. It has been shown that the maximum effect of furosemide is observed when taking it at 10 am, and it is better to prescribe a double prophylactic administration of heparin at 11 am and 5 pm. AT last years are being developed new drug delivery methods to their place of action. Liposomes from phospholipids are used to transport beclamethasone to the lungs (the goal is to prolong the effect), berotek, amphotericin B (toxic effects are reduced). Drug carriers can be erythrocytes, platelets, encapsulated cells, macromolecules, etc.

Methods should be considered treatment control. It is necessary to actively ask the patient about possible side effects of the drug. For example, when treated with beta-blockers, nightmares are possible, which at night can provoke an attack of angina pectoris or an increase in blood pressure. Important laboratory control (certain parameters of the coagulogram in the treatment of anticoagulants and thrombolytics, immunological parameters when using immunomodulators, etc.). When treating with some drugs, their concentration in the blood is examined (in the treatment with eufillin, a response from the laboratory is obtained 30-60 minutes after taking blood).

4. The question "WHEN?"

The start of treatment should be timely. Diogenes owns the words: "Do not delay treatment for a long time. Wine can be stored for a long time with benefit for him, and this only harms the tree." The treatment started should not compromise the accuracy of the diagnosis. For example, in infective endocarditis (except for acute destructive forms), a delay of 5-7 days in prescribing antibiotics is justified in order to make a series of blood cultures and identify the pathogen.

You need to know exactly when the drug begins to work effectively. Corticosteroids administered intravenously in status asthmaticus show their effect after about 6 hours (and this time period should be "covered" with sympatholytics). Far from immediately with planned treatment bronchial asthma Intal and ketotifen begin to act. A stable hypotensive effect of enalapril is established more often on the 4-6th week, a prolonged calcium antagonist Lomir - after 3 weeks, etc. In this regard, B.A. Sidorenko (1998) noted: "When we treat arterial hypertension, we must be patient." Sometimes both doctors and patients say that "the drug does not work" almost from the first day of treatment. The antiplatelet effect of aspirin appears an hour after administration, and ticlid - after 7-8 days, so ticlid is used not in acute situations, but for planned therapy.

In the treatment of a number chronic diseases(bronchial asthma, rheumatoid arthritis, etc.) stages can be distinguished tactical therapy(removal of exacerbation symptoms) and strategic therapy(use of basic means affecting pathogenic mechanisms disease). So, to the means of tactical therapy rheumatoid arthritis include non-steroidal anti-inflammatory drugs (diclofenac, indomethacin, etc.), corticosteroids, including for intra-articular administration (hydrocortisone, kenalog), dimexide topically. Strategic therapy is carried out with cytostatics, D-penicillamine, gold preparations, salazopyridazine, drugs for drug synovectomy, and it is recommended to start basic therapy much earlier than before (V.A. Nasonova, Ya.A. Sigidin, 1996). There are supporters of aggressive basic therapy for rheumatoid arthritis already in the debut of the disease.

In a number of diseases (CHD, arterial hypertension, bronchial asthma, chronic obstructive bronchitis, cardiac arrhythmias, etc.) the so-called step therapy. or the "healing pyramid" method, with a gradual increase in the intensity of treatment. Professor Dujardin-Bometz (1882) fits this principle: "Be prudent masters of your therapeutic forces, do not spend them at once, but as a military general, always have strong reserves in reserve to achieve victory."

Duration of treatment may be different. In a number of diseases (hypertension, diabetes, Addison's disease, pernicious anemia etc.) therapy is lifelong. In other cases, it is important to complete the treatment on time. So, too long use of antibiotics can contribute to the chronicity of the process, the development of resistant strains of the pathogen, superinfection, inhibition immune system, the development of dysbacteriosis, an increase in the frequency of allergic and adverse reactions.

With infective endocarditis, the duration of antibiotic therapy depends on the type of pathogen: if it is streptococcus, then at least 4 weeks, staphylococcus - at least 6 weeks, gram-negative pathogens - at least 8 weeks.

With pneumonia in recent years there has been a tendency to reduce the duration of antibiotic therapy. In non-severe pneumonia (treated on an outpatient basis), the effectiveness of a 3-day course of azithromycin (Sumamed) at a dose of 0.5 g once a day has been proven.

At long-term treatment it is necessary to take into account the possibility of developing tolerance to the drug. Often this phenomenon is observed during treatment with nitrates, in 20% of cases - with the use of calcium antagonists. A serious problem is the development of insulin resistance in diabetes mellitus. Treatment of patients with osteoporosis with calcitonin in 10-15% of cases leads to resistance due to the production of neutralizing antibodies.

When finishing treatment, one should be aware of the possibility of drug withdrawal syndrome. It has been described in beta-blockers, clonidine, nitrates, nifedipine, anticoagulants, corticosteroids, antidepressants, and others.

5. The question "FOR WHAT PURPOSE?"

Treatment can be etiological, Ibn Sina wrote about this ("And I repeat again: treat the causes. This is the main principle of our medicine"), pathogenetic(here the words of Paracelsus are appropriate: "The doctor must remove the disease in the same way as a woodcutter cuts off a tree, namely, at the roots") and, finally, symptomatic. About the last B.E. Votchal wrote: "Symptomatic therapy has always been considered a 'low grade' therapy. Meanwhile, for psychotherapy it is the most important."

Immediate goal therapy can be a cure for the patient (with acute infections, pneumonia and others, including diseases that were incurable in the past: lymphogranulomatosis, acute leukemia, chronic myeloid leukemia, etc.) or suppression of disease activity, improvement of the patient's condition.

distant goals there may be a prevention of the progression of the process and the development of complications, the prevention of exacerbations, and an improvement in prognosis.

The effect of the drug on the quality of life is assessed: physical and psychological condition patient, social activity, working capacity, general well-being, sexual sphere (Zh.D. Kobalava et al., 1996). Even more important is the effect of treatment on amount of life(survival and mortality of patients), although one should pay tribute to the remark of D. Lawrence: "Sometimes you can extend life, but it will be of such quality that a person will not rejoice in it." It is possible to improve the quality of life, but at the same time increase mortality. An example is the problem of treating cardiac patients with short-acting nifedipine drugs that arose in 1995-96, the results of the use of group 1C antiarrhythmic drugs and lidocaine in myocardial infarction. Non-glycoside inotropic agents in the treatment of chronic heart failure turned out to be "a whip and spurs for a sick horse" (milrinone during clinical research increased the mortality of patients by 2.5 times).

In the treatment of heart failure with cardiac glycosides, the quality of life improves, but not its duration; it is also "stimulation with damage to cardiomyocytes" (V. P. Andrianov et al., 1996). At the same time, ACE inhibitors reduced mortality in patients with heart failure of II-III functional class according to the NYILA classification by 30%. Carvedilol, which combines the properties of a β-blocker and a peripheral vasodilator, inhibits apoptosis, the natural death of cardiomyocytes, increases the survival rate of patients, and now claims to be the drug of choice for heart failure in foreign countries. It has been shown that the good old drug aldactone (at a dose of 0.25 g per day) increases the survival rate of patients with chronic insufficiency circulation. Small doses of cordarone have a similar effect, preventing death from fatal arrhythmias, which takes about 40% of decompensated cardiac patients.

There are also specific therapy goals. To prevent night and morning attacks of bronchial asthma, prolonged preparations of theophylline or beta-agonists are prescribed in the evening. In order to influence nocturnal and morning arterial hypertension, which significantly increases the risk of myocardial infarction and stroke, it is recommended to take prolonged antihypertensive drugs at night, etc. In our time, unusual goals of therapy are also being discussed: for example, should soldiers be prescribed tranquilizers in between battles in Chechnya (study by I.I. Kozlovsky et al. "Pharmacological correction of combat stress", 1996).

Conclusion

This is a short and far from complete list of questions that a doctor faces when choosing a drug therapy. Of course, it is extremely difficult to weigh and evaluate all the numerous criteria for choosing a drug. Many doctors avoid new, unfamiliar remedies or are cautious, give minimal doses (therapy such as ut aliquid fieri videatur - "to make it seem like something is being done"). Probably, the number of medical errors is also increasing, but they are not as carefully studied and taken into account as diagnostic errors.

A number of measures that have been implemented in recent years can improve the situation:

• decrease in pharmaceutical flow, withdrawal of vital drugs, reduction in the number of analogues (Norway is a good example in this regard);
• introduction of medical standards for different nosological forms. The standard gives the doctor more confidence, is effective means fight against "cowardly treatment", but it should not be identified with a template;
• improving the training of doctors in clinical pharmacology (M.P. Konchalovsky noted, speaking of institute lectures: "We, therapists, are often accused of being too carried away with issues of diagnosis, and when it comes to therapy, we start looking at the clock");
• introduction to the state of large medical institutions position of clinical pharmacologist, whose task is to advisory assistance in difficult cases, correction of therapy, early detection and warning side effects medicines, etc.;
• the creation of information and advisory computer programs, the promise of which for the optimization of pharmacotherapy was pointed out by D. Lawrence back in 1987.

Pharmacoprophylaxis is the prevention of diseases with the help of medicines. For prophylactic purposes, antiseptic and disinfectant drugs are used (to prevent the spread infectious diseases), vitamin preparations (for the prevention of hypovitaminosis), iodine preparations (for the prevention of endemic goiter), etc.

Pharmacotherapy (drug therapy) is the treatment of diseases with the help of medicines. For future pharmacists, pharmacotherapy corresponds to the academic discipline " clinical pharmacology”and is the next step after general and private pharmacology in mastering the science of the interaction of drugs with living organisms.

The use of medicines for the prevention and treatment of diseases is based on knowledge of: the causes and conditions for the occurrence of diseases; mechanisms of disease development; external manifestations of disease.

There are the following types of drug therapy.

Etiotropic (causal) therapy (from the Greek. aethia- cause, tropos- direction and from lat. causa- cause) is aimed at eliminating or limiting the cause of the disease. Medicines that eliminate the cause of the disease are called etiotropic. These include chemotherapeutic agents that suppress the vital activity of pathogenic microorganisms that cause infectious diseases, antidotes that bind toxic substances that cause poisoning.

Pathogenetic therapy (from the Greek. pathos- disease, genesis- origin) is aimed at limiting or eliminating the mechanisms of disease development. Medicines used for this purpose are called pathogenetic. Thus, antihistamines eliminate the effect of histamine released during allergic reaction, but they do not stop the body's contact with the allergen and do not eliminate the causes of the development of an allergic reaction. Cardiac glycosides increase myocardial contractility in heart failure, but do not eliminate the causes that caused it.

Replacement therapy is aimed at filling the lack of endogenous substances in the body. For this purpose, hydrochloric acid is used.

acid and enzyme preparations for insufficient function of the digestive glands, hormonal preparations for hypofunction of the endocrine glands, vitamin preparations for hypovitaminosis. Substitution therapy drugs do not eliminate the cause of the disease, but reduce or eliminate the manifestations of a deficiency of a particular substance necessary for the life of the body. As a rule, such drugs are used for a long time.

Symptomatic therapy is aimed at limiting or eliminating individual undesirable manifestations (symptoms) of the disease. Medicines used for this purpose are called symptomatic. These drugs do not affect the cause and mechanisms of the disease. For example, pain relievers and antipyretics reduce pain and elevated temperature bodies that are symptoms of various, including infectious diseases.

The method of treatment and prevention of diseases, which is based on the use of drugs of natural or artificial origin, is called drug therapy. In other words, this is a generalized concept that implies medication treatment.

Medical therapy is divided into several types. Doctors use symptomatic therapy based on the elimination of a specific symptom of the disease. An example is the appointment of antitussive drugs for bronchitis.

Etiotropic therapy destroys the causative agent of the disease with the help of drugs, that is, eliminates the causes of the disease. For example, the use of chemotherapeutic agents in the treatment of infectious lesions.

Elimination of the main mechanism of development of the pathological process provides pathogenetic therapy. An example of a medicinal effect in this type of therapy is the use of painkillers for various injuries. First of all, the medicines used resist the development of pain syndrome.

Substitution therapy is also included in a number of varieties drug treatment. It includes the process of restoring the deficiency of substances that are formed in the human body. These substances include vitamins, enzymes, hormones that regulate the main physiological functions. Substitution therapy is not intended to eliminate the causes of the disease, but it is able to ensure the normal functioning of a person for a long time. An example of the use of replacement therapy can be the administration of insulin to a patient suffering from. With regular use of insulin, a normal carbohydrate metabolism in his body is ensured.

Finally, another form of drug exposure is considered to be preventive therapy aimed at preventing the onset of diseases. For example, the use of disinfectants or antiviral drugs during influenza epidemics. Similarly, the use of anti-tuberculosis drugs helps to counter the occurrence of exceeding the epidemiological threshold. An illustrative example of preventive therapy is routine vaccination of the population.

In a more detailed consideration of the above types of drug therapy, it should be noted that in practice the marked directions in their pure form are implemented quite rarely. The course of pathological processes can be influenced by various therapeutic methods and types. medications. For example, substitution therapy may well be used for preventive purposes. Physiological and biological processes are strongly interrelated in the human body. Therefore, the effect of drugs on systems, organs, tissues is multiple.

When prescribing medications to a patient, the doctor must constantly take into account a wide variety of individual factors, choose from the many available treatment options the most appropriate type of therapy. Therefore, the doctor's decision-making is based on strategic principles. The main thing is that in each case it is necessary to ensure a reasonable balance of safety, tolerability and therapeutic efficacy of the drug used.

An important role in the process of drug therapy is played by the timeliness and correctness of the diagnosis. The doctor must adequately assess and take into account the patient's condition, the possibilities of the protective forces of his body, age, gender, the presence of concomitant diseases, sensitivity to a certain type of drug. The specialist must take into account possible reaction the patient's body with the simultaneous appointment of several drugs. Of course, the behavior of the patient himself is essential in any type of therapy, how accurately he follows all the instructions and recommendations of the attending physician.

Each drug has a number of specific pharmacological features Therefore, to obtain the desired effect from the treatment, medications are introduced into the body in various ways. Enteral administration involves taking the drug through the mouth. In this case, the drug is absorbed through the intestines into the blood. The use of the drug sublingually, under the tongue, makes it possible for the therapeutic agent to enter the mucous bloodstream, bypassing the intestines. The direct introduction of the drug into the rectum is called rectal. Also, drugs are delivered to the body by injection, inhalation, electrophoresis. All methods of drug administration are an integral part of any type of therapy.

Properly selected drug allows you to solve the main task of the doctor - to cure the patient.

Drug therapy (Pharmacotherapy) - treatment with drugs, or otherwise, pharmacological agents. Chemotherapy refers to pharmacotherapy as applied to oncology. Pharmacotherapy is referred to as conservative (non-invasive) methods of treatment. Pharmacotherapy is also called the branch of pharmacology that studies drug therapy.

Types of pharmacotherapy

There are the following types of pharmacotherapy:

Etiotropic therapy - an ideal form of pharmacotherapy. This type of pharmacotherapy is aimed at eliminating the cause of the disease. Examples of etiotropic pharmacotherapy can be the treatment of infectious patients with antimicrobial agents (benzylpenicillin for streptococcal pneumonia), the use of antidotes in the treatment of patients with poisoning by toxic substances.

Pathogenetic therapy - is aimed at eliminating or suppressing the mechanisms of the development of the disease. Most currently used drugs belong to the group of drugs of pathogenetic pharmacotherapy. Antihypertensive agents, cardiac glycosides, antiarrhythmic, anti-inflammatory, psychotropic and many others medications have a therapeutic effect by suppressing the corresponding mechanisms of the development of the disease.

Symptomatic therapy - is aimed at eliminating or limiting individual manifestations of the disease. Symptomatic drugs include painkillers that do not affect the cause or mechanism of the disease. Antitussives are also a good example of symptomatic remedies. Sometimes these drugs (elimination of pain in myocardial infarction) can have a significant impact on the course of the underlying pathological process and at the same time play the role of pathogenetic therapy.

Replacement therapy - used in case of deficiency of natural nutrients. Substitution therapy includes enzyme preparations (pancreatin, panzinorm, etc.), hormonal drugs (insulin for diabetes mellitus, thyroidin for myxedema), vitamin preparations (vitamin D, for example, for rickets). Substitution therapy drugs, without eliminating the causes of the disease, can ensure the normal existence of the body for many years. It is no coincidence that such a severe pathology as diabetes is considered a special lifestyle among Americans.

Preventive therapy - is carried out in order to prevent diseases. Some antiviral agents are prophylactic (for example, during an influenza epidemic - rimantadine), disinfectants and a number of others. The use of anti-tuberculosis drugs such as isoniazid can also be considered preventive pharmacotherapy. A good example of preventive therapy is the use of vaccines.

should be distinguished from pharmacotherapy chemotherapy . If pharmacotherapy deals with two participants in the pathological process, namely, a drug and a macroorganism, then in chemotherapy there are already 3 participants: the drug, the macroorganism (patient) and the causative agent of the disease. Medicine affects the cause of the disease (treatment of infectious diseases with antibiotics; poisoning with specific antidotes, etc.).

One of the types of etiotropic therapy is substitution pharmacotherapy, in which drugs replace the physiologically missing active substances(use of vitamins, hormonal drugs with insufficient function of the endocrine glands, etc.)

Most tumors are treated with drugs today. This is the most versatile and most common method of cancer treatment due to its features:

• ease of administration to the patient (intravenously or orally);
• drug access simultaneously to all cells and tissues of the body;
• the possibility at any stage to adjust the dose and mode of administration of the drug or change the medicine;
• reducing the risk of survival of malignant cells (cancer cells) in hard-to-reach and remote places and the resumption of tumor growth.

Types of drug therapy

With the development of nanotechnology, molecular medicine and genetic engineering, many new anticancer drugs have appeared in the portfolio of oncologists, drugs have become more selective for malignant cells and less toxic to healthy tissues and the body as a whole. Targeted drugs have appeared, the so-called targeted ones, the molecules of which act more selectively on cancer cells.

All cancer drugsaccording to the mechanism of action are divided into cytostatic and cytotoxic. First, cytostatic, inhibit the reproduction of malignant cells and cause their apoptosis, or a program of self-destruction, cell decay. Second, cytotoxic, drugs cause cell death due to their intoxication, destruction of the cell membrane and nucleus, other structures, and ultimately tumor necrosis.

Given the different mechanisms of action, in most cases, oncologists select a combination of two or three drugs of different pharmacological groups.

Medical treatments for cancer include:

1. Chemotherapy.
2. hormone therapy.
3. Immunotherapy.
4. Target therapy.
5. photodynamic therapy.

Drug treatment is usually carried out in courses. The course includes the time of administration of the drug (from 1 to 5 days for intravenous drugs, may be longer for tablet drugs) and a break time to restore the body and reduce the risk of side effects of treatment. Before the start of each new course, blood tests are usually monitored and an oncologist is consulted to decide whether it is necessary to adjust the doses of drugs and / or increase the interval until the next administration of the drug.

For a long drug treatment there is a concept of "lines" of treatment. The "line" of treatment is the sequential appointment of the same courses of chemotherapy (or other types) of therapy. The “line” of treatment is carried out until the desired effect is achieved or until the moment of loss of sensitivity from the side of the disease. If the tumor continued to grow against the background of one chemotherapy regimen, a change in drugs is performed. Continuing treatment with a new chemotherapy regimen is called "second (third, fourth, etc.) line" treatment.

Chemotherapy

Chemotherapy is the most common type of drug therapy. Chemotherapy is:

1. Therapeutic - when chemotherapy is the main method of treating the disease. For example, for many patients with leukemias, lymphomas, and testicular germ cell tumors, chemotherapy can be the main treatment, which often leads to recovery. For most patients with advanced forms of cancer, with metastases to various organs, chemotherapy is the main method of treatment, which gives the maximum opportunity to contain the disease for a long time.

2. Neoadjuvant - when chemotherapy precedes the main method of treatment. Most often, such chemotherapy is prescribed before certain types of operations, in order to reduce the tumor and reduce the activity of its cells.

3. Adjuvant - it is also called "prophylactic". It is prescribed after the main method of treatment, most often after surgery, in order to reduce the risk of a return of the disease.

The most common anticancer drugs include the following groups:

1. Alkylating antineoplastic drugs.

The mechanism of their action is based on the introduction of the alkyl group of the drug to the DNA of a cancer cell: a violation of the DNA structure occurs and it cannot continue to divide, apoptosis is triggered. This group includes: derivatives of bis-B-chloroethylamine - historically the first cytostatic antitumor agents; nitrosourea derivatives and platinum preparations containing divalent platinum.

2. Alkylating triazines.

Non-classical alkylating agents, prodrugs that, in order to display their antitumor activity, must undergo a series of metabolic transformations in the body, as a result of which methylating agents are formed. The latter, invading the DNA and RNA of a cancer cell, do not allow it to divide further.

3. Antimetabolites.

Competitively intervene in the process of cell division, causing its apoptosis.

4. anthracycline antibiotics.

Their mechanism of action is based on cytotoxic action. They inhibit DNA synthesis, disrupt the permeability of cell membranes and other mechanisms of cell vital activity.

5. Topoisomerase I and topoisomerase II inhibitors, microtubule formation inhibitors and spindle inhibitors.

Cytostatic drugs that selectively disrupt the structure of DNA and the division of cancer cells at different stages.

Chemotherapy drugs in most cases are administered intravenously or orally, then they have a systemic effect on the entire body. But they can also be used locally, for example, during surgical operation for processing the surgical field, or regionally, for example, in the ventricles of the brain.

hormone therapy

Indicated only for hormone-sensitive cancers. Whether the tumor will respond to hormone treatment or not will be determined using special tests and laboratory research cellular material taken from the tumor.

Hormone-responsive tumors are often found in reproductive system and endocrine glands, for example, these are:

• mammary cancer
• prostate cancer
• ovarian cancer
• endometrial cancer (cancer of the body of the uterus).

Hormone therapy can be prescribed before the tumor is removed in order to stabilize its growth or reduce its size, then it is called neoadjuvant. Or after - in order to prevent re-growth or metastasis, such therapy is called adjuvant.

In late inoperable stages of tumors sensitive to this treatment, hormone therapy can be used as the main treatment. As a palliative treatment for some types of cancer, it is quite effective and can prolong the patient's life by 3-5 years.

Immunotherapy

The immune system plays an important role in preventing and fighting cancer. Normally, immune bodies recognize the atypical cell and kill it, protecting the body from tumor development. But when immunity is compromised different reasons, and there are many cancer cells, then the tumor begins to grow.

Immunotherapy for cancer helps the body cope with the disease by activating protective resources and preventing the development of recurrent tumors and metastases. In oncology, interferons, cancer vaccines, interleukins, colony-stimulating factors, and other immune drugs are used.

The treatment is selected by the immunologist based on laboratory data on the state of the immune system of the oncologist together with the attending oncologist and other specialists involved in the treatment of a particular patient.

The main mechanisms of immunotherapy:

• suppression of the growth of tumor cells and their subsequent destruction;
• prevention of tumor recurrence and the formation of metastases;
• reduce the side effects of anticancer drugs, radiotherapy;
• prevention of infectious complications in the treatment of tumors.

Targeted Therapy

From English target - goal, target.They are considered promising methods of molecular medicine, the future in the treatment of oncopathologies, as well as the development of vaccines against cancer.

Targeted drugs are very specific and are developed for a specific mutated gene of a cancer cell of a given type of tumor. Therefore, before targeted treatment, a genetic study of the material taken for biopsy is mandatory.

For example, effective targeted drugs have been developed for the treatment of various genetic forms of breast cancer, multiple myeloma, lymphoma, prostate cancer, and melanoma.

Due to their specificity and targeted targeting of the cancer cell, targeted drugs are more effective for treating tumors than, for example, classical anticancer drugs. And less harmful to normal cells that do not have the characteristics of tumor. Many targeted methods are referred to as immunotherapy, since in fact they form the desired immune response.

Photodynamic therapy

It is carried out by drugs, acting on cancer cells with a light flux of a certain wavelength and destroying them.

Side effects of cancer drug treatment

The most famous and frightening complication of cancer patients after chemotherapy is hair loss. It happens because anticancer drugs toxic to young actively dividing cells, which are, among other things, hair follicles and nail plates. In practice, not all types of chemotherapy cause hair loss. This complication is typical for a narrow range of drugs, many patients do not experience it. For the duration of the drug, the activity of renewing body cells may decrease, due to which nails and hair stop growing, hair loss occurs, and the hematopoietic system is inhibited. After a course of chemotherapy, recovery period during which the body returns to normal.

Severe complications are not observed in all patients, but their risk increases with increasing duration of treatment.

The following are common side effects after drug therapy:

• hair loss, brittle nails;
• nausea, vomiting;
• loss of appetite, change in taste;
• anemia, bleeding;
• impaired immunity;
• diarrhea;
• infertility, violation of the sexual and reproductive sphere.

Most complications can be corrected, with proper treatment, many of them can be prevented or stopped at the first manifestation. Severe complications can cause an increase in the intervals between chemotherapy courses.

Efficiency

The earlier cancer is detected and the type of tumor cells is diagnosed more accurately, the more successful the treatment of cancer and the more favorable the prognosis for recovery. Therefore, you should constantly monitor your health, undergo diagnostic tests according to age, and do not turn a blind eye to malaise or periodic discomfort in the body. It is also better not to waste time trying to cure yourself or with the help of alternative medicine that does not have any convincing evidence of effectiveness, ignoring modern methods medical treatment. So you can only start the oncological process, aggravate the stage of the disease and complicate subsequent treatment. Do not waste precious time, be examined in specialized centers with modern equipment by highly qualified doctors.