ВЫБОР САХАРОСНИЖАЮЩИХ ПРЕПАРАТОВ У БОЛЬНЫХ САХАРНЫМ ДИАБЕТОМ 2-ГО ТИПА ОЧЕНЬ ВЫСОКОГО СЕРДЕЧНО-СОСУДИСТОГО РИСКА (ЧАСТЬ 1)

В первой части обзора представлены особенности выбора традиционных сахароснижающих препаратов у больных сахарным диабетом 2-го типа в сочетании с сердечно-сосудистыми заболеваниями атеросклеротического генеза. Особое внимание уделено больным с хронической сердечной недостаточностью. В тактике ведения пациентов с сахарным диабетом 2-го типа очень высокого сердечно-сосудистого риска отражено большое значение определения индивидуализированного выбора целевого уровня гликированного гемоглобина, который у данной категории больных более высокий. Проведен анализ безопасности выбора сахароснижающих препаратов из групп бигуанидов, меглитинидов, ингибиторов альфа-глюкозидазы, инсулина и сульфанилмочевины. Оценка рандомизированных клинических исследований, метаанализов опубликованных исследований по безопасности сахароснижающих препаратов в отношении сердечнососудистой системы показала, что препаратами первой линии в инициации лечения больных очень высокого сердечно-сосудистого риска, как в монотерапии, так и в комбинации, в зависимости от исходного уровня гликированного гемоглобина, являются бигуаниды (метформин) — лекарственные средства, улучшающие прогноз, обеспечивающие снижение риска развития сердечно-сосудистых событий. Применение ряда препаратов инсулина ухудшает прогноз больных при наличии сердечно-сосудистых заболеваний. Безопасность в отношении кардиоваскулярных исходов доказана для инсулина гларгина. Препараты сульфонилмочевины (за исключением гликлазида), меглитиниды, ингибиторы альфа-глюкозидазы не рекомендуются для лечения больных сахарным диабетом 2-го типа очень высокого сердечно-сосудистого риска из-за наличия доказательств негативного влияния на прогноз, либо из-за отсутствия достаточных аргументов в пользу безопасности в отношении сердечно-сосудистой системы, либо результаты исследований противоречивы. Особенности выбора и назначения «новых» групп сахароснижающих препаратов будут представлены во второй части статьи.

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