c ჰეპატიტის მართვა · 2017-06-02 · hepatitebi. amave klasifikaciit...
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danarTi 2
C ჰეპატიტის მართვა
კლინიკური მდგომარეობის მართვის სახელმწიფო
სტანდარტი
(პროტოკოლი)
damtkicebulia saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis
ministris 2011 wlis 20 ivnisis
# 01-119/o brZanebiT
miRebulia “klinikuri praqtikis erovnuli
rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo
standartebis (protokolebi) SemuSavebis,
Sefasebisa da danergvis erovnuli sabWos"
2009 wlis 30 dekembris #2 sxdomis
gadawyvetilebis Sesabamisad
2
C ჰეპატიტის მართვა
პროტოკოლი
1. C ჰეპატიტის დეფინიცია, კლასიფიკაცია
C hepatiti
infeqciuri daavadebaa, romelsac iwvevs hepatotropuli rnm virusi,
C hepatitis virusi (HCV). C hepatitis dros viTardeba RviZlis anTebiTi dazianeba. daavadebas aqvs mwvave da qronikuli forma. Sem-TxvevaTa 70-85%-Si igi qronikuli mimdinareobisaa. klinikuri gamov-linebis mixedviT mwvave forma SeiZleba iyos simptomuri (siyviTliT an usiyviTlo) da usimptomo. qronikul formas ki SeiZleba hqondes: latenturi, perioduli gamwvavebebiT da mudmivad progresirebadi mimdinareoba. RviZlis qronikuli anTebiTi procesis Sedegad viTardeba RviZlis fibrozi da, moprogrese fibrozis fonze, avadmyofTa 20-40%-s inficirebidan daaxloebiT 20-30 weliwadSi SesaZloa ganuviTardes RviZlis cirozi, hepatoceluluri karcinoma da RviZlis ukmarisoba. daavadebas aseve axasiaTebs sxvadasxva eqstrahepaturi gamovlinebebi.
klasifikacia
janmrTelobis msoflio organizaciis daavadebaTa klasifikaciisa da kodi-rebis sistemis mixedviT (Disease classification and coding systems DIMDI-ICD-10-
WHO-2007) C hepatiti ganekuTvneba daavadebaTa jgufs virusuli hepatitebi. amave klasifikaciiT gamoyofen daavadebis 2 formas:
1. mwvave C hepatiti: kodi B17.1;
2. qronikuli C hepatiti: kodi B18.2.
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2. kriteriumebi daavadebis gansazRvrisTvis
damadasturebeli:
C hepatitis damadasturebeli klinikuri kriteriumebi ar arsebobs, radgan is simptomebi, romelic iSviaTad magram mainc gvxvdeba daavadebis dros, aseve SeiZleba Segvxvdes sxva etiologiis (infeqciuri da arainfeqciuri) hepatitis dros.
aqedan gamomdinare, C hepatiti miekuTvneba laboratiriulad sadiagnostiko daavadebebs.
C hepatitis virusiT daavadebis damadasturebeli kriteriumebia: C hepatitis virusis sawinaaRmdego antisxeulebis arseboba sisxlis SratSi imunofermentuli analizis meTodiT da/an C hepatitis virusis rnm-is aRmoCena sisxlSi polimerazuli jaWvuri reaqciis meTodiT.
gamomricxavi:
C hepatitis virusiT infeqciis gamomricxavi kriteriumebia: C hepatitis virusis sawinaaRmdego antisxeulebis ar arseboba da/an C hepatitis virusis rnm-is ar arseboba sisxlSi polimerazuli jaWvuri reaqciis meTodiT.
3. simptomebi da niSnebi, daavadebis simZimis Sefaseba
C hepatiti mwvave stadiaze ZiriTadad usimptomod mimdinareobs, mxolod SemTxvevaTa 25%-Si SesaZloa gamovlindes simptomebi:
siyviTle;
saerTo sisuste;
Sardis gamuqeba;
ganavlis gaRiaveba;
zogjer sxeulis temperatutis momateba;
diskomforti muclis RruSi;
gulisrevis SegrZneba;
Rebineba da intoqsikaciis sxva movlenebi.
daavadeba SemTxvevaTa daaxloebiT 70-85%-Si qronikul mimdinareobas iRebs. qronikuli C hepatiti praqtikulad usimptomo mimdinareobiT xasiaTdeba, SesaZlebelia gamoxatuli iyos mxolod zogadi saerTo sisuste.
RviZlis qronikuli anTebiTi procesis Sedegad viTardeba RviZlis fibrozi da, moprogrese fibrozis fonze, avadmyofTa 20-40%-s inficirebidan daaxloebiT 20-30 weliwadSi SesaZloa ganuviTardes RviZlis cirozi, hepatoceluluri karcinoma da RviZlis ukmarisoba.
qronikuli HCV infeqciis progresirebis, daavadebis simZimis Sefasebis, mniSvnelovani maCvenebelia RviZlis fibrozi.
anTeba da fibrozi aris ori ZiriTadi histologiuri maxasiaTebeli HCV-Ti gamowveuli RviZlis daavadebis simZimis Sesafaseblad. anTebis aqtivoba da fibrozis xarisxi zustad korelirebs cirozis ganviTarebis riskTan (cxrili #1 da cxrili #2).
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cxrili # 1
RviZlis histologiis Sefaseba
fibrozis stadia
METAVIR
Ishak
0
fibrozis ar arsebiba
fibrozis ar arseboba
1
fibrozis eqspansia
periportulad
fibrozis eqspansia portul areSi ramdenime adgilas,
mokle fibrozuli septebiT
2
P-P septebi (>1 septa)
fibrozis eqspansia ZiriTadad portul areSi, mokle fibrozuli
septebiT
3
P-C septebi
fibrozis eqspansia ZiriTad portul areSi, iSviaTi P-P xidakebiT
4
cirozi
fibrozis eqspansia (gavrceleba) portul areSi mniSvnelovani
(mravlobiTi) xidakebiT. (P-P* an P-C**)
5
–––––
mravlobiTi xidakebi (P-P* an P-C**) erTeuli kvanZebi (kunZulebi)
arasruli cirozi
6 ––––– cirozi
* P–P portul-portuli.
** P–C portul-centraluri.
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cxrili # 2
anTebis xarisxi (A)
A0: anTebis ar arseboba, nekrozis ar arseboba
A1: minimaluri anTeba, nekrozis ar arseboba
A2: zomieri anTeba, iSviaTi nekrozi
A3: mniSvnelovani anTeba, mZime fokaluri nekroziT
A4: gavrcelebuli anTeba, nekrozis xidakebi
4. diagnostikur-laboratoriuli testebi
C hepatitis laboratoriuli diagnostikis ZiriTadi saSualebebia:
1. virusis sawinaaRmdego antisxeulebis gansazRvra;
2. virusis genetikuri masalis gansazRvra.
1) virusis sawinaaRmdego antisxeulebis gansazRvra
C hepatitis virusis sawinaaRmdego antisxeulebis gansazRvris meTodebi or jgufad iyofa:
pirveladi anu skrininguli;
damadasturebeli anu konfirmaciuli.
2) virusis genetikuri masalis gansazRvra
C hepatitis virusis genetikuri masalis gansazRvris meTodebia:
1. HCV rnm-is Tvisobrivi gansazRvra;
2. HCV rnm-is raodenobrivi gansazRvra;
3. HCV genetikuri tipis gansazRvra.
1. HCV rnm-is Tvisobrivi gansazRvra gamoiyeneba HCV infeqciis adreuli diagnostikisa da daavadebis stadiis (aqtiuri Tu latenturi) gansaz-RvrisTvis.
2. HCV rnm-is raodenobrivi gansazRvra gamoiyeneba mkurnalobis monito-ringisa da mkurnalobis efeqturobis prognozirebisTvis.
3. HCV genotipirebis meTodi saSualebas iZleva ganisazRvros HCV sxvadasxva genotipi da subtipi.
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4.1. pirebi, romelTac unda Cautardes HCV infeqciaze gamokvleva
narkotikebis inieqciuri gziT momxmareblebi;
aiv inficirebulebi;
hemofiliiT daavadebuli avadmyofebi;
hemodializze myofi avadmyofebi;
sisxlis an sisxlis produqtebis recipientebi;
organotransplantirebuli pirebi;
HCV pozitiuri dedebis Svilebi;
med. personali, visac HCV inficirebul sisxlTan hqonda Sexeba: kanqveSa kontaqtis (Cxvleta, gaWra) an lorwovanze sisxlis moxvedris SemTxvevaSi;
HCV inficirebuli pirebis sqesobrivi partniorebi;
pirebi, romelTac aReniSnebaT aminotransferazebis aqtivobis gaurkveveli momateba.
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4.2. C hepatitis laboratoriuli diagnostikis algoriTmi
HCV infeqciis laboratoriuli diagnostikis algoriTmi
* aiv infeqcia/SidsiT avadmyofebi, organotransplantirebuli pirebi, onkologiuri avad-
myofebi, xangrZlivad hormonoTerapiaze myofi pirebi.
New York State 2005 Guideline.
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4.3. HCV infeqciis laboratoriuli diagnostikis oficialuri rekomendaciebi
HCV infeqciaze saeWvo yvela avadmyofs unda Cautardes anti-HCV antisxeulebze gamokvleva ifa meTodiT (Grade, II).
Anti-HCV (+) pozitiuri Sedegis SemTxvevaSi, dabali riskis mqone avad-myofebSi, unda Catardes anti-HCV antisxeulebze gamokvleva RIBA
(rekombinantuli imunoblotingi ) meTodiT (Grade, II).
Anti-HCV (+) pozitiuri Sedegis SemTxvevaSi, saSualo da maRali riskis mqone avadmyofebSi anti-HCV antisxeulebze gamokvleva RIBA (rekombi-nantuli imunoblotingi) meTodiT aucilebeli ar aris (Grade, II).
ifa meTodiT Anti-HCV (+) pozitiuri da RIBA (rekombinantuli imunoblotingi) meTodiT Anti-HCV (-) negatiuri Sedegi mianiSnebs, rom imunofermentuli analiziT miRebuli iyo cru dadebiTi Sedegi, HCV infeqcia ar aris da Semdgomi gamokvleva saWiro ar aris (Grade, II).
yvela Anti-HCV (+) pozitiur pirs unda CautardeT sisxlSi HCV rnm-is (Tvisobrivi) gansazRvra (Grade, I).
HCV rnm (+) pozitiuri Sedegi aqtiuri HCV infeqciis maniSnebelia. (Grade, I).
Anti-HCV (-) negatiur pirebs, RviZlis saeWvo daavadebiT (mag. siyviTle, ALT-s momatebuli aqtivoba da sxv.) unda CautardeT HCV rnm-is (Tvisobrivi) gansazRvra. HCV rnm (+) pozitiuri Sedegi mwvave C hepatitis maniSnebelia (ra Tqma unda Tu HAV, HBV da sxva hepatitebis markerebi uaryofiTia). dasawyisSi Anti HCV (-) negatiuri Sedegi da daxloebiT 1-3 Tvis intervalis Semdeg Anti HCV (+) pozitiuri Sedegi axal serokonversiaze mianiSnebs) (Grade, II).
Anti-HCV (-) negatiur imunokomprometirebul pirebs, RviZlis saeWvo daavadebiT, unda CautardeT sisxlSi HCV rnm-is gansazRvra, radgan Anti-
HCV-s ar arsebobis mizezi aseT pirebSi SesaZloa imunodeficituri mdgomareoba iyos (Grade, II).
Anti-HCV (+) pozitiuri da HCV rnm (-) negatiuri Sedegi gamojanmrTe-lebul, latentur an okultur HCV infeqciaze mianiSnebs (Grade, I).
yvela HCV rnm (+) pozitiur pirs unda Cautardes HCV genotipis gansaz-Rvra mkurnalobis xangrZlivobis gadawyvetilebis misaRebad da mkurnalobis efeqturobis prognozirebisTvis (Grade, I).
yvela HCV rnm (+) pozitiur pirs unda Cautardes HCV rnm-is (raode-nobrivi) gansazRvra SemdgomSi mkurnalobis efeqturobis Sesafaseblad (mkurnalobis monitoringisTvis) (Grade, I).
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4.4. damatebiTi diagnostikur-laboratoriuli gamokvlevebi
1. sisxlis saerTo analizi.
2. bioqimiuri maCveneblebis gansazRvra: ALT, AST, G-GT, ALP, bilirubini, albumini, proTrombini (proTrombinis dro, proTrombinis indeqsi,
INR), amiaki.
3. RviZlis ultrabgeriTi gamokvleva.
4. RviZlis daavadebis simZimis (fibrozis da anTebis xarisxis) gansazRvra invaziuri an arainvaziuri meTodebiT.
a) arainvaziuri:
RviZlis elastografia (fibroskani);
fizbrozis pirdapiri da arapirdapiri serologiuri markerebi.
b) invaziuri:
RviZlis biofsia.
qvemoT mocemulia RviZlis fibrozis Sesafasebeli arainvaziuri meTodebi da Sesabamisi serologiuri markerebi.
gamokvleva
serologiuri
markerebi
Sesafasebeli
sistema
APRI AST, Trombocitebi Ishak
Forns-is
indeqsi
asaki, G-GT, qolesterini ,
Trombocitebi Metavir
FibroTest™
α2- makroglobulini,
α2- globulini, γ-globulini,
apolipoproteini A1, G-GT da
saerTo bilirubini
Metavir
Fibrospect
hialuronis mJava, metaloproteinaza -1-is qsovlovani
inhibitori (TIMP-1) da
alfa 2-makroglobulini
Metavir
SHASTA hialuronis mJava, AST da albumini Ishak
ELF
propeptid III kolageni, TIMP 1,
hialuronis mJava
Scheuer
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5. C hepatitis mkurnaloba
5.1. kombinirebuli antivirusuli mkurnalobis reJimebi HCV genotipis mixedviT
HCV
genotipi
pegilirebuli
interferoni
ribavirini
mkurnalobis
xangrZlivoba
genotipi
1, 4, 5, 6
peginterferoni 2a
180 mkg 1 x kviraSi
an
peginterferoni 2b
1,5 mkg/kg 1 X kviraSi
1200 mg dReSi
wona > 75 kg
an
1000 mg dReSi
wona < 75 kg
48 kvira
genotipi
2, 3
peginterferoni 2a
180 mkg 1 x kviraSi
an
peginterferoni 2b
1,5 mkg/kg 1 x kviraSi
800 mg dReSi
24 kvira
5.2. mkurnalobamde avadmyofis Sesafasebeli gamokvlevebi
gamokvlevis saxe
aucilebeli
anamnezis Sekreba, fsiqiatriuli anamnezis CaTvliT;
fizikaluri gamokvleva, yuradRebis gamaxvilebiT RviZlis dekompensaciis niSnebze, rogoricaa asciti, encefalopaTia da sxv.;
laboratoriuli gamokvlevebi: sisxlis saerTo analizi, ALT,
AST, kreatinini, glukoza, albumini, bilirubini, INR, ANA, TSH
Sefaseba Child-Pugh-s mixedviT;
HBsAg, Anti-HBs, Anti-HBc (total), Anti HAV IgG;
ultrasonografiuli gamokvleva;
RviZlis elastografia (fibroskani);
HCV genotipi;
HCV RNA raodenobivi (VL);
HIV antisxeulebze testireba.
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gamokvlevis saxe
mkacrad rekomendebuli gansakuTrebul SemTxvevebSi
RviZlis biofsia (roca es saWiroa) an RviZlis fibrozis
Sefaseba arainvaziuri meTodebiT, gansakuTrebiT HCV 1
genotipiT avadmyofebisTvis;
cirozze saeWvo avadmyofebSi endoskopiuri gamokvleva
saylapavis venebis varikozis sadiagnostikod;
AFP, cirozze saeWvo SemTxvevaSi;
orsulobis testi (produqciuli asakis qalebisTvis);
ofTalmoskopiuri gamokvleva (diabetiT da hipertenziiT
avadmyofebSi);
Sratis glukoza da/an glikozirebuli hemoglobini (diabetiT
avadmyofebSi);
Sratis rkina; feritini; transferinis saturacia;
narkotikebis saeWvo momxmareblebisTvis Sardis
toqsikologiuri skriningi: opiatebze, kokainze, amfetaminze;
ekg da datvirTvis testi gulis daavadebiT avadmyofebSi;
AMA, ASMA, LKM RviZlis autoimunur daavadebebze eWvis
SemTxvevaSi;
antiTireoiduli antisxeulebi farisebri jirkvlis
autoimunur daavadebebze saeWvo SemTxvevaSi.
5.3. vis unda Cautardes mkurnaloba
avadmyofebi, romelTaTvis mkurnaloba naCvenebia
asaki 18 weli da meti;
RviZlis biofsiiT an arainvaziuri meTodebiT dadgenili mniSvnelovani fibrozi (meti vidre portuli fibrozi: Metavir-iT ≥ 2; Ishak-iT ≥ 3);
RviZlis kompensirebuli daavadeba: saerTo bilirubini <1,5 g/dl. INR <1.5; albumini >3.4 g/dl. Trombocitebi > 75 x 109/l, encefalopaTiis da ascitis ar arseboba;
misaRebi hematologiuri da bioqimiuri maCveneblebi: hemoglobini >13 g/dl mamakacebisTvis da >12 g/dl qalebisTvis. neitrofilebi >1.5 x 109/l , kreatinini <1.5 mg/dl;
avadmyofis survili da mzadyofna mkurnalobis pirobebis mimarT;
ukuCvenebebis ar arseboba (ix. avadmyofebi, romelTaTvis mkurnaloba ukunaCvenebia).
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avadmyofebi, romelTaTvis mkurnaloba ukunaCvenebia
arakontrolirebadi depresia;
organo (guli, filtvi, Tirkmeli) transplantirebuli pirebi (garda RviZlisa);
autoimunuri hepatiti an sxva autoimunuri daavadebebi, romlebic SesaZloa damZimdes interferoniT da ribaviriniT mkurnalobis dros;
aranamkurnalebi an arakontrolirebadi farisebri jirkvlis daavadebebi;
orsulebi an is pirebi, romlebic ar akontroleben daorsulebis process adeqvaturi kontraceptiuli saSualebebiT;
mZime Tanmxlebi daavadebebi: RviZlis mZime dekompensacia, mZime hipertenzia, gulis ukmarisoba, gamoxatuli gulis koronaruli (iSemiuri) daavadeba, cudad kontrolirebadi diabeti, filtvebis obstruqciuli daavadeba, fsiqozi, gulyrebi da sxva;
2 welze qveviT asaki;
momatebuli mgrZnobeloba HCV medikamentebis mimarT;
gamoxatuli leikopenia;
gamoxatuli Trombocitopenia;
gamoxatuli neitropenia.
avadmyofebi, romelTa mkurnalobis sakiTxi
unda gadawydes individualurad
avadmyofebi, romelTac ukve CautardaT mkurnaloba, magram mkurnalobaze iyvnen armopasuxe an Semdeg ganviTarda recidivi;
pirebi, romlebic arian narkotikis da alkoholis aqtiuri momxmareblebi, magram survili aqvT monawileoba miiRon programebSi, rogoricaa: meTadoniT Canacvlebis programa, alkoholze Tavis danebebis programa da sxv.;
RviZlis biofsiiT an RviZlis arainvaziuri meTodebiT gamokvleviT fibrozis ar arseboba an msubuqi fibrozi: (portuli fibrozi: Metavir-iT < 2; Ishak-iT < 3);
mwvave C hepatiti;
aiv-iT ko-infeqcia;
2-dan 18 wlamde asaki;
Tirkmelebis qronikuli daavadeba;
RviZlis dekompensirebuli daavadeba;
RviZltransplantirebuli pirebi.
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5.4. HCV infeqciis antivirusuli mkurnalobis oficialuri rekomendaciebi
HCV infeqciis SerCevis mkurnalobaa pegilirebuli interferonis da ribavirinis kombinacia (Grade, I).
mkurnalobis kandidatia yvela visac HCV rnm gansazRvradi aqvs mgrZnobiare meTodiT (gansazRvris limitiT 50 IU/ml) (Grade, I).
qronikuli HCV infeqciis mkurnalobis dawyebis win aucileblad unda ganisazRvros HCV genotipi, radgan genotipis mixedviT unda gadawydes mkurnalobis xangrZlivoba da ribavirinis doza (Grade, I).
mkurnalobis dawyebis win aseve aucileblad unda ganisazRvros HCV rnm-is koncentracia, radgan virusis koncentraciis cvlileba mkurnalobis procesSi mkurnalobis efeqturobis Sesafasebeli ZiriTadi maCvenebelia (Grade, I).
HCV 1 genotipiT avadmyofebSi mkurnalobis efeqturoba Seadgens mxolod 42-46%-s. mkurnalobamde unda ganisazRvros RviZlis daavadebis simZime (RviZlis biofsiiT an arainvaziuri meTodebiT). mkurnaloba naCvenebia im avadmyofebisTvis, visac aqvs Metavir-iT ≥ 2;
Ishak-iT ≥ 3 fibrozi an kompensirebuli cirozi (Grade, III) (ix. cxrili visTvisac mkurnaloba naCvenebia). ufro naklebi xarisxis fibroziT avadmyofebis mkurnalobis sakiTxi unda gadawydes individualurad, sxva maCveneblebis mixedviT.
HCV 1 genotipiT avadmyofebSi mkurnalobis xangrZlivoba 48 kviraa. mkurnalobis reJimi orgvaria:
peginterferoni alfa 2a 180 mkg kviraSi 1-jer da ribavirini:
dRiuri doza 1000 mg ≤ 75 kg wonis avadmyofebisTvis, xolo 1200 mg >75 kg wonis avadmyofebisTvis.
an peginterferoni alfa 2b 1,5 mkg kviraSi 1-jer da ribavirini:
800 mg < 65 kg wonis avadmyofebisTvis, 1000 mg 65-85 kg avadmyofebisTvis, 1200 mg 85-105kg avadmyofebisTvis da 1400 mg >105 kg avadmyofebisTvis (Grade, I). calkeul SemTxvevebSi zogierTi specialisti iyenebs ribavirinis ufro maRal dozebs 1600 mg-mde, Tumca am sakiTxze saboloo rekomendaciebi jer SemuSavebuli ar aris.
HCV 2 an 3 genotipiT avadmyofebSi mkurnalobis efeqturoba 76-82%-s Seadgens. amitom am genotipiT avadmyofebs, rogorc wesi, unda SevTavazoT antivirusuli mkurnaloba, Tu mkrnalobis ukuCvenebebi ar arsebobs (Grade, I).
HCV 2 an 3 genotipiT avadmyofebSi mkurnalobis xangrZlivoba Seadgens 24 kviras. ribavirinis doza ki – 800 mg dReSi (Grade, I). Tumca, bolo dros sul ufro xSirad iyeneben ribavirinis ufro maRal dozebs.
HCV yvela genotipiT avadmyofebSi Tu sisxlSi HCV rnm antivirusuli mkurnalobis dawyebidan 12 kviraze gaxda
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aragansazRvradi an Semcirda sul cota 2 log-iT, es niSnavs, rom mkurnalobaze adreuli virusuli pasuxi (EVR) miRebulia da mkurnaloba unda gagrZeldes, radgan kvlevebma aCvena, rom aseT SemTxvevaSi myari virusuli pasuxis miRebis albaToba maRalia (Grade, I).
HCV yvela genotipiT avadmyofebSi Tu sisxlSi HCV rnm antivirusuli mkurnalobis dawyebidan 12 kviraze sul cota 2 log-iT ar Semcirda, es niSnavs, rom mkurnalobaze adreuli virusuli pasuxi (EVR) ar aris miRebuli da mkurnaloba unda Sewydes (Grade,
I). Tumca, gadawyvetileba SesaZloa individualizebul iqnes Semdegi faqtorebis gaTvaliswinebiT: mkurnalobisadmi tolerantoba, daavadebis simZime, HCV rnm-is kinetika, mkurnalobaze bioqimiuri pasuxi da sxv. (Grade, III).
HCV 1 genotipiT avadmyofebSi Tu mkurnalobis dawyebidan 12 kviraze ar aris miRebuli sruli adreuli virusuli pasuxi (aragansazRvradi
HCV rnm), Semdegi gamokvleva unda Catardes mkurnalobis 24 kviraze da Tu HCV RNA rCeba gansazRvradi mkurnaloba unda Sewydes (Grade, I).
HCV 1 genotipiT avadmyofebSi Tu 12 kviraze ar aris miRebuli sruli adreuli virusuli pasuxi, xolo 24 kviraze virusi gaxda aragansazRvradi (delaid virus clearance), SesaZloa ganxilul iqnas mkurnalobis 72 kviramde gagrZeleba (Grade, III).
mkurnalobis dawyebidan 24 kviraze HCV 2 an 3 genotipiT avadmyofebSi da mkurnalobis dawyebidan 48 kviraze HCV 1 genotipiT avadmyofebSi unda ganisazRvros HCV rnm maRali mgrZnobelobis meTodiT (gansazRvris limitiT < 50 IU/ml). Tu HCV rnm aragansazRvradia es niSnavs, rom mkurnalobis bolos pasuxi (EOT) miRebulia (Grade, I).
im avadmyofebSi, romlebSic mkurnalobis bolos pasuxi (EOT) miRebulia, mkurnalobis damTavrebidan 6 Tvis (24 kviris) Semdeg kvlav unda ganisazRvros HCV rnm maRali mgrZnobelobis meTodiT (gansazRvris limitiT < 50 IU/ml). aragansazRvradi HCV rnm niSnavs mkurnalobaze myari virusuli pasuxis (SVR) miRebas, ris Semdegac daavadebis recidivis ganviTarebis albaToba Zalian mcirea (Grade, I).
HCV 4,5,6 genotipiT avadmyofebisTvis mkurnalobis rekomendaciebi iseTivea, rogorc HCV 1 genotipiT avadmyofebisTvis, Tumca monacemebi SedarebiT mwiria (Grade, II).
15
mkurnalobis dawyebis da mkurnalobis efeqturobis Sesafasebeli
algoriTmi HCV 1, 4, 5, 6 genotipiT avadmyofebisTvis
* avadmyofis maRali motivacia, mkurnalobis efeqturobis dadebiTi da uaryofiTi
prognozuli markerebis gaTvaliswineba.
16
mkurnalobis dawyebis da mkurnalobis efeqturobis Sesafasebeli
algoriTmi HCV 2, 3 genotipiT avadmyofebisTvis
17
mkurnalobis monitoringi HCV-1 da HCV-4 (aseve genotipi 5,6) genotipiT
avadmyofebisTvis
mkurnalobis periodi
(kvireebi)
mkurnalobis
Semdeg
( k v ireebi )
1 2 4 8 12 16 20 24 28 32 36 40 44 48 4 12 24
sisxlis
saerTo
analizi
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
bioqimiuri
gamokvlevebi
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HCV RNA
Tvisobrivi X X X
HCV RNA
raodenobrivi
X
wona X X X X X X X X X X X X X
TSH X X X X
AFP/
ultra-
sonografia
ciroziT
avadmyofebSi
X
X
X
orsulobis
testi
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
depresiis
monitoringi X X X X X X X X X X X X
mkurnalobis
reJimis
dacvis
kontroli
X
X
X
X
X
X
X
X
X
X
X
X
X
X
gverdiTi
efeqtebis
monitoringi
X
X
X
X
X
X
X
X
X
X
X
X
X
X
18
mkurnalobis monitoringi HCV-2 da HCV-3 genotipiT avadmyofebisTvis
mkurnalobis periodi (kvireebi)
mkurnalobis Semdeg
(kvireebi)
1
2
4
8
12
16
20
24
4
12
24
sisxlis saerTo analizi
X X X X X X X X X X
bioqimiuri gamokvlevebi
X
X
X
X
X
X
X
X
X
HCV RNA Tvisobrivi
X
X
HCV RNA raodenobrivi
X
wona X X X X X X X
TSH X X
AFP/ ultrasono-
grafia ciroziT
avadmyofebSi
X
X
orsulobis testi
X
X
X
X
X
X
X
X
X
depresiis monitoringi
X X X X X X
mkurnalobis reJimis dacvis
kontroli
X
X
X
X
X
X
X
X
gverdiTi efeqtebis
monitoringi
X
X
X
X
X
X
X
X
19
medikamentebis dozis modifikacia mkurnalobaze ganviTarebuli
hematologiuri gverdiTi efeqtebis dros
laboratoriuli
maCvenebeli
pegilirebuli
interferoni ribavirini
leikocitebi < 1.5
X109/L
leikocitebi < 1.0
X109/L
dozis Semcireba 50%-iT
mkurnalobis Sewyveta
–––––
mkurnalobis
Sewyveta
neitrofilebi
< 0.75 X109/L
< 0.5 X109/L
dozis Semcireba 50%-iT
mkurnalobis Sewyveta
–––––
mkurnalobis
Sewyveta
Trombocitebi < 50
000/ml
Trombocitebi < 25
000/ml
dozis Semcireba 50%-iT
mkurnalobis Sewyveta
–––––
–––––
hemoglobini < 10.0
g/dL
–––––
Semcireba 200 mg-iT
hemoglobini < 8.5 g/dL
mkurnalobis Sewyveta
mkurnalobis
Sewyveta
avadmyofebi gulis
daavadebiT
≥2 g/dL –iT daqveiTeba
nebismieri 4 kviris
ganmavlobaSi
–––––
ribavirinis
Semcireba
600 mg-mde
avadmyofebi gulis
daavadebiT
Tu dozis Semcirebidan
4 kviris ganmavlobaSi
mainc rCeba <12 g/dl
mkurnalobis
Sewyveta
mkurnalobis
Sewyveta
20
HCV mkurnalobaze ganviTarebuli gverdiTi efeqtebi da maTi marTva
gverdiTi efeqtebi
medikamentebi menejmenti
anemia
eriTropoetini
ribavirinis dozis Semcireba an mkurnalobis
Sewyveta
neitropenia
granulocitebis kolonia mastimulirebeli faqtori
(G-CSF)
interferonis dozis Semcireba (ix. dozis modifikaciis cxrili)
Trombocitopenia
adamianis rekombinantuli interleikin 11 (Oprelvekin,
Neumega)
interferonis dozis Semcireba
(ix. dozis modifikaciis cxrili)
depresia
seleqtiuri serotoninis ukumitacebis inhibitorebi
(SSRIs) , fluoqsetini, paroqsetini, sertralini
da sxv
saSualo xarisxis depresiis dros
interferonis dozis ganaxevreba; mZime depresiis dros mkurnalobis Sewyveta
uZiloba
saZile (sedaciuri) saSualebebi:
difenhidramini, trazodoni, mirtazapini,
temazepami, lorazepami da sxv.
varjiSi, kofeinisgan da alkoholisgan Tavis Sekaveba; Zilis higiena
sisuste
meTilfenidati, acetaminofeni
adeqvaturi hidratacia, msubuqi varjiSebi,
dasvenebis periodebi Warbad
gripismagvari simptomebi
acetaminofeni, arasteroiduli anTebis sawinaaRmdego (NSAIDs) saSualebebi. (NSAIDs ciroziT avadmyofebSi sifrTxiliT unda iqnas
gamoyenebuli)
adeqvaturi hidratacia; pegilirebuli interferonis
administrireba Zilis win.
anoreqsia/wonaSi kleba
megestroli, dronabinoli,
antidepresantebi
maRalkaloriuli sakvebi, sakvebi danamatebi,
mcire ulufebiT kveba
21
gverdiTi
efeqtebi
medikamentebi
menejmenti
hipoTireozi
levoTiroqsini (T4),
lioTironini (T3)
endokrinologis
konsultacia;
arakontrolirebadi
darRvevebis dros
mkurnaloba wydeba
hiperTireozi
karbimazoli, meTimazoli,
propilTiouracili.
endokrinologis
konsultacia;
arakontrolirebadi
darRvevebis dros
mkurnaloba wydeba
Saqriani
diabeti
antidiabeturi
medikamentebi.
insuliniT CanacvlebiTi
Terapia
dieta; endokrinologis
konsultacia;
arakontrolirebadi
Saqriani diabetis dros
mkurnaloba wydeba
qavili
antihistaminuri
saSualebebi:
loratadini
hidroqsizini
adgilobrivad steroiduli
malamoebi
grili Sxapi;
damatenianebeli
losionebi
ribavirinis
gamonayari
adgilobrivad steroiduli
malamoebi
mZime SemTxvevebSi SesaZloa
saWiro gaxdes ribavirinis
dozis Semcireba
kanis simSrale damatenianebeli kremebi adeqvaturi hidratacia
Tmis cvena
–––––
dermetologis
konsultacia;
moeridon Tavis xSir
dabanas; gamoiyenon Tmis
damatenianebeli
saSualebebi
22
6. reabilitacia da dakvirveba
avadmyofebi, romlebTanac mkurnalobis Sedegad miRebulia myari virusuli pasuxi (aragansazRvradi HCV rnm mkurnalobis damTavrebidan 6 Tvis Semdeg), SemdgomSi gansakuTrebul zedamxedvelobas ar saWiroeben.
avadmyofebi, romlebTanac adgili hqonda warumatebel mkurnalobas SemdgomSi saWiroeben dinamikaSi dakvirvebas daavadebis progresirebis Sesafaseblad. aRniSnul avadmyofebSi SesaZlebelia ganxilul iqnas ganmeorebiTi mkurnalobis sakiTxi, Tumca ganmeorebiTi mkurnalobis efeqturoba maRali ar aris.
ganmeorebiTi mkurnalobis sakiTxi yovel konkretul SemTxvevaSi unda ga-dawydes individualurad mosalodneli sargebelis da riskis mixedviT.
7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli -
,,C hepatitis marTva”