treatment of a chronic hepatitis With

Final point of antiviral treatment is achievement of the proof virologic answer (SVO) which is defined as absence RNK VGS
In blood after 24 weeks after end of antiviral therapy. Repeated definition of a virus load at the patients who have reached SVO, has shown, that more than at 99 % of patients among adults [404] and at 98 % of patients of children's and teenage age, RNK HCV was not defined during 5-year-old periods of observation that is regarded as eradikatsija a virus [277, 375, 389].

After eradikatsii a virus With the necrotic inflammation stops and fibrosis development stops.

Until recently standard PVT at children was combinations IFN - an and ribavirina, providing formation SVO in 27-64 % of observations (on the average - 48 %) [266, 275, 294, 320, 418]. At becoming infected HCV of 2 and 3 genotypes higher indicators SVO (89 %) while at becoming infected HCV of 1 genotype it was registered lower indicators of frequency SVO (44 %) [22, 275, 294, 308, 370, 431] were observed. Level of a starting virus load and expression of a fibrosis of a liver at PVT a combination INF and ribavirinom also concerned prognostic factors of the answer to treatment [397, 452, 279].

The steady virologic answer at the combined therapy short INF and ribavirina is registered at 51 % sick of a chronic hepatitis With (at 1 genotype - at 41 %, at not 1 genotype - at 69 % of patients) [94, 405]. At children of patients HGS a genotype lb mono therapy by preparations rekombinantnogo INF is a little effective, proof remission is absent. At patients with a genotype 4 long full remission is formed in 38,5 %, at children with other genotypes HCV - in 28,9 % of cases. Efficiency of treatment at chronic hepatitises In and With at children with a somatic pathology has no differences at use of parenteral and rectal forms rekombinantnogo interferon an alpha. [39, 112, 188].

Since 2011 in the Russian Federation the monotherapy stage rekombinantnym by interferon (IFN) at children with HGS which provided achievement SVO according to various researches from 0 % to 76 %, on the average - in 36 % of observations is finished, that, is unconditional, appreciable above than at adults (10-15 %) [338,
370, 372, 431]. Modern schemes of therapy allow to become successful in 80-90 % of cases [332, 360, 405,]. In adult practice the Gold standard PVT a chronic virus hepatitis With is the combination of preparations pegilirovannyj interferon альфа-2Ь (PegIntron) with ribavirinom (Rebetol). Combination Пег-ИФН-а2Ь and ribavirina is officially registered for treatment HGS at children and teenagers from 3 till 18 years in the USA since 2008, in the European Union countries since 2009, in the Russian Federation since 2011 [238, 288, 292, 323, 334, 413, 434]. In 2011 these preparations are resolved in the Russian Federation to application for children at treatment HGS [170]. Now in variety clinical researches efficiency and safety combined PVT pegilirovannym by interferon-a (Пег-ИФН-a) (Peg - ИФН-а2Ь - 60 mkg/m2/ned, Пег-ИФН-а2а - 100 mkg/m2/ned or 180 mkg/1,73m2/ned) and ribavirinom (Rebetol) (15 mg/kg/sut) at children and teenagers is studied.

Ribavirin - analogue of a guanosine. Being an inhibitor of Inosinum-Mononatrii phosphas of a dehydrogenase, the preparation brakes synthesis virus RNK and DNA. It is noted also its favorable immunomodulirujushchy effect - level normalisation interlejkina-6. At monotherapy rebetolom only immediate answer to treatment which disappears after preparation cancellation is reached. The combination of different mechanisms of antiviral action If and rebetola does a combination of these preparations of the most effective at HG-WITH, uveliyochivaja number with firmness answered treatment at least twice in comparison with monotherapy If. The combined therapy in 2-3 times is better than monotherapy If [279, 332, 358].

For the patients infected with a virus of a hepatitis About a genotype 1 duration of treatment is recommended makes 48 ned. For the patients infected with a virus of a hepatitis With a genotype 2 and 3: duration of treatment is recommended makes 24 weeks.

At combined PVT Пег-ИФН-a and ribavirinom general frequency SVO makes according to various clinical researches from 29 % to 82 % (in
Average - in 68 %), at becoming infected HCV of 1 genotype - 40-53 % at duration of treatment of 48 weeks, at becoming infected HCV 2 and 3 genotypes - 93-100 % at duration PVT of 24 weeks [169, 340, 413, 452], that significantly above, than at combination ИНФ-a and ribavirina. Thus, monotherapy Peg - ИФН-a allows to reach SVO only at 21 % of patients [355, 414, 435]. As well as at adults, the major prognostic instruments of achievement SVO at use of combination Пег-ИФН-a and ribavirina at children are formation of the fast virologic answer (frequency SVO - 100 %) and the early virologic answer (frequency SVO - 94 %) [334, 340, 341, 343, 415, 425, 434].

prediktorom the good answer on interferonoterapiju also can be at HGS initially intensive production IL-113 and IFN - y and a low virus load [227, 340, 341, 425, 434].

Shipping of combination Пег-ИФН-a and ribavirina at children is better, than at adults [323, 340, 414, 425, 279]. At use of combination Пег-ИФН-a and ribavirina depression of mass of a body and some backlog in growth rate on certain age at children receiving PVT is observed, however after the treatment termination fast normalisation of weight [452] is observed. Sometimes the delay of physical development during PVT is caused interferon - by the induced hypothyrosis that dictates necessity of a careful estimation of function of a thyroid gland as prior to the beginning PVT at children, and during its carrying out [300, 413, 451].

Reception of these preparations is accompanied by the traditional undesirable phenomena during PVT at children - grippopobdobnyj a syndrome and zheludochnoyokishechnye symptoms (a nausea, vomiting, a diarrhoeia). There is an irritability, a sleeplessness, alarm, however, not demanding application antidepresantov and, especially, premature termination of treatment much less often. The anaemia at PVT Пег-ИФН-a at children is observed less often, than at adults, reflecting the well-known fact of high tolerance of children of 3-11 years at influence
gematotoksicheskih medical products [257, 383].

At becoming infected HCV of 2 and 3 genotypes higher indicators SVO (89 %) while at becoming infected HCV of 1 genotype it was registered lower indicators of frequency SVO (44 %) [240, 294, 343, 431] were observed. Level of a starting virus load and expression of a fibrosis of a liver at PVT a combination INF and ribavirinom also concerned prognostic factors of the answer to treatment [172, 397, 451].

Now there are preparations for combined and triad therapy HGS: telaprevir, simeprivir sofosbuvir, including at children [239, 279, 318].

Application after end of basic course PVT at patients HGS of a combination immunotropnyh preparations "Ronkolejkin" and "Likopid" under the scheme developed by us authentically enlarges number of patients with the stable virologic answer [151]. The important question is duration of conservation SVO after the therapy termination. In research Kelly D.A., Haber B., Gonzalez-Peralta R.P. The good survival rate within 5 years [333] is shown.

Special group - patients HGS with constantly normal level of aminotransferases testifying to immune tolerance to a virus. Among adult patients they make 10-20 % infected HCV [91, 245, 285, 382, 422]. In children's practice of such patients much more to 40 % [109]. In variety of works it is shown, that at 2/3 patients HGS with PNALT the minimum fibrosis or its absence becomes perceptible. A number of researchers as a result of dynamic observation with carrying out of repeated biopsies of a liver notice, that soft illness of a liver with the minimum signs of advance [91, 406, 422] is inherent to this patients. At the same time, in this group of patients level viremii authentically does not differ from aminotransferases having hyperactivity, and the expressed histological changes of a liver, including with development of a cirrhosis [398] are quite often observed. It is known, that HGS gistologicheski progresses at small clinical expression. For the decision of a question on treatment of such patients it is necessary
Liver biopsy, irrespective of clinical semiology and level of aminotransferases. "Standard" monotherapy If at patients with constantly normal level of aminotransferases, by results of the majority of researches, is noneffective; breaking immune tolerance, it it is frequent (in 47 % of cases) raises level of enzymes, does not lead to disappearance viremii and promotes disease advance. To the most effective is modern combined PVT Peg-ifn and ribavirinom practically without dependence from initial level ALT [91, 245, 437].

Choice of the scheme of treatment of patients HGS which not answered an initial course of antiviral therapy or has given an exacerbation after the answer to it, - a difficult problem.

In the medical literature a little given about repeated PVT at children with HGS, failed at the previous course PVT. However to children who have not reached SVO as a result of monotherapy ИФН-a and combined therapy ИНФ-a and ribavirinom/lamivudinom, it is necessary repeated PVT Peg-ifn - and and ribavirinom/lamivudinom. The question on tactics of conducting children with failure from previous PVT combination Пег-ИФН-a and ribavirina remains opened as efficiency of refresher course of treatment Пег-ИФН-a and ribavirinom at children is not known, and efficiency and safety "triad" PVT Пег-ИФН-a, ribavirinom and antiviral preparations of direct action is not studied. [239, 279, 352, 391]

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Scientific source Dmitriev Tatyana Gennadevna. CHRONIC VIRUS HEPATITISES At CHILDREN And TEENAGERS In REGION GIPERENDEMICHNOM. The PROGRAM of PERFECTION of RENDERING of the MEDIKO-SOCIAL HELP. The dissertation on competition of a scientific degree of the doctor of medical sciences. Yakutsk - 2014. 2014

Other medical related information treatment of a chronic hepatitis With:

  2. 1.1. Epidemiologija chronic hepatitises at children and teenagers
  3. 1.5.3. Definition of activity HG.
  4. 1.5. The general principles of antiviral therapy of chronic hepatitises at children and teenagers.
  5. treatment of chronic hepatitis V
  6. treatment of chronic hepatitis D.
  7. treatment of a chronic hepatitis With
  8. 1.6. Mediko-social problems of chronic hepatitises at children and teenagers.
  10. Chapter 8. The CONCLUSION
  13. bases of a pathogenesis of an anaemia at chronic illnesses
  15. clinical implications of a HIV-infection
  16. treatment sick of a tuberculosis, sochetannym with a HIV-infection in the conditions of children's tubercular unit of scientific research institute FP