За месяцы, когда коронавирус правит миром, терапия заболевания успела кардинально измениться
Пандемию весь мир встретил фактически безоружным: никто не знал, чем лечить новый коронавирус. В общем, эффективных лекарств нет до сих пор, однако ученые продолжают искать, а врачи – пробовать из того, что есть и что теоретически может сработать.
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За те месяцы, что пандемия правит миром, терапия заболевания успела измениться несколько раз, причем, кардинально. Сначала ставку делали на противовирусные препараты, потом от них практически отказались. Сейчас появляется все больше данных о том, что антибиотики, которыми тоже пытались действовать наугад, скорее приносят больше вреда, чем пользы. Мало того: теперь врачи не сомневаются в том, что поражение легких при ковид не имеет ничего общего с пневмонией. “Казалось бы, что меняетcя от названия заболевания: пневмония, пневмонит или интерстициопатия? На самом деле очень многое, – рассказывает врач Денис Прокофьев – От этого зависит все: диагностика, лечение, реабилитация. Нам необходимо указывать диагноз, используя для COVID-19 правильный термин: “интерстициопатия” – процесс, проявляющийся воспалением и нарушением структуры альвеолярных стенок. Эта формулировка заставит врача не прибегать к неоправданному назначению антибиотиков, а задуматься об использовании других средств терапии, прежде всего противовоспалительных препаратов”.
На тему, использовать или нет аппараты ИВЛ, тоже случилось немало споров, особенно, когда выяснилось, что выживают на них далеко не все. “Раньше мы ориентировались на количество ИВЛ, а сейчас стремимся не переводить пациентов туда, где более высокая летальность”, – говорит академик РАН, генеральный директор Национального медицинского исследовательского центра имени В.А. Алмазова, президент Российского кардиологического общества Евгений Шляхто.
Кроме того, не оправдала себя схема применения гидроксихлорохина с азитромицином, которую поначалу сочли за панацею: последние исследования показали, что при низкой эффективности она существенно повышает смертность пациентов.
Зато на арену вышли и прочно на ней закрепились анотикоагуалянты и низкомолекулярные гепарины – препараты, препятствующие образованию тромбов, главного и наиболее частого осложнения COVID-19.
“Сначала мы думали, что новый вирус следует лечить подобно ОРВИ, но инфекция оказалась совсем другой. Например, возлагались надежды на калетру, как эффективный противовирусный препарат, но сейчас от нее почти отказались”, – говорит Евгений Шляхто.
Еще одним открытием стало использование в терапии нового заболевания препаратов группы глюкокортикостероидов – стероидных гормонов, продуцируемых корой надпочечников. Оказалось, они обладают мощным противовоспалительным и иммуномодулирующим действием в отношении новой инфекции. “Поначалу считалось, что они при новом вирусе противопоказаны, так как могут стимулировать усиленное размножение вируса в клетке. Но сейчас они выхолят на первое место и стали основными препаратами, которые назначают таким пациентам. При возникновении критической ситуации вируса в организме уже почти нет, и крайне важно не пропустить терапевтическое окно для назначения глюкокортикоидов, чтобы остановить цитокиновый шторм. Практика показывает, что начинать их у таких пациентов надо максимально рано, не в реанимации, когда шторм уже сложно остановить, – говорит академик Шляхто. – Цитокиновый шторм приводит к колоссальным последствиям, развитию фиброзов, легочной недостаточности, сосудистых осложнений “.
…Сегодня в мире ведутся тысячи исследований по препаратам для борьбы с новым коронавирусом. Например, в области тканевой инженерии: ученые недавно обнаружили, что человеческий белок АПФ2 уменьшает инфекцию короны в клетках. Идут попытки создать рекомбинантный человеческий АПФ2. На его основе ведется разработка биомолекул-“ловушек” (decoy biomolecules), способных нейтрализовать вирус и уменьшить поражение легких. Предварительные исследования показали, что препараты, созданные на основа растворимого рекомбинантного АПФ2, эффективны у пациентов на ранней стадии заболевания.
Еще одна перспективная разработка – наночастицы для восстановления легочной ткани и подавления цитокинового шторма. Например, известно, что при респираторном синцитиальном вирусе избыточная экспрессия защищающего дыхательную систему цитокина под названием LIF улучшает восстановление легких при пневмонии. И хотя роль LIF при SARS-Cov-2 не изучена, ученые предполагают, что это может сработать. Опыты с наночастицами LIF на лабораторных мышах уже проводились и показали их иммуномоделирующий эффект, а также способность уменьшать воспаление в легочной ткани. Предполагается, что вдыхание LIF-наночастиц может стать новой терапией восстановления легочной ткани и подавления цитокинового шторма у пациентов с “короной”.
Как рассказывает директор Института биоорганической химии НАН Беларуси Светлана Бабицкая, разработка оригинального препарата с нуля требует минимум десяти лет упорной работы и около миллиарда долларов, а сейчас у ученых нет ни времени, ни денег. Из имеющихся на рынке препаратов около 150 считаются перспективными против коронавирусов. Среди них – и противовирусные, и иммуномодуляторы (для ограничения чрезмерной реакции иммунной системы, и антитела (включая как плазму, так и созданные в лаборатории). Если говорить о новинках, то в соседней с нами Беларуси начался проект по изучению влияния на коронавирусную инфекцию инъекций мезенхимальных стволовых клеток.
Пандемия коронавируса. Хроника событий
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