1

danarTi 1

alergiuli rinitis marTva

pirveladi jandacvis

dawesebulebebSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris 2010 wlis 24 seqtembris # 307/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

alergiuli rinitis marTva pirveladi

jandacvis dawesebulebebSi

1. daavadebis ganmarteba, sinonimebi, klasifikacia da

terminologia

alergiuli riniti, misi sixSiris, cxovrebis xarisxze gavlenisa da asTmasTan kavSiris gamo, respiraciuli sistemis erT-erTi mniSvnelovani qronikuli paTologiaa. ojaxis eqimebis roli alergiuli rinitis marTvaSi sakmaod farToa da gulisxmobs am paTologiis adeqvatur diagnostikasa da marTvas pirvelad jandacvaSi arsebuli resursebiT, rinitis asTmasTan Tanaarsebobis SemTxvevaSi asTmis droul gamovlenasa da kontrolis Sefasebas da, saWiroebis SemTxvevaSi, droul referals viwro specialistTan.

gaidlaini moicavs alergiuli rinitis diagnostikasa da marTvas pirveladi jandacvis rgolis doneze, specialistTan referalis kriteriumebs. gaidlainSi ar aris Sesuli komorbiduli daavadebebis marTva, rogoricaa rinosinusiti, asTma da sxva.

gaidlaini gankuTvnilia pirvelad jandacvaSi momuSave eqimebisa da praqtikosi alergologebisaTvis.

pacientTa populacia – mozrdilebi da bavSvebi.

gaidlainSi gamoyenebuli Semoklebebi

gaidlainSi gamoyenebulia Semdegi Semoklebebi

AAAAI – amerikis alergiis, asTmisa da imunologiis

akademia;

ARIA – alergiuli riniti da misi gavlena asTmaze;

Bet v 1 – Betula verucosa-s antigeni 1 (aryis xis mtvris

mTavari antigeni);

CO – naxSirbadis monoqsidi;

CO2 – naxSirbadis dioqsidi;

CXCR, CXC – qemokin receptorebi;

CysLT – cisteinuri leikotrienebi;

ECM eqstracelularuli matriqsi;

ECP – Eosinophil cationic protein – eozinofilebis kaTionuri proteini;

FceRI – maRali mgrZnobelobis receptori IgE -s mimarT ;

FceRII – dabali mgrZnobelobis receptori IgE -s mimarT;

3

Fel d 1 – Felix domesticus allergen 1 (katis mTavari alergeni);

fqod – filtvis qronikuli obstruqciuli daavadeba;

GM CSF – granulocit-makrofagebis koloniebis mastimulirebeli faqtori;

HEPA – High Efficiency Particulate Air Filter - makronawilakebis maRalefeqturi sahaero filtri;

i/n – intranazaluri;

i/o – intraokuluri ; i/m – Intrmuskuluri; LTC4 – leikotrieni C4;

LTD4 – leikotrieni D4;

mAb – Monoclonal antibody - monoklonuri antisxeuli; NO – azotis oqsidi;

NO2 – azotis dioqsidi;

PCR – polimerazas jaWvuri reaqcia;

Phl p – Phleum pratense;

PM10 – Particulate matter nivTieri makronawilakebi <10um;

SO2 – gogirdis dioqsidi;

Th – helperi limfociti;

VCAM-1 – Vascular Cellular Adhesion Molecule-1 sisxlZarRvovani ujreduli adheziuri molekula - 1;

VEGF – Vascular Endothelial Growth Factor sisxlZarRvovani endoTeluri zrdis faqtori.

alergiuli rinitis ganmarteba da klasifikacia

riniti warmoadgens cxviris lorwovanis anTebas, romlsac axasiaTebs wina an ukana rinorea, cemineba, cxviris gaWedva da/an cxviris qavili. es simptomebi grZeldeba 2 an meti Tanmimdevruli dRis manZilze, umetes dReebSi 1 saaTze meti xnis ganmavlobaSi1,13.

rinitebi iyofa 3 jgufad:

araalergiuli;

infeqciuri;

alergiuli.

4

araalergiuli rinitebis etiologia multifaqtorulia da mocemulia cxrilSi 1.

infeqciuri riniti ufro xSirad, gamowveulia virusebiT, naklebi sixSiriT gvxvdeba baqteriuli, sokovani da protozouli riniti. infeqciuri riniti bevrad ufro mZimed mimdinareobs alergiul pacientebTan, gansakuTrebiT, Tu infeqcia emTxveva alergenis zemoqmedebis periods.

alergiuli riniti cxviris simptomuri dazianebaa, romelic gamowveulia cxviris lorwovanze alergenis zemoqmedebiT da ganpirobebulia IgE–gaSualebuli anTebiTi reaqciiT 1 . is xSirad asocirebulia okularul simptomebTan.

alergiuli rinitis klasifikacia:

efuZneba simptomebs da cxovrebis xarisxis parametrebs;

iTvaliswinebs daavadebis mimdinareobis xangrZlivobas da iyofa ,,intermisiul” da ,,persistul” formebad;

efuZneba daavadebis simZimes da iyofa ,,msubuq” da ,,saSualo/mZime” formebad simptomebisa da daavadebis cxovrebis xarisxze zemoqmedebis mixedviT1 (ix. suraTi 1).

5

suraTi 1 alergiuli rinitis klasifikacia

alergiuli riniti adre iyofoda: sezonur, wlis manZilze mimdinare da profesiul formebad2. mTeli wlis manZilze mimdinare alergiuli rinitebi ufro xSirad ganpirobebulia karSida alergenebiT, rogoricaa: oTaxis mtvris tkipa, cxovelTa bewvi, obis sokoebi, mwerebi (taraknebi) da sxva, xolo sezonuri rinitebis gamomwvevia kargareTa alergenebi, ZiriTadad mcenaris mtveri da sokovani alergenebi. aseTi klasifikacia ar iyo calsaxa Semdegi mizezebis gamo:

zog regionSi mcenaris mtveri da obis sokoebi mTeli wlis ganmavlobaSia haerSi. amis gamo maT mier inducirebuli alergiuli riniti SesaZlebelia mTeli wlis manZilze mimdinareobdes, anu daikargos rinitebis sezonuroba2.

mTeli wlis manZilze mimdinare rinitma SesaZlebelia miiRos sezonuri xasiaTi, magaliTad, oTaxis mtvris tkipiT inducirebuli rinitis SemTxvevaSi, pacientTa did nawils aReniSneba msubuqi an saSualo/mZime intermisiuli riniti 3 xmelTaSua zRvis arealSi, sadac oTaxis mtvris tkipis alergenebis done dabalia zafxulobiT;

persistuli simptomebis xangrZlivoba >4 dRe/kviraSi da >4 kvira/weliwadSi

intermisiuli simptomebis xangrZlivoba <4 dRe/kviraSi an <4kvira/weliwadSi

msubuqi mimdinareoba yvela CamoTvlili normaluri Zili;

ar aris SezRuduli yoveldRiuri aqtivoba, sporti, dasveneba;

ar aris SezRuduli SromiTi da saskolo aqtivoba;

ar aris Semawuxebeli simptomebi.

saSualo/mZime mimdinareoba erTi an meti qvemoT CamoTvlili Zilis darRveva;

yoveldRiuri aqtivobis, sportisa da dasvenebis SezRudva;

SromiTi da saskolo aqtivobis SezRudva;

Semawuxebeli simptomebi.

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polisensibilizaciis mqone pacientebs mTeli wlis manZilze mimdinare rinitiT aReniSnebaT gamwvavebebi trigeruli mcenaris yvavilobis periodSi.

aqedan gamomdinare, sezonuri da mTeli wlis ganmavlobaSi mimdinare rinitebis nacvlad SemoRebuli iqna terminebi intermisiuli da persistuli, romlebic ufro zustad asaxaven daavadebis mimdinareobas.

cxrili 1 araalergiuli rinitebis savaraudo trigerebi

(BSACI gaidlaini alergiuli da araalergiuri rinitebisaTvis 2008w)

tipi SesaZlo mizezi niSnebi, simptomebi eozinofiluri an araalergiuli rinitebi eozinofiliis sindromiT

pacientTa 50 %-Si mogvianebiT viTardeba asTma an nazaluri polipozi.

kanis testebi negatiuria, magram nazalur nacxSi aRiniSneba eozinofilia. simptomebi aris paroqsizmuli xasiaTis mTeli wlis manZilze. 50%-ze mets aReniSneba bronquli hiperreaqtiuloba.

avtonomiuri (vazomotoruli)

trigerul faqtors warmoadgens fizikuri an qimiuri agentebi

ufro xSiria saSualo asakSi, axasiaTebs wyliseburi rinorea, gansakuTrebiT dilaobiT, alergiul rinitze cudad emorCileba mkurnalobas, savaraudod, gamowveulia parasimpatikuri hiperaqtivobiT.

medikamenturi

alfa adrenerguli blokatorebi, agf, qlorpromazini

cxviris gaWedva.

dekongestantebi Rhinitis medikamentosa qronikuli nazaluri blokadiT.

kokaini rinorea, fufxebis gaCena, tkivili, cxviris Zgidis perforacia, ynosvis daqveiTeba.

aspirini, sxva aass mwvave rinitis simptomebi, SesaZloa asTma, urtikaria, angioedema, Soki.

cxrili 1 (gagrZeleba) araalergiuli rinitebis savaraudo trigerebi

(BSACI guidelines for allergic and non-allergic rhinitis) tipi SesaZlo mizezi niSnebi, simptomebi hormonaluri orsuloba,

pubertantuli periodi, hormon-CanacvlebiTi Terapia, hipoTireozi, akromegalia

yvela CamoTvlils SeuZlia gamoiwvios cxviris gaWedva da/an rinorea.

sakvebismieri alkoholi, sunelebi, wiwaka.

rinorea, saxis siwiTle.

atrofiuli Klebsiella Ozonae, an meoradi - travmis, qirurgiuli Carevis an radiaciis gamo

cudi sunis SegrZneba, fufxebi, hiposmia, nazaluri blokada.

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lorwos pirveladi defeqti (primary mucus defect)

cisturi fibrozi bavSvebs gamovlenili nazaluri polipebiT unda CautardeT skriningi cistur fibrozze.

pirveladi ciliaruli diskinezia

karTageneris da iungis (Young) sindromi

rinosinusiti, bronqoeqtaziebi, daqveiTebuli fertiloba,

sistemuri/anTebiTi

Segrenis sindromi, mglura, revmatoiduli arTriti

cxviris gaWedva

Carg-strausis sindromi polipebi, sinusiti, asTma, eozinofilia imunodeficiti antisxeulebis deficiti qronikuli infeqciuri sinusiti avTvisebiani limfoma, melanoma,

sqvamozur-ujredovani karcinoma

SesaZlebelia sisxliani da Cirqovani gamonadeni, tkivili da cxviris gaWedva.

struqturuli paTologia

cxviris Zgidis gamrudeba

cxviris calmxrivi gaWedva naklebad mosalodnelia damatebiTi mizezis, mag. rinitis gareSe.

idiopaTuri gamoricxvis diagnozi SesaZloa efeqturi iyos topikuri kafsaikini

granulomatozuri daavadebebi

sarkoidozi vegeneris daavadeba

cxviris ukana gasavlis SeSupeba, sisxldena, Zgidis perforacia.

sezonuri da mTeli wlis manZilze mimdinare rinitebi ar aris sinonimi intermisiuli da persistuli rinitebisa 4 . sezonuroba SesaZlebelia axasiaTebdes rogorc intermisiul, aseve persistul alergiul rinits.

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2. epidemiologia

alergiuli rinitebi janmrTelobis globalur problemas warmoadgens, romelic avadobisa da uunarobis gamomwvevi erT-erTi umTavresi mizezia da Mmsoflios yvela qveynis, yvela eTnikuri jgufisa Tu asakis pacientebSi gvxvdeba.

marTalia, alergiuli rinitebi, Cveulebriv, mZime daavadebebs ar miekuTvneba, magram cvlis pacientTa socialur yofas, iwvevs Zilis darRvevebs, gavlenas axdens saskolo saqmianobasa Tu muSaobis xarisxze. garda amisa, rinitebiT gamowveuli xarjebic mniSvnelovania.

asTma da alergiuli riniti xSirad sasunTqi gzebis erTian daavadebad ganixileba: ,,erTi sasunTqi gza, erTi daavadeba.”

alergiuli rinitebis sixSire mkveTrad gaizarda bolo 50 wlis ganmavlobaSi. zogierT qveyanaSi axalgazrda Taobis 50%-s, xolo msoflioSi savaraudod 500 milion adamians aReniSneba alergiuli rinitis simptomebi. msoflios umravles qveynebSi, da ZiriTadad iq, sadac daavadebis dabali an saSualo maCvenebeli iyo, sixSire mkveTrad matulobs. maSin, roca maRali prevalentobis qveynebSi aRiniSneba alergiuli rinitis gavrcelebis SeCerebis an Semcirebis tendenciac ki. evrokavSirisa da zogierT sxva qveyanaSi, rogoricaa, magaliTad, kanada, mimdinareobs specifikuri programebis SemuSaveba, raTa ukeT iqnas Seswavlili, marTuli da moxdes alergiuli rinitebisa da zogadad alergiuli daavadebebis prevencia.

saqarTveloSi alergiuli rinitis/rinokoniunqtivitis gavrceleba Seswavlilia ISAAC - is (bavSvTa Soris asTmisa da alergiis saerTaSoriso kvlevis) farglebSi (1996-2003ww). kvleva miznad isaxavda asTmis, alergiuli rinitis/rinokoniunqtivitisa da egzemis gavrcelebis Seswavlas sxvadasxva qveynebSi. asTmisa da alergiuli rinitis prevalentobas Soris korelacia mkveTrad iyo gamoxatuli yvela qveyanaSi, maT Soris saqarTveloSi.

ISAAC-is pirveli da mesame fazebis monacemebiT saqarTvelo ganixileba rogorc alergiuli rinitis/rinokoniunqtivitis, asTmisa da egzemis simptomebis SedarebiT dabali prevalentobis mqone qveyana (13-14 wlis populaciaSi <6%, xolo 6-7 wlis populaciaSi <8%-ze)5,6,7,8,9,10.

ISAAC kvlevis monacemebis grafikuli gamosaxuleba mocemulia me-2 suraTze.

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suraTi 2 ISAAC I – 13.516 monawile, ISAAC III – 11.655 monawile

(Tbilisisa da quTaisis erToblivi monacemebi)

asakobrivi jgufi 13/14 w.

3,1

3,6

5,4

4,14,1

5,65,4

4,3

0

3

6

diagnostirebuli

asTma

mimdinare xixini mimdinare

rinokoniunqtiviti

mimdinare egzema

ISAAC I (%)- 1996

ISAAC III (%) -2003

asakobrivi jgufi 6/7 w.

3,1

7,6

3,3

5,7

3,4

7,8

2,5

4,7

0

3

6

9

diagnostirebuli

asTma

mimdinare xixini mimdinare

rinokoniunqtiviti

mimdinare egzema

preval

entoba (%

)

ISAAC I (%)- 1996

ISAAC III (%) -2003

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3. etiopaTogenezi

etiologia

alergiuli rinitis ganviTarebis risk-faqtorebi

alergiuli riniti multifaqtoruli daavadebaa, gamowveuli genetikuri da garemo faqtorebis urTierTqmedebiT;

alergiuli rinitis gamomwvevia karSida da kargareTa aeroalergenebi;

mTavari kargareTa alergenebia: yvavilis mtveri da obis soko;

ZiriTadi karSida alergenebia: tkipebi, cxovelTa bewvi, mwerebi da obis soko;

sakvebismieri alergenebi iSviaTad warmoadgens izolirebuli nazaluri simptomebis mizezs;

profesiulma faqtorebma SeiZleba gamoiwvios riniti rogorc alergiuli, ise araalergiuli meqanizmebiT;

karSida da kargareTa haeris damabinZureblebi savaraudod aseve mniSvnelovania, magram meti monacemia saWiro maTi efeqtis Sesafaseblad;

socialur-ekonomikuri gansxvavebebic mniSvnelovania alergiul daavadebebSi, magram meti monacemis arsebobaa saWiro specifikuri rekomendaciebis SesamuSaveblad.

genetika da ojaxuri anamnezi

alergiuli riniti multifaqtoruli daavadebaa, romlis ganviTarebazec gavlenas axdens rogorc genetikuri, aseve garemo faqtorebis zemoqmedeba. alergiul daavadebebs, rogoricaa asTma da riniti, aqvT mWidrod dakavSirebuli fenotipi da xSirad gvxvdeba atopiasTan erTad. gadajaWvulia am daavadebebis etiologiuri faqtorebic. bolo aTwleulis manZilze identificirebuli iqna HLA sistemis antigenebi, romlebic pasuxismgebelia sezonuri alergiuli rinitis ganviTarebaze11.

qarTul populaciaSi ambroziis gavrcelebis endemiur keraSi (lagodexis raioni) gamovlenilia HLA-kompleqsTan SeWiduli genebi (HLA-A3; B7; DR2; DR2,DR5 da proteqtori HLA-DR4), romlebic akontroleben specifikur IgE - imunur pasuxs ambroziis kompleqsuri alergenis mimarT da ambroziis yvavilobis periodSi ganapirobeben polinozis fenotipis (riniti / rinokoniunqtiviti /asTma) gamovlinebas12.

alergenebi warmoadgens antigenebs, romlebic ainducireben da urTierTqmeden specifikur IgE antisxeulebTan. alergenebis wyaros

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warmoadgens cxovelebis, mwerebis, mcenareebis, sokoebisa da profesiuli faqtorebis farTo speqtri. antigenebi miekuTvneba cilebs an glikoproteinebs da ufro iSviaTad, glikanebs, rogorc magaliTad, Candida albicans SemTxvevaSi13.

alergenebis nomenklatura mowodebul iqna WHO/IUIS alergiis nomenklaturis qvekomitetis mier14.

alergenebi

inhalaciuri alergenebi

aeroalergenebi xSirad gvevlinebian alergiuli rinitisa da asTmis gamomwvevead 15 . isini, Cveulebriv, iyofa karSida (tkipebi, Sinauri cxovelebi, mwerebi, mcenareebi, magaliTad, fikusi), kargareTa (yvavilis mtveri, obis sokoebi) da profesiul agentebad.

klasikurad, kargareTa alergenebi iTvleba sezonuri rinitebis gamomwvevad, xolo karSida_asTmisa da wlis manZilze mimdinare rinitebis gamomwvev faqtorebad. Tumca, ARIA kvlevebma gviCvena, rom yvavilis mtvris mimarT sensibilizebuli pacientebis 50%-s aReniSneba persistuli alergiuli riniti, xolo zogadad populaciaSi oTaxis mtvris tkipis mimarT sensibilizebuli pacientebs aqvT msubuqi intermisiuli alergiuli riniti 16 . alternaria da mwerebis alergenebi aseve kavSirSia asTmisa da alergiuli rinitebis ganviTarebasTan.

karSida Tanamedrove garemo SesaZloa, xels uwyobdes atopiuri daavadebebis gavrcelebas. mravalferovani karSida alergenebis wyaroebs SesaZloa, sinergiuli efeqti hqondeT atopiur ko-morbidul paTologiebze17.

sxvadasxva regionis klimaturi pirobebi ganapirobebs alergenebis gavrcelebis Taviseburebebs. mniSvnelovania, eqimebma gansazRvron TavianTi regionis alergenebi. magaliTad, saqarTveloSi arsebobs ambroziis gavrcelebis ori endemuri kera: gagrisa da lagodexis raionebSi. dadgenilia, rom ambroziuli polinozis ganviTarebisaTvis garkveul risks (RR-2,09) warmoadgens bavSvis dabadeba ambroziis yvavilobis periodSi (agvisto, seqtemberi, oqtomberi), maSin rodesac ambroziuli polinozis ganviTarebis minimaluri riski (RR-0,44) aRiniSneba noember/dekemberSi, rodesac ukve savsebiT dasrulebulia ambroziis alergenis eqspozicia18.

tkipebi

oTaxis mtvris tkipebi. oTaxis mtvris tkipebi karSida alergenebis udides nawils warmoadgenen da miekuTvnebian Pyroglyphidae ojaxs,

Acari qveklass, Arachnid klass, Arthropods tips. yvelaze mniSvnelovani saxeobebia: Dermatophagoides pteronyssinus, Dermatophagoides farinae, Euroglyphus

12

mainei, Lepidoglyfus destructor, da Blomia tropicalis. es ukanaskneli ZiriTadad, magram ara mxolod, tropikul da subtropikur regionebSia gavrcelebuli. tkipebis alergenebis umravlesoba asocirebulia enzimur aqtivobasTan, rasac pirdapiri araspecifikuri zemoqmedeba gaaCnia respiraciuli traqtis epiTeliumze da ganapirobebs Th2 ujredebis pasuxs19. Dermatophagoides

da Euroglyphus tkipebi ikvebebian adamianis aqerclili kanis nawilakebiT. isini ZiriTadad binadroben sawolebSi_baliSebSi, leibebSi, sabnebSi, aseve xaliCebSi, avejis safarsa Tu fumfula saTamaSoebSi. tkipebis maqsimaluri gamravleba aRiniSneba Tbil (>200C) da nestian garemoSi (80% fardobiTi tenianoba). roca tenianoba 50%-ze naklebia, tkipa gamoSreba da kvdeba.

mtvris tkipas alergeni asocirebulia daavadebis mgrZnobelobisa da kontrolis prevalensTan. 1 gram oTaxis mtverSi 100 tkipas arseboba sakmarisia Cvilis sensibilizaciisaTvis. rac ufro maRalia tkipebis raodenoba mtverSi, miT ufro adre viTardeba mstvinavi sunTqvis pirveli epizodi 20 . tkipebis mimarT sensibilizaciis sixSire zogadad populaciaSi metad mniSvnelovania notio havis regionebSi mSrali havis regionebTan SedarebiT.

sxva tkipebi: tkipebis sxva saxeobebi-Storage mites (Glyciphagus domesticus

and Glyciphagus destructor, Tyrophagus putrecentiae, Dermatophagoides microceras,

Euroglyphus maynei and Acarus siro) gvxvdeba marcvleulisa da fqvilis maragSi. es saxeobebi mravladaa nestiani saxlebis mtverSi, tropikul zonaSi, sadac xelsayreli pirobebi iqmneba obis sokos zrdisTvis. es tkipebi ZiriTadad asocirebulia fermerTa alergiebTan da SeiZleba persistuli alergiuli rinitis simptomebis gamomwvevi gaxdes21.

Y

yvavilis mtveri

yvavilis mtveri yvavilovan mcenareTa mamrobiTi elementebia. igi Sedgeba umciresi marcvlebisagan, romelTa forma mcenaris saxeobazea damokidebuli da Seicavs alergiuli cilebis did raodenobas. transportirebis saxis mixedviT maT yofen anemofilur da entomofilur tipebad. anemofiluri yvavilis mtveri gadaitaneba qaris meSveobiT da didi raodenobiT SeiZleba gadaadgildes aseul kilometrzec ki, maSasadame, SesaZloa gavlena moaxdinos Sor manZilze myof adamianebzec. entomofiluri yvavilis mtveri gadaaqvs mwerebs, romelTac izidavs Wreli da surnelovani mcenareebi 22 . zogi mcenare, magaliTad babuawvera warmoadgens rogorc entomofilur, ise anemofilur saxeobebs.

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cxovelTa alergenebi

katisa da ZaRlis alergenebi: bolo 30 wlis ganmavlobaSi mniSvnelovnad gaizarda Sinauri cxovelebis raodenoba, gansakuTrebiT dasavleTis qveynebis qalaqebSi. cxovelebis bewvi da sekreti mZlavri alergenebis matarebelia23.

katisa da ZaRlis alergens wamyvani adgili ukavia asTmis, rinitis, rinokoniunqtivitis, xvelis ganviTarebaSi, magram iSviaTad iwvevs urtikariasa da angioedemas.

ZaRlisa da katis alergenebis wyaros warmoadgens nerwyvi da bewvi. maTi gadatana xdeba haeris nawilakebis meSveobiT. aseTi nawilakebi mravlad grovdeba oTaxis mtverSi, avejis gadasafareblebsa da naklebad-leibebSi. ufro metic, es alergenebi SesaZloa aRmoCndes iseT adgilebSic, sadac cxovelebi ar binadrobs. magaliTad, skolebSi, sazogadoebriv transportSi, hospitalur qselSi da iseT saxlebSic ki, sadac cxovelebi ara hyavT. aseT SemTxvevebSi alergiis inducireba SesaZloa moxdes Zlier sensibilizebul pirebSi24.

adamianebs, romelTac aqvT alergia ZaRlebisa da katebis alergenebis mimarT, aReniSnebaT IgE reaqtiuloba sxva cxovelebis alergenebis mimarTac.

mRrnelebi

mRrnelebis (bocveri, virTxa, Tagvi, zRvis goWi da sxva) bewvi, Sardi, nerwyvi da Srati aseve Seicavs alergenebs 25 . Cveulebriv aRiniSneba jvaredini mgrZnobeloba mRrnelebis mimarT.

am cxovelebma SeiZleba gamoiwvion aseve profesiuli sensibilizacia laboratoriis TanamSromlebsa da maT bavSvebSi. sensibilizacia mRrnelebis mimarT vlindeba weliwadze nakleb droSi, rodesac pirs uSualod aqvs Sexeba cxovelebTan.

sxva cxovelebi

cxenebis mimarT alergiuli pacientebis umravlesobas Tavdapirvelad uviTardeba nazaluri an Tvalis simptomebi, magram seriozuli garTuleba - asTmac araiSviaTia. alergenebi advilad mqrolavia da SeuZlia sensibilizaciis gamowveva cxovelebTan rogorc pirdapiri, ise arapirdapiri kontaqtisas. Aalergenebs Seicavs cxenis bewvi, ofli da Sardi. zogjer jvaredini sensibilizacia aRiniSneba sxva msgavsi cxovelebis (poni, jori, viri, zebra) da katis, ZaRlisa da zRvis goWebis cilebs Soris.

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rqosani pirutyvis mimarT alergia SedarebiT Semcirda maTi moSenebisa da wvelis procesis avtomatizaciis Sedegad. Mmagram is kvlavac gvxvdeba mecxoveleobis zonebSi26.

sokovani alergenebi

I. obi:

zedapiruli soko, obisa da safuaris sokoebi mcenareebia, romelTac ar gaaCniaT qlorofili, magram gamoimuSaveben didi raodenobiT alergiul sporebs KkarSida da gare sivrceSi. obis sokos sporebi warmoadgenen alergenebis wyaros, romlis mniSvneloba naTlad vlindeba asTmis mqone pacientebis hospitalizaciis gaxSirebaSi 27 . isini mravlad gvxvdeba lpobad mcenareebsa da haerSi da gavrcelebulia yvelgan, garda dabali temperaturis an Tovliani adgilebisa, sadac maTi zrda mniSvnelovnad ferxdeba. maTi gamravleba intensiurad mimdinareobs cxel da nestian adgilebSi, riTac aixsneba maTi sezonuri pikebi da siuxve aseT areSi.

obis sokoebi Zalze mcire zomisaa da, amitomac, Rrmad aRwevs respiratorul traqtSi. maT SeiZleba gamoiwvion rogorc riniti, aseve asTma. bavSvebi metad arian mgrZnobiareni obis sokos mimarT, vidre mozrdilebi, Tumca am movlenis mizezi jerjerobiT ucnobia.

ganasxvaveben sami ZiriTadi tipis obisa da safuaris sokoebs:

1. mTavari atmosferuli (kargareTa) obis sokoebia: Cladosporium

da Alternaria, romelTa piki aRiniSneba zafxulSi, aseve Aspergillus

da Penicillium, romelTac gansazRvruli sezoni ara aqvT. mniSvnelovania regionaluri gansxvavebebic28.

2. karSida obis sokoebi aseve Zalze mniSvnelovania. es mikroskopuli sokoebi mTeli wlis ganmavlobaSi gamoimuSaveben sporebs da ganapirobeben mTeli wlis maZilze simptomebis ganviTarebas, gansakuTrebiT Tbil da nestian garemoSi 29 . karSida obis sokoebi asocirebulia nestTan. maT aseve aqvT gamravlebis unari sahaero (magaliTad, centraluri gaTbobisa da kondicirebis) da wylis milebSi. isini uxvad binadroben saabazanoebsa da samzareuloebSi. obis sokoebi izrdeba aseve oTaxis mcenareebze, cxovelur an mcenareul narCenebze, avejis gadasafareblebze, Spalerze, leibebsa da rbil saTamaSoebze.

3. obis sokoebi (Penicillium, Aspergillus da Fusarium, iSviaTad ki Mucor) bunebrivad SeiZleba iyos sakvebSic, aseve danamatebSi, romlebic kvebis mrewvelobaSi gamoiyeneba. Tumca, am

15

alimenturi obis sokoebis rolis gansazRvra alergiis paTogenezSi rTulia.

II. safuaris sokoebi

yvelaze alergiul safuaris sokoebad iTvleba: Candida albicans,

Saccaromyces cerevisiae, Saccaromyces minor da Pityrosporum.

IgE-gaSualebuli mgrZnobeloba safuaris mimarT gansakuTrebiT mniSvnelovania atopiur dermatitebSi. safuaris sokoebis umravlesoba warmoadgens jvaredinad moreagire antigenebs. isini arseboben rogorc haerSi, aseve sakvebSic. Sporobolomyces

pasuxismgebelia rinitsa da asTmaze30.

III. Basidiomycetes da Ascomycetes.

maTi sporebi mravladaa haerSi da alergenebs warmoadgenen asTmisa da rinitis mqone pacientTaTvis, Mmagram maTi roli, rogorc atmosferuli alergenebisa, jerjerobiT bolomde gansazRvruli ar aris. aRsaniSnavia, rom zedapiruli sokoebis sporebiT gamowveuli profesiuli alergiebis SemTxvevebi arc Tu iSviaTia31.

mwerebi

mwerTa narCenebis inhalaciam SesaZloa gamoiwvios IgE-gaSualebuli respiraciuli alergiebi. wyvilfrTiani mwerebis hemoglobini an tropomiozini identificirebul iqna, rogorc alergenebi32.

alergeni aRmoCenilia taraknebis gastrointestinalur sekretsa da qitinis safarvelze. alergenebi warmodgenilia makronawilakebis saxiT, romlebic haeriT ar gadaitaneba. taraknebi grovebad binadroben bnel adgilebSi. dRisiT maTi gamoCena maT did raodenobaze metyvelebs. alergenebi Ceveulebriv mimofantulia aseT saxlebSi. maRali koncentraciiT is gvxvdeba did SenobebSi, qalaqis dasaxlebebSi, 1940 wlamde binebsa da dabali socialuri fenis adamianTa sacxovrebel binebSi. aseT pirobebSi taraknis alergenebma SeiZleba gamoiwvion mZime garTuleba - asTmac ki33.

sxva inhalaciuri alergenebi

baqteriebis alergiuli rolis Sefaseba amJamad Zalze rTulia. asTmisa da rinitebis calkeul SemTxvevebSi dadgenilia baqteriis mimarT specifikuri IgE-s arseboba. Tumca, baqteriuli warmoSobis da industriul sferoSi gamoyenebadi enzimebi SesaZloa iyos asTmis an rinitis xSiri gamomwvevi mizezi.

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Ficus benjamina, cnobili aseve, rogorc Java willow, Ceylon willow an Bali

fig tree, warmoadgens tropikul arayvavilovan mcenares, romelsac farTod aSeneben dekoratiuli mizniT saxlebsa da sazogadoebriv adgilebSi. dadgenilia Ficus - isa da lateqsis jvaredini reaqtiuloba. Cveulebriv, mcenaris wvenSi lokalizebuli alergenebi gvxvdeba aseve misi foTlebis zedapiridan mogrovil mtversa da saxlis iatakis mtverSi, sadac alergeni mcenaris gadaadgilebis Semdegac ki rCeba Tveebis ganmavlobaSi 34 . sxva dekoratiuli mcenarec SesaZloa potenciur alergens warmoadgendes.

sakvebismieri alergenebi:

sakvebismieri alergia iSviaTia sxva simptomebis gareSe mxolod alergiuli rinitis mqone pacientebSi. meores mxriv, riniti aris sakvebismieri alergiis Cveuli simptomi pacientebSi sxvadasxva organuli gamovlinebiT. 6 Tveze naklebi asakis CvilebSi alergiuli reaqciis mTavari mizezia Zroxis rZe an soios formula. Zroxis rZis mimarT alergiuli Cvilebis 50%-ze mets uvlindeba alergiuli riniti. mozrdilebSi gavrcelebuli alergenebia: araqisi, nigozi, Tevzi, kibosnairebi, kvercxi, rZe, soio, niaxuri, vaSlisa da atmismagvari xilis zogierTi saxeoba.

xil-bostneulis mimarT alergia TiTqmis yovelTvis ukavSirdeba mcenareuli mtvrisadmi alergias. magaliTad, yvelaze cnobili asociacia aryis xis mtvris da xilis (maT Soris vaSlis), bostneulisa da Txilis saxeobebs Soris 35 . antigenebis jvaredini reaqtiuloba gamovlenili iqna lateqssa da banans Soris, aseve wablsa da balaxeulis mtvers Soris. alergenebis identifikaciam xilsa da bostneulSi gviCvena maTi IgE-jvaredini reaqtiulobebi aryis xis mtvris Bet v 1 da Bet v 2 mniSvnelovan alergenebTan.

profesiuli agentebi

profesiuli respiratoruli daavadebebi (prd) moicavs asTmas, rinits, filtvis qronikul obstruqciul daavadebasa (fqod) da qronikul xvelas.

pnevmokoniozi da fibrozi sxva profesiuli respiratoruli daavadebebia, magram ar Sedis prd-Si. am oTx daavadebas bevri aqvs saerTo da, SesaZloa, mkveTri zRvris gavleba maT Soris rTulic iyos. ufro metic, profesiuli da araprofesiuli respiraciuli daavadebis mqone bevr pacients araerTi risk-faqtori gaaCnia, amitomac ar aris ioli daavadebis profesiuli warmoSobis dadastureba.

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klasifikacia da definicia: profesiiT ganpirobebuli riniti da asTma SeiZleba daiyos minimum or nozologiur erTeulad36:

profesiuli riniti da/an asTma, ganpirobebuli profesiuli agentebiT. profesiuli agentebi SesaZloa iyos alergenebi, gamaRizianebeli nivTierebebi an orive erTad.

asTma an riniti, romelic uaresdeba muSaobisas sxva mizezebis gamo (samuSao pirobebiT - gauaresebuli an gamwvavebuli asTma).

xSirad, da gansakuTrebiT maRalmolekuluri wonis gamaRizianebeli agentebis SemTxvevaSi, profesiuli riniti asTmis winapirobas warmoadgens.

profesiuli saqmianobiT ganpirobebuli xvela xSirad asocirebulia asTmasTan an fqod-Tan. fqod-s ar gaaCnia mkveTrad identificirebuli profesiuli klinikuri subkategoria, radgan viTardeba nela da ramodenime Tanmxlebi risk-faqtoris (umTavresad Tambaqos moweva) zemoqmedebiT. Tumca, zogierT pacients SesaZloa hqondes riniti, asTma da sxvadasxva xarisxiT gamoxatuli mravlobiTi profesiuli agentisa da ko-faqtorebis, (rogoricaa Tambaqos, karSida da gare alergenebis, upiratesad ki biosawvavis kvamlis) urTierTqmedebis Sedegad gamowveuli profesiuli respiraciuli daavadeba.

ZiriTadi profesiuli agentebi, romlebic iwveven rinitisa da asTmis ganviTarebas.

umravles qveynebSi asTmisa da rinitis gamomwvevi erTi da igive agentebi arian 37 : izocianidebi, fqvili da marcvleuli, mtveri, glutaraldehidi da anhidridebi, laboratoriuli cxovelebi, mwerebi, fisi da webo, lateqsi, liTonTa marilebi da persulfati.

mcire zomis ZuZumwovrebma SesaZloa gamoiwvion profesiuli sensibilizacia laboratoriis personalSi (gamovlenili pirebis 10-50%). ori gansxvavebuli sindromi iqna identificirebuli. pirveli – riniti kanis uaryofiTi prik-testiT; meore – riniti kanis dadebiTi prik-testiTa da asTmisken progresirebis tendenciiT. atopia da aqtiuri mweveloba warmoadgens laboratoriuli cxovelebis mimarT alergiis ganviTarebis risks. laboratoriuli cxovelebis mimarT alergiis ganviTarebis sixSire Zalze maRalia.

industriaSi gamoyenebuli rezinis lateqsis nakeTobebi miRebulia Hevea brasiliensis (Euphorbiaceae family)-dan. ramdenadac lateqsis warmoebaSi gamoyenebuli qimiuri danamatebi aris dayovnebuli tipis hipermgrZnobelobis (kontaqturi dermatiti) mizezi, IgE-gaSualebuli alergia bunebrivi kauCukis lateqs-proteinis mimarT seriozul problemas warmoadgens jandacvis muSakebisaTvis da

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sxva profesionalebisaTvis. lateqsis alergiis simptomebi moicavs kontaqtur dermatits, rinitsa da asTmas, zogjer ki anafilaqsias. kanis testebi da Sratis specifikuri IgE-s gansazRvra SeiZleba gamoviyenoT lateqs-alergiis diagnostikaSi. saWiroebis SemTxvevaSi SesaZloa gakeTdes provokaciuli sinjebi.

mcxobelebSi xSirad aRiniSneba asTma da riniti. sacxobis alergenebis (fqvili), enzimebis an narCenebis mimarT IgE-

sensibilizacia mcxobelTa asTmisa da rinitis ZiriTadi mizezebia.

IgE-gaSualebuli riniti da asTma SeiZleba gamowveuli iqnas mravali sxva maRalmolekuluri wonis alergeniT: soflis meurneobis tkipebiT, yavis marcvlebiT, proteolizuri fermentebiT, sxva enzimebiT, mwerTa narCenebiT, mcenareebiTa da yvavilebiT.

rinitisa da asTmis xelSemwyobi profesiuli agentebia: izocianidebi, aldehidebi, anhidridebi, anhidrini, farmacevtuli naerTebi da sxva. 250-ze meti qimiuri faqtori iqna identificirebuli. qloris msgavsi zogi naerTi iwvevs rinitis simptomebs masTan momuSave personalis 30-50%-Si38.

formaldehidi mcired aqroladi qimiuri naerTia, romelic farTod gamoiyeneba industriaSi da aseve medicinaSi sterilizaciisaTvis. maRali koncentraciiT toqsiuria da SeiZleba gamoiwvios gamaRizianebeli gverdiTi efeqtebi, magram is moqmedebs, rogorc reaqtiuli hapteni da SesaZloa gaxdes alergenic, rasac sabolood mivyavarT an IgE- gaSualebul reaqciasa an kontaqtur dermatitTan. Tumca IgE-gaSualebuli alergiuli reaqciebi, rogorc Cans, ufro metad viTardeba formaldehidis farmacevtuli miznebiT gamoyenebisas. saxlebSi, skolebsa Tu profesiul adgilebSi formaldehidi moqmedebs, rogorc gamaRizianebeli, magram ara yovelTvis39.

ganviTarebadi qveynebisaTvis specifikuri problemebi

wlebis win cnobili iyo, rom maRaroelebi, meSaxteebi da mdnobelebi avadoben pnevmokonioziT, rac xSirad asocirebulia tuberkulozsa da Tambaqos moxmarebasTan. mogvianebiT ganviTarebad qveynebSi gamovlinda asTmis, fqod-is, qronikuli xvelisa da/an rinitis profesiuli buneba 40 . profesiuli asTmis erTidaigive agentebi iqna aRmoCenili ganviTarebul da ganviTarebad qveynebSi, magram zogierTi agenti specifikuria ganviTarebadi qveynebisaTvis da maTi gamomJRavnebis donec Cveulebriv arakontrolirebadia, rac ganapirobebs daavadebis met sixSiresa da garTulebebs ganviTarebul qveynebTan SedarebiT. Tambaqos moxmareba, haeris dabinZureba, SesaZloa tuberkulozic da aseve maTi Sedegebi warmoadgenen erTmaneTTan dakavSirebul faqtorebs.

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garemos polutantebi

1970 wlamde evropasa da aSS-Si zamTris atmosferuli dabinZureba xSirad iwvevda mwvave sasikvdilo epidemiebs kardiovaskularuli da sasunTqi sistemis daavadebebis saxiT. am efeqtebis asaxsnelad mniSvnelovania gogirdis dioqsidis (SO2) maRali koncentracia da, aseve, nivTieri makronawilakebi qalaqebis haerSi, arasasurvel meteorologiur pirobebTan erTad. dasavleTis qveynebSi mniSvnelovnad Semcirda garemos samrewvelo dabinZureba fabrikebis kvamlsadeni milebidan efeqturi filtrebis meSveobiT, aseve, Semcirda sawvaviT dabinZureba, radgan benzini, miT umetes eleqtrooba, naklebad abinZurebs garemos. qalaqebis haeris dabinZureba mniSvnelovani problemaa bevr ganviTarebad qveyanaSi da ufro naklebad, ganviTarebul qveynebSi.

mTel msoflioSi KkarSida alergenebi, Tambaqos moxmareba da profesiuli faqtorebi umniSvnelovanesi problemaa. gazrdili reaqtiuloba gamaRizianebeli faqtorebisadmi aris fenotipuri maxasiaTebeli alergiuli da araalergiuli rinitisa, magram dabinZurebis roli rinitebis ganviTarebaSi dRemde kamaTis Temas warmoadgens.

kargareTa polutantebi alergiuli rinitebis ganviTarebaSi

dabinZureba, IgE sensibilizacia da rinitis sixSire. epidemiologiurma kvlevebma aCvena, rom zogadad alergiuli rinitebi da polinozi, gansakuTrebiT iaponuri kedris mtvris mimarT, farTodaa gavrcelebuli intensiur saavtomobilo moZraobaTa teritoriaze. yvavilis mtvris mimarT sensibilizacia gansakuTrebiT izrdeba satvirTo avtomobilebis gadaadgilebis areebSi41.

wiaRiseuli sawvavis namwvi produqtebi SesaZloa moqmedebdes, rogorc adiuvantebi imunur sistemaSi da ganapirobon alergiuli anTebis zrda. am meqanizmiT, dizelis gamonabolqvi SeiZleba asTmisa da alergiuli rinitis sixSiresa da avadobis zrdis xelSemwyobi iyos. dizelis gamonabolqvis nawilakebi, rogorc Cans, mimarTavs imunur pasuxs IgE produqciisaken da iwvevs alergiul anTebas.

kargareTa haeris polutantebis mwvave efeqtebi. kargareTa agentebis-gazebisa Tu kvamlis mwvave efeqtebi ar aris zustad Seswavlili nazalur simptomebTan mimarTebaSi. amJamad arsebuli ramodenime kvleva aracalsaxa daskvnas gvaZlevs rinitis simptomebis gaxSirebasa da alergiuli rinitebis gamo konsultaciebis ricxvis zrdaze dabinZurebis pikis periodSi. dabinZureba da meteorologiuri faqtorebi mWidro kavSirSia

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araalergiuli, arainfeqciuri, wlis manZilze mimdinare rinitis mqone pacientTa Civilebis gamovlenasTan42.

kargareTa haeris polutantebis qronikuli efeqtebi. Seswavlil iqna atmosferuli polutantebis qronikuli efeqtebi, magram garda PM-is cnobili zemoqmedebisa qveda respiratorul traqtze, gansazRvruli Sedegebi ver iqna miRebuli.

rogorc mexikos gamokvlevebma cxadyo, dabinZureba nazaluri simptomebis mniSvnelovan mizezs warmoadgens araalergiul pacientebSi43.

erT-erTi kvlevis monacemebiT, pacientebs, romlebic cxovrobdnen gadatvirTuli saavtomobilo moZraobis areebSi, aReniSnebodaT rinitisa da koniunqtivitis ufro Zlieri simptomebi, vidre araintensiuri moZraobis zonaSi mcxovreblebs. haeris dabinZureba, rogorc Cans, ainducirebs alergiuli rinitis simptomebs44.

karSida haeris dabinZureba.

ganviTarebuli qveynebi. es faqtori aqtualuri gaxda mas Semdeg, rac industriul qveynebSi samuSao saaTebis 80%-ze mets SenobaSi atareben. Sesabamisad, adgili aqvs oTaxis alergenebisa da karSida airebis zemoqmedebas, romelTa Soris gansakuTrebiT mniSvnelovania Tambaqos kvamli45. sxva polutantebidan aRsaniSnavia sawvavis an xis wvis produqtebi, (maT Soris naxSirbadis oqsidi, NO, PM, VOC, SO2), roca SenobaSi aris Sesabamisi Rumeli. zogierT kvlevaSi gamovlinda uaryofiTi kavSiri saxlSi xis an qvanaxSiris Rumelis gamoyenebasa da atopiur sensibilizaciasa da alergiul rinitTan bavSvTa asakSi.

gazis Rumelebmac SesaZloa ganapirobos respiratoruli simptomebi, gansakuTrebiT qalebSi da atopiur pirebSi.

ganviTarebadi qveynebi: biosawvavis gamoyeneba ganviTarebadi qveynebisaTvis sakmaod did problebas warmoadgens. daaxloebiT 2 miliardi adamiani, umTavresad ganviTarebad qveynebSi, saxlebSi energiis wyaros mizniT qvanaxSirsa da xes iyenebs. es masalebi gamoyofs arasruli wvis produqtebs. Sedegad, qalebi da bavSvebi dRis ganmavlobaSi imyofebian KkarSida dabinZurebuli haeris zemoqmedebis qveS. xolo weliwadSi aRiniSneba 1,5-2,0 milioni naadrevi sikvdilianoba da fqod-is maRali sixSire. Aam SemTxvevebSi mwiri informacia moipoveba alergiul rinitze.

Tambaqo

IgE-sensibilizacia. alergiuli rinitis mqone bevri pacienti Tambaqos mwevelia. mweveloba aramudmivad zrdis saerTo da specifikuri IgE-s dones da IgE-damokidebul sensibilizacias profesiuli agentebis mimarT. Tumca, xangrZlivi kvlevebis

21

ararsebobis gamo Znelia dadgena, romel SemTxvevebSia Tambaqo alergiis gamomwvevi46.

Tambaqos moxmareba prenatalur da adreul postnatalur periodebSi zrdis sensibilizacias zogierT jgufSi, magaliTad, biWebSi pirveli 3 wlis ganmavlobaSi.

Tambaqos moxmarebasa da alergiuli rinitis sixSires Soris urTierTkavSiris dasadgenad jerjerobiT sakmarisi kvlevebi ar arsebobs. sam kvlevaSi, TviTaRmocenebuli nazaluri alergiis simptomebis sixSire mwevelebSi naklebi iyo aramwevelebTan SedarebiT. kvlevam, romelSic mozardebi iyvnen CarTuli, aCvena, rom Tambaqos moxmareba zrdida rinokoniunqtivitebis raodenobas. meores mxriv, ar iqna dadasturebuli saxlSi Tambaqos kvamlis gavlena alergiul sensibilizaciaze an alergiuli rinitis ganviTarebaze.

Tambaqos moxmarebis zegavlena nazalur simptomebze: dadgenilia, rom mwevelobis intensivobasTan erTad izrdeba qronikuli rinitebis gamovlineba, iseve, rogorc rinorea da/an nazaluri obstruqcia. Tambaqos moxmarebam SesaZloa Secvalos mukociliaruli klirensi da gamoiwvios eozinofiluri da cxviris lorwovanis ,,alergiulis msgavsi” anTeba araatopiur bavSvebSi. zogierT pacientTan alergiuli rinitiT aqtiuri an pasiuri mweveloba iwvevs.

pasiuri mweveloba SesaZloa asocirebul iyos nazalur simptomebTan, magram kvlevebi yovelTvis amas ar adasturebs. rigi kvlevebis mixedviT, moweva saxlSi Zlier aris asocirebuli dabali saskolo asakis bavSvebSi asTmisa da rinitis simptomebTan.

alergiuli rinitis ganviTarebis meqanizmebi

alergiuli riniti klasikurad ganixileba, rogorc IgE-gaSualebuli pasuxi asocirebuli sxvadasxva intensivobis nazalur anTebasTan. ujredebi, mediatorebi, citokinebi, qemokinebi, neiropeptidebi, iseve, rogorc adheziuri molekulebi da ujredebi, urTierTqmedeben kompleqsurad da iwveven specifikur simptomebsa da araspecifikur nazalur hiperreaqtiulobas.

daavadebis meqanizmebis codna mniSvnelovania racionaluri Terapiis SemuSavebisaTvis, romelic dafuZnebuli iqneba kompleqsur anTebiT reaqciaze da ara mxolod simptomebze.

IgE-gaSualebuli meqanizmebi: alergia ZiriTadad ganpirobebulia IgE-s mdgradi, Warbi produqciiT zogadad garemos antigenebis mimarT, rogoricaa: karSida da kargareTa alergenebi, sakvebi da sxva alergenebi 47 . IgE TavisTavad adamianis SratSi warmoqmnis

22

totaluri antisxeulebis Zalze mcire fraqcias (50–300 ng/ml IgE vs 10 mg/ml IgG). Tumca IgE-s biologiuri aqtivoba mkveTrad izrdeba specifikuri ujredebis zedapiruli receptorebis aqtivobis Sedegad, romelTac igi ukavSirdeba da romelic, SesaZloa, maTTan dabali an maRali fenotipuri msgavsebis iyos.

IgE-s produqcia aris alergenebisaB da T – ujredebis, poxieri ujredebisa da bazofilebis kompleqsuri urTierTqmedebis Sedegi, procesSi interleikinebis IL-4, IL-13 da IL-18 CarTviT.

warmodgena lokaluri IgE-s produqciaze 40 welze metia kargadaa cnobili. didi xnis ganmavlobaSi, IgE-s maproducirebel B –ujredebze dakvirveba xdeboda lokalur limfoidur qsovilSi. Tumca aRmoCnda, rom IgE producireba xdeba lokalur limfoidur qsovilebSi da lokalurad cxvirisa da bronqebis lorwovanSi. persistuli alergiuli rinitis dros IgE sinTezirdeba cxviris lorwovanSi yvavilovani sezonis ganmavlobaSi da mis Semdgomac48.

alergen-specifikuri IgE, romelic sinTezirebulia alergenebis sapasuxod, fiqsirdeba poxieri ujredebisa da bazofilebis membranebis FceRI-ze. poxieri ujredebis akumulacia sasunTqi gzebis lorwovanSi mniSvnelovani paTofiziologiuri movlenaa alergiuli rinitsa da asTmis dros, ramdenadac CasunTquli alergenebi moqmedeben cxvirisa da/an filtvebis lorwovan zedapirebze. receptor-dakavSirebuli IgE-s molekulebis specifikuri alergenebis mimarT agregacias Sedegad mohyveba mediatorebis (histamini, leikotrienebi da a. S.) gamoTavisufleba, rac ganapirobebs alergiul pasuxs. dauyovnebeli pasuxi damokidebilia samizne organos struqturaze da vlindeba qavilis, ceminebis, rinoreisa da cxviris gaWedvis, bronqokonstriqcisa da mstvinavi sunTqvis saxiT.

mogvianebiTi fazis alergiul reaqciebi ganapirobebs qronikul anTebiT cvlilebebs T-ujredebis, poxier ujredebisa da eozinofilebis monawileobiT. IgE-damokidebul reaqciasa da rinits an asTmas Soris kavSiri dadgenil iqna anti-IgE monoklonuri antisxeulebis gavleniT am daavadebaze49.

dauyovneblivi da mogvianebiTi IgE-gaSualebuli anTebis meqanizmi da asocirebuli simptomebi asaxulia me-3 suraTze.

ara IgE-gaSualebuli meqanizmebi: Th2 imunuri pasuxis Sedegad gamoTavisufldeba citokinebi da qemokinebi, rac ainducirebs sasunTqi gzebis anTebas IgE-s damoukideblad. ufro metic, Der p 1-s SeuZlia Secvalos epiTeluri Sesqelebuli zedapirebi, amavdroulad epiTelis SeRwevadobis gazrdiT 50 . ara-IgE da IgE–gaSualebuli meqanizmebis SedarebiTi mniSvneloba sabolood garkveuli ar aris.

23

cxviris lorwovanis anTebis roli alergiul rinitSi: yvavilis mtvriT ganpirobebuli riniti IgE-gaSualebuli alergiuli daavadebis yvelaze metad damaxasiaTebeli mdgomareobaa. cxviris lorwovanis ujreduli infiltraciis gamokvlevam aCvena, rom izrdeba sxvadasxva anTebiTi ujredebis raodenoba, rac korelaciaSia simptomebis simZafresTan da araspecifikur hipereaqtiurobasTan 51 . eozinofilebi umTavresad vlindeba lorwovanSi, aradesqvamirebul epiTelur ujredebs Soris, submukozasa da nazalur sekretSi;

karSida alergiis SemTxvevaSi nazaluri eozinofilia ar vlindeba permanentulad - lorwovanSi poxieri ujredebi yovelTvis momatebuli ar aris.

mniSvnelovania warmodgena ,,minimaluri persistuli alergiuli rinitis anTebaze" 52 . pacientebSi persistiuli alergiuli rinitiT alergiuli gamovlinebis intensivoba meryeobs wlis ganmavlobaSi da aris periodebi, rodesac gamovlineba minimaluria. Tundac simptomebis arqonis drosac ki aseT pacientebSi aRiniSneba cxviris lorwovanis anTeba.

24

suraTi 3. alergiuli rinitis meqanizmi.

anTebis ujredebi: anTebiTi infiltratis CamoyalibebaSi monawileoben sxvadasxva ujredebi. poxieri ujredebi ara marto adreuli fazaSi monawile ujredebia, aramed did rols TamaSoben alergiuli anTebis procesSic. eozinofilebi warmoiSoba winapari ujredebisagan cxviris lorwovanSi yvavilobis sezonze. maTi raodenoba da aqtivacia cxviris lorwovanSi maRalia simptomuri alergiuli rinitebis SemTxvevaSi.

T-ujredebi, makrofagebi, fibroblastebi da sxva ujredebi monawileoben cxviris lorwovanis anTebiTi infiltratis warmoqmnaSi alergiuli rinitis mqone pacientebSi.

ujreduli pasuxis gamoxatulebaa:

qemotaqsisi, ujredebis seleqtiuri dajgufeba da trans-endoTeluri migracia53;

anTebiTi ujredebis migracia cxviris lorwovanis sxvadasxva nawilebSi;

sxvadasxva tipis ujredebis aqtivacia da diferenciacia;

alergeni

eozino-filebi

B ujredebi

T ujredebi

poxieri ujredebi

rinitis mwvave simptomebi

qavili, cemineba;

wylisebri rinorea

cxviris gaWedva

rinitis qronikuli simptomebi

cxviris blokada

cxviris hiper-reaq tiuloba

VCAM-1

IL-4

GM-CSF

IL-3, -5

histamini triptaza leikotreinebi prostaglandinebi bradikinini PAF IgE

25

am ujredebis sicocxlisunarianobis gaxangrZliveba;

gaaqtiurebuli ujredebidan mediatorebis gamoTavisufleba;

lokaluri da sistemuri IgE-s sinTezi;

kavSiri imunur sistemasa da Zvlis tvins Soris.

mediatorebi: rigi mediatorebisa gamoiyofa nazalur sekretSi yvavilis mtvris mTeli sezonis ganmavlobaSi.Ees moicavs CysLT, ECP da aramudmivad, histamins54 55 56.

citokinebi, qemokinebi, neiropeptidebi, adheziuri molekulebi da ujredebi kompleqsurad moqmedebis Sedegad iwveven alergiuli rinitebis specifikur simptomebsa da araspecifikur hiperreaqtiulobas. cisteinuri leikotrienebi - anTebiTi lipiduri mediatorebis ojaxidan, sinTezirdebian araqidonis mJavidan sxvadasxva ujredebis: poxier ujredebis, eozinofilebis, bazofilebisa da makrofagebis mier, romlebic asruleben alergiuli rinitebis multifunqciuri mediatorebis rols.

neirogenuli mediatorebi. cxvirs gaaCnia dacviTi da homeostazuri funqciebi, rac ganapirobebs swraf reaqcias fizikur da qimiur stimulebze. Sedegad, is SeiaraRebulia kompleqsuri nervuli sistemiT, rac moicavs: sensorul, parasimpaTikur da simpaTikur nervebs. sensoruli nervebi agzavnian signals lorwovanidan, rac iwvevs iseT SegrZnebebs, rogoricaa qavili, cemineba da parasimpaTikur da simpaTikur refleqsebs, romlebic gavlenas axdens cxviris jirkvlovan da vaskularul organoebze. cxvirisken mimarTuli refleqsebi SesaZloa sxeulis sxva regionebidanac momdinareobdes. maSasadame, yvela simptomi, romelic qmnis rinitis nozologias, SeiZleba provocirebul iqnas nervuli gzebiT. neirotropinebi, rogoricaa nervis zrdis faqtori, nervuli hipermgrZnobelobis umniSvnelovanes mediatorebs warmoadgenen57.

remodelirebis procesebi. alergiul rinitis mimdinareobisas am procesebis roli bolomde garkveuli ar aris.

alergiuli rinitis mqone pacientebSi epiTelis dazianeba mxolod minimaluria. wlis manZilze mimdinare rinitis mqone ramodenime pacientis nazalur bioptatSi nanaxi iqna epiTeluri ujredebis metaplazia. miuxedavad imisa, rom cxvirisa da bronqebis lorwovani garemos erTnair mavne zemoqmedebas ganicdis, epiTelis cvlilebebi ufro aSkaraa asTmisa da rinitis mqone pacientis bronqebSi, vidre cxvirSi.

nazaluri hiperreaqtiuloba da araspecifikuri trigerebi

araspecifikuri nazaluri hiperreaqtiuloba alergiuli da araalergiuli rinitebis mniSvnelovani maxasiaTebelia da SesaZloa ganisazRvros, rogorc momatebuli nazaluri pasuxi Cveulebriv

26

gamRizianeblebze, rasac mohyveba cemineba, cxviris gaWedva da sekrecia izolirebulad an erTmaneTTan kombinaciaSi.

es fenomeni SesaZloa gamomJRavndes nazaluri stimulaciis Semdeg, rogoricaa58:

cxviris lorwovanis gaTboba;

cxviris lorwovanze civi haeris zemoqmedeba, romelsac SeuZlia anTebiTi sapasuxo reaqciis gamowveva poxieri ujredebis aqtivaciiTa da gviani-fazis reaqciis gamovlinebiT;

cxviris lorwovanze histaminiT an metaqoliniT zemoqmedeba;

akrolini;

kafsaikini;

mZafri suni;

pozis cvlileba;

sxeulis temperaturis cvlileba;

cxeli sasmelebis miReba.

4. klinikuri simptomatika

simptomebi

alergiuli rinitis tipiuri simptomebia: wyliseburi wina rinorea, cxviris gaWedva, cxvirisa da sasis qavili, cemineba, gansakuTrebiT paroqsizmuli, da koniunqtiviti.

pacientis simptomebTan erTad unda Sefasdes daavadebis gavlena cxovrebis xarisxsze. rogorc simptomebis, aseve cxovrebis xarisxis Sesafaseblad SesaZloa vizualuri analogiis Skalebis gamoyeneba. aRniSnuli Skalebi damxmarea rogorc daavadebis klasificirebisaTvis, aseve mkurnalobis Sedegis Sesafaseblad (ix. suraTi 4).

27

suraTi 4

vizualuri analogiis Skala

garTulebebi

alergiuli rinitis SesaZlo garTulebebis nusxa mocemulia me-2 cxrilSi.

cxrili 2 alergiuli rinitis garTulebebi

garTuleba mozrdili bavSvi asTmis gamwvaveba X X saxis zrdis deviacia X Hiposmia X X wina kbilebis protruzia X malokluzia (sasis maRali TaRi, Tankbilvis darRveva)

X

nazaluri polipebi X ? Sua yuris anTeba gamonadeniT X X Sinusiti X X Zilis darRveva X X X – SesaZlo; ? – gaurkveveli

alergiuli rinitis gavlena asTmaze

epidemiologiuri da paTogenezuri kavSiri kavSiri asTmasa da rinits Soris:

alergia asocirebulia rinitTanac da asTmasTanac;

pacientTa umravlesobas asTmiT aqvs aseve alergiuli riniti;

rinitis mqone bevr pacients aqvs asTma;

asTmis ganviTarebis riski izrdeba rinitis dros, gansakuTrebiT persistuli rinitis da/an saSualo/mZime mimdinareobis mqone alergiuli rinitis dros;

profesiul agentebs SeuZliaT gamoiwvion rogorc riniti, aseve asTma;

saerTod ar aris Semawuxebeli

10 sm ukiduresad Semawuxebelia

28

riniti, SesaZloa asocirebuli iyos bronqebis araspecifikur hiperreaqtiulobasTan;

rinitis Tanaarseboba auaresebs asTmis kontrols;

bevr pacients asTmiT aReniSneba CT kvleviT dadasturebuli rinosinusiti da am ori daavadebis simZime xSirad korelirebs;

asTmis mqone pacietebs aReniSnebaT eozinofiluri infiltracia rogorc bronqebis lorwovanSi, aseve cxviris Rrus lorwovanSi59;

aRniSnuli epidemiologiuri da paTogenezuri monacemebis gaTvaliswinebiT, alergiuli rinitis mqone yvela pacientTan kiTxvaris saSualebiT unda Sefasdes asTmis arseboba, xolo diagnostirebuli asTmis SemTxvevaSi – misi kontrolis xarisxi (ix. suraTi 5).

suraTi 5 asTmis arsebobisa da kontrolis Sefaseba.

pacientma ar icis, aqvs Tu ara asTma

gqoniaT Tu ara mstvinavi sunTqvis 1 an rekurentuli Setevebi;

gqoniaT Tu ara Semawuxebeli xvela, gansakuTrebiT RamiT;

gaqvT Tu ara xvela an mstvinavi sunTqva fizikuri datvirTvis Semdeg;

gaqvT Tu ara gul-mkerdis areSi SeboWvis SegrZneba.

Tu erT kiTxvaze mainc aris dadebiTi pasuxi, pacients SesaZloa hqondes asTma.

Tu erT kiTxvaze mainc aris dadebiTi pasuxi, pacients aqvs arakontrolirebuli asTma.

gqoniaT Tu ara Zilis problemebi asTmis simptomebis gamo?

gaqvT Tu ara asTmis simptomebi dRis manZilze?

giSliT Tu ara asTma xels yoveldRiuri aqtivobebSi?

gWirdebaT Tu ara damatebiT simptomebis makontrolebeli inhalatoris moxmareba dReSi 1-ze metad?

pacients dadgenili aqvs asTma

referali alergologTan

29

rinitisa da asTmis mkurnaloba – erTiani midgoma

pacientebs, romelTac aqvT asTma da alergiuli riniti, da aqvT SesaZlebloba umkurnalon alergiis orive manifestacias, asTmis mkurnalobasTan erTad unda CautardeT alergiuli rinitis mkurnalobac.

oraluri H-1 antihistaminebi ar aris rekomendebuli asTmis samkurnalod, magram arc ukunaCvenebia60.

intranazaluri glukokortikosteroidebi saSualoze metad axdens efeqts asTmaze61;

intrabronquli glukokortikosteroidebis gavlena alergiul rinitze cnobili ar aris62;

montelukasti efeqturia rogorc asTmis, aseve alergiuli rinitis samkurnalod mozrdilebSi da 6 Tveze ufros bavSvebSi63;

kanqveSa imunoTerapa rekomendebulia rogorc mozrdilebSi, aseve bavSvebSi, magram axasiaTebs gverdiTi movlenebi, gansakuTrebiT asTmis mqone pacientebSi 64;

anti-IgE monoklonuli antisxeulebi efeqturia orive daavadebis dros65

5. daavadebis diagnozi

sadiagnozo kriteriumebi

alergiuli rinitis diagnozi dafuZnebulia tipiuri alergiuli simptomebis arsebobasa da diagnostikuri testebis erTobliobaze.

alergiuli rinitis tipiuri simptomebia: rinorea, cemineba, cxviris gaWedva, qavili;

alergiul rinits xSirad Tan axlavs alergiuli koniunqtivitis simptomebi (C), Tvalis simptomebi xSiria gansakuTrebiT im pacientebSi, romelTac aReniSnebaT mcenaris mtvriT inducirebuli alergiuli riniti66;

ZiriTadi diagnostikuri testebi dafuZnebulia alergen-specifikuri IgE-s demonstrirebaze kanze (kanis testebi), an sisxlSi (Sratis specifikuri IgE);

alergiuli rinitis diagnozis dasadastureblad totaluri saerTo IgE-s gansazRvra ar aris informatiuli67;

30

zogierT asimptomur pacients aReniSneba dadebiTi kanis testebi da Sratis specifikuri IgE-s momateba, aqedan gamomdinare, specifikuri IgE-s momateba alergiuli rinitis sadiagnozod ganxiluli unda iqnas mxolod klinikur konteqstSi;

pacientebi persistuli alergiuli rinitiT an mZime/saSualo simptomebiT saWiroeben detalizebul alergologiul kvlevas/diagnozs.

anamnezi

daavadebis anamnezi mniSvnelovania rogorc diagnozis dasasmelad, aseve alergiuli rinitis simZimisa da mkurnalobaze pasuxis Sesafaseblad.

qvemoT mocemulia klinikur simptomebze dafuZnebuli kiTxvari, romlis saSualebiTac SesaZlebelia garkveva, gagrZeldes kvleva alergiuli rinitis diagnozis dasadastureblad, Tu, aRniSnuli diagnozi naklebad savaraudoa (ix. cxrili 3)

cxrili 3 alergiuli rinitis klinikur simptomebis Sesafasebeli kiTxvari (Allergic rhinitis management pocket reference 2008, World Organization of Family

Doctors ) alergiuli rinitis simptomuri kiTxvari 1. gaqvT Tu ara qvemoT CamoTvlili simptomebi? pasuxi simptomebi mxolod cali nestodan (unilateraluri simptomebi)

diax ara

sqeli, yviTeli an mwvane gamonadeni cxviridan diax ara postnazaluri wveTva sqeli lorwoTi an rinoreiT diax ara saxis tkivili diax ara ganmeorebiTi sisxldena cxviridan diax ara ynosvis dakargva diax ara 2. gqoniaT Tu ara erT-erTi qvemoT CamoTvlil simptomTagan minimum 1 saaTis manZilze umravles dReebSi (an umravles dReebSi sezonze, Tu simptomebi sezonuria)?

wyliseburi rinorea diax Ara cemineba, gansakuTrebiT Zlieri an Setevis saxiT diax Ara cxviris gaWedva diax Ara cxviris qavili diax Ara koniunqtiviti (Tvalis gawiTleba, qavili) diax Ara

31

kiTxvaris Sedegebis Sefaseba

pirvel kiTxvaSi aRwerili simptomebi ar aris damaxasiaTebeli alergiuli rinitisaTvis. nebismier simptomze dadebiTi pasuxis SemTxvevaSi gaiTvliswineT sxva diagnozis arsebobac da/an ganaxorcieleT referali otorinolaringologTan.

SeniSvna: Cirqovani gamonadeni, postnazaluri wveTva, saxis tkivili, ynosvis dakargva damaxasiaTebelia sinusitebisaTvis. imis gaTvaliswinebiT, rom pacientTa did nawils sinsusitTan erTad aseve aReniSneba rinitic (ara yovelTvis alergiuli), am situaciaSi aseve unda Sefasdes alergiuli rinitis arseboba.

meore SekiTxvaSi aRwerili simptomebi tipiuria alergiuli rinitisaTvis.

wyliseburi rinoreis arsebobisas sxva 1 an 2 simptomTan erTad maRalia alergiuli rinitis diagnozis albaToba.

pacients mxolod wylisebri rinoreiT SeiZleba hqondes alergiuli riniti, (gasaTvaliswinebelia, rom zog SemTxvevaSi cxviris gaWedvac SesaZlebelia alergiuli rinitis erTaderTi simptomi iyos).

sufTa, refraqtoruli rinorea, gansakuTrebiT travmis an qirurgiuli Carevis Semdgom periodSi, SesaZloa, cerebro-spinaluri siTxis dinebas warmoadgnedes.

Tu pacients aqvs cemineba, cxviris qavili da/an koniunqtiviti, magram ara aqvs wylisebri rinorea, gaiTvliswineT sxva diagnozis arsebobac da/an ganaxorcieleT referali otorinoltaringologTan, ofTalmologTan, alergologTan.

im SemTxvevaSi, Tu mozrdil pacients aReniSneba gvian dawyebuli riniti, ivaraudeT pofesiuli mizezebis arseboba. profesiuli rinitebi xSirad win uZRvis an Tan axlavs profesiuli asTmis ganviTarebas. profesiul paTologiaze saeWvo pacientebi unda gaigzavnon specialistTan Semdgomi gamokvlevisa da SefasebisaTvis.

alergiuli rinitis damaxasiaTebeli sxva simptomebi da niSnebi:

mniSvnelovani hiposmia an anosmia sakmaod iSviaTia alergiuli rinitis dros, ufro xSirad SesaZlebelia Segvxvdes zomieri hiposmia68;

SesaZlebelia aRiniSnebodes xvrinva, Zilis problemebi69;

32

SesaZloa postnazaluri wveTva an qronikuli xvela, gansakuTrebiT qronikuli rinosinusitis Tanaarsebobis dros70;

rinitis dros SesaZlebelia iyos sedacia71;

mcenaris mtvriT inducirebuli rinitebis mqone pacientTa umravlesobas aseve aReniSneba koniunqtiviti. alergiuli koniunqtivitis simptomebze dafuZnebuli dif-diagnozis sqema72 ix. suraTze 6.

ojaxuri anamnezi

asTmis, atopiis an alergiuli rinitis ojaxuri anamnezi metad savaraudos xdis alergiuli rinitis diagnozs

socialuri anamnezi

savaraudo alergenis dasadgenad aucilebelia sacxovrebeli da samuSao pirobebis gamokiTxva, cxovelebTan kontaqtis arsebobis dadgena, patara bavSvebTan – kvebis detalebis dadgena.

33

suraTi 6 alergiuli koniunqtivitis simptomebze

dafuZnebuli diagnostikuri sqema

medikamenturi anamnezi

mniSvnelovania detaluri medikamenturi anamnezis Sekreba imis gaTvaliswinebiT, rom rigi medikamentebisa iwvevs rinitis simptomebs (ix. cxrili 1).

obieqturi Sefaseba

nazalur simptomebs, alergiuli rinitis garda, mravali sxva daavadeba iwvevs (ix cxrili 1), maT Soris sistemuri daavadebebic, amas garda, aucilebelia komorbiduli daavadebebis arsebobis gaTvaliswinebac. aqedan gamomdinare, pacienti nazaluri simptomebiT srulad unda iqnes gamokvleuli.

simptomebi, romlebic miuTiTeben alergiul koniunqtivitze

1 an meti simptomi minimum 1 saaTis manZilze umravles dReebSi (an umravles dReebSi sezonze, Tu simptomebi sezonuria)

rinitTan asocirebuli simptomebi;

bilateraluri Tvalis simptomebi;

Tvalebis qavili;

wiTeli Tvali;

fotofobiis ararseboba.

1 an meti qvemoT CamoTvlil simptomTagan:

simptomebi, romlebic ar asocirdebian rinitTan;

unilateraluri simptomebi;

Tvalebis wva, magram ara qavili;

mSrali Tvali;

fotofobia.

simptomebi, romlebic ar miuTiTeben alergiul koniunqtivitze

simptomebi Semawuxebelia?

diax referali specialistTan

34

zogadi dakvirveba: saxis sifermkrTale, upiratesad piriT sunTqva, sistemuri daavadebis nebismieri gamovlineba.

Tvalebi: Warbi cremldena, koniuqtivas eriTema, tarzaluri koniunqtivas marcvlovneba, quTuToebis SeSupeba an dermatiti, venuri stazi qveda quTuTos qveS (alergiuli brwyinvaleba).

cxviri: gadamkveTi horizontaluri xazebi (alergiuli rinitis damaxasiaTebeli), cxviris deformacia, mag. unagiriseburi cxviri, Zgidis gamrudeba an perforacia, osteofitebis arseboba, wylulebi lorwovanze, eqskoriaciebi an gaZlierebuli sisxlmomarageba, cxviris niJarebis hipertrofia, SeSupeba, sifermkrTale an eriTema, gamonadeni – feri, konsistencia, mxareoba, raodenoba), polipebi, aseve, ucxo sxeuli an simsivne (rinoskopiiT).

yurebi: dafis apkis eriTema, retraqcia, perforacia (otoskopiiT).

pir-xaxa: halitozi, Tankbilvis darRveva, maRali sasis rkali, tonzilebis an adenoidebis hipertrofia, faringialuri postnazaluri Camonadeni, lorwovani garsis mdgomareoba.

yeli: limfadenopaTia, farisebri jirkvlis gadideba an tkivili.

gul-mkerdi: gul-mkerdis kedlis deformacia an tkivili, asTmis niSnebi, auskultacia-perkusiiT - paTologiuri xmianoba.

muceli: mtkivneuloba, daWimuloba, RviZlis an elenTis gadideba.

kani: gamonayari, gansakuTrebiT egzematozuri an urtikariuli, an dermografizmi.

diferenciuli diagnozi

alergiuli rinitisaTvis damaxasiaTebeli simptomebi msgavsia sxva daavadebebis simptomebisa, rogoricaa persistuli araalergiuli riniti eozinofiliis sindromiT, nazaluri polipozi, virusuli infeqcia, qronikuli rinosinusiti, da sxva. I cxrilSi mocemulia araalergiuli rinitis SesaZlo gamomwvevi trigerebis nusxa da damaxasiaTebeli klinikuri niSnebi.

diferenciuli diagnozis gatarebisas gasaTvaliswinebelia, rom pacientTa 44-88%-s aReniSneba alergiuli da araalergiuli rinitis kombinacia da kombinirebuli rinitebi ufro xSiria, vidre calke alergiuli an araalergiuli riniti (C).

persistuli araalergiuli riniti eozinofiliiT - heterogenuli sindromia da moicavs minimum 2 qvejgufs: araalergiul rinits eozinofiluri sindromiT da aspirinze hipermgrZnobelobas 73 . aralergiuli riniti eozinofiluri sindromiT SesaZloa

35

ganvixiloT, rogorc idiopaTuri riniti, romelis alergiuli genezi ar dasturdeba da xasiaTdeba nazaluri eozinofiliiT da persistuli simptomebiT – cemineba, qavili, rinorea da iSviaTad ynosvis dakargva. asTmis ganviTareba ar aris damaxasiaTebeli, magram pacientTa naxevars aReniSneba araspecifikuri bronquli hiperreaqtiuloba 74 . rig SemTxvevebSi araalergiuli eozinofiluri riniti SesaZloa warmoadgendes aspirinze hipermgrZnobelobis adreul stadias. araalergiuli eozinofiluri rinitis SemTxvevaTa 50%-Si ki mogvianebiT viTardeba aspirinze hipermgrZnobeloba asTmiTa da nazaluri polipoziT75.

36

suraTi 6 alergiuli rinitis simptomebze

dafuZnebuli dif-dianozis algoriTmi

nazaluri polipozi - alergiuli riniti xSirad TandarTulia nazaluri polipoziT, Tumca alergia, rogorc polipozis mizezi, ar aris dadasturebuli. nazaluri polipozi sakmaod xSiri paTologiaa da Cveulebriv, viTardeba 40 wlis Semdeg 76 . polipebis qsovilSi aRiniSneba eozinofilebis arseboba. aspiriniT gamwvavebuli respiraciuli daavadeba - aspirinuli triada moicavs

diax ara

simptomebis aRmoceneba sezonurad wlebis manZilze Seferili

gamonadeni da/an saxis tkivili

naklebad savaraudoa, rom pacienti alergiuli iyos

daadastureT alergiuli rinitis diagnozi kanis testebiT da/an Sratis specifikuri Ig-E-Ti

bilateraluri Tvalis simptomebi: qavili cremldena siwiTle

postnazaluri wveTva

cxviris gaWedva

daadastureT rinosinusitis diagnozi gamosaxulebiTi kvleviT

eWvi miitaneT qronikul rino-sinusitze

pacienti SeiZleba

alergiuli iyos

pacienti, savaraudod, alergiulia

pacienti, maRali albaTobiT, alergiu lia

+

+

+

+

+

wyliseburi wina rinorea da cemineba

37

nazalur polipozs, acetilsalicilis mJavisadmi intolerantobas da asTmas da aRiniSneba pacientTa 13 – 40%-Si77 78.

qronikuli rinosinusiti praqtikosma eqimma unda gaiTvaliswinos, rom alergiuli rinitis diagnozi ar gamoricxavs qronikuli rinosinusitis arsebobasa da piriqiT. araerTi epidemiologiuri kvleva adasturebs sensibilizaciis maRal prevalenss qronikuli rinosinusitis dros 79 80 . qronikuli rinosinusitisaTvis damaxasiaTebeli simptomebia saxis tkivili an simZimis SegrZneba, Cirqovani gamonadeni cali an orive nestodan, SesaZloa iyos cxeleba an xvela, xSirad viTardeba virusul infeqciis an alergiis gamwvavebis fonze, simptomebis intensivoba talRiseburad icvleba, axasiaTebs qronikuli hiposmia. alergiuli rinitisa da qronikuli rinosinusitis simptomebze dafuZnebuli dif-diagnostikuri algoriTmi gamosaxulia me-6 suraTze.

6. gamokvlevis gegma

alergiuli rinitis diagnozi efuZneba tipiuri klinikuri simptomebis arsebobasa da alergen-specifikuri IgE-s demonstrirebas kanze (kanis testebi), an sisxlSi (Sratis specifikuri IgE). rutinulad unda Catardes rinoskopia anatomiuri mizezebis gamorcxvis an dadasturebis mizniT.

kanis testebi - alergen-specifikuri IgE-s gansazRvra kanis testebiT naCvenebia pacientis simptomebis alergiuli genezis dasadastureblad, savaraudo mizezebis gamosaricxad an dasadastureblad, specifikur alergenze mgrZnobelobis Sesafaseblad, raTa Catardes alergenis Tavidan asacilebeli RonisZiebebi da/an imunoTerapia (B).

pirveladi jandacvis doneze kanis testebi xSirad xelmisawvdomi ar aris, amitom pacientebs damaxasiaTebeli simptomebiT utardebaT skrining-testi - specifikuri IgE-s gansazRvra SratSi (Phadiatop da sxva), dadebiTi pasuxis SemTxvevaSi ganixileba alergologTan referalis sakiTxi kanis testebis Casatareblad.

faqtorebi, romlebic gavlenas axdenen kanis testebze

didi mniSvneloba aqvs alergenis eqstraqtis xarisxs, Tu SesaZlebelia, gamoyenebuli unda iqnas standartizebuli alergenebi;

medikamentebi: rigi medikamentebisa gavlenas axdens kanis testebze da Sesabamisad, testebis Catarebamde unda

38

Segrovdes detaluri medikamenturi anamnezi. H-1 antihistaminebi (saSualod 3-10dRiT adre miRebuli), imipraminebi, fenoTiazini, topikuri da xangrZlivad miRebuli oraluri gkukokortikosteroidebi amcireben kanis testze reaqtiulobas da supresia klinikurad mniSvnelovania 81 , montelukasti ar amcirebs kanis testebze reaqtiulobas da ar aris aucilebeli misi Sewyveta testirebamde82.

medikamentebi, romlebic gavlenas axdenen kanis testebze, ar moqmedeben Sratis specifikuri IgE-s doneze;

kanis testis Catareba SesaZloa ver moxerxdes pacientebTan kanis daavadebebiT demografizmis (utikaria), an kanis didi nawilis dazianebis SemTxvevaSi.

kanis testebis Sedegi unda Sefasdes klinikuri istoriis konteqstSi. mxolod pozitiuri kanis testi ar adasturebs alergenze klinikur reaqtiulobas83.

Sratis saerTo da specifikuri IgE

Sratis saerTo IgE, misi dabali specifikurobisa da mgrZnobelobis gamo alergiuli rinitis diagnostirebisaTvis aRar gamoiyeneba 84 , Tumca am testis Rirebuleba sakmaod maRalia asTmis ganviTarebisa da simZimis riskis Sesafaseblad85;

Sratis specifikuri IgE–s monacemebi standartizebuli sadiagnozo alergenis gamoyenebis SemTxvevaSi mWidrod korelirebs kanis testebisa da cxviris provokaciuli testebTan;

calkeuli alergenebis testireba Sratis specifikuri IgE-s saSualebiT sakmaod ZviradRirebuli meTodia;

skrining-testi (Phadiatop) – Sratis specifikuri IgE-s gansazRvra, rodesac erT sinjSi aRebulia mravali alergenis narevi. am dros sxvadasxva alergenebi isazRvreba erTi analiziT. am testis validuroba (specifikuroba da mgrZnobeloba) maRalia – 85%-ze meti, ris gaTvaliswinebiTac SesaZlebelia misi gamoyeneba alergiuli daavadebis skrining-testad. aRsaniSnavia, rom am testiT ar aris SesaZlebeli konkretuli alergenis gansazRvra, testis Sedegi gvaZlevs saSualebas pacientebi davyoT alergiulad da araalergiulad86.

39

sxva gamokvlevebi:

wina rinoskopia xelmisawvdomia pirveladi jandacvis doneze, martivia teqnikurad, saSualebas iZleva daTvalierdes cxviris niJarebi, SesaZlebelia polipozis dadgena, Tumca mcire zomis polipebis vizualizacia am meTodiT ar xerxdeba, SesaZlebelia Sefasdes Cirqovani gamonadenis arseboba/ararseboba. rinoskopia rutinulad unda Catardes rinitis simptomebis mqone pacientTan.

nazaluri endoskopia SesaZleblobas iZleva daTvalierdes cxviris ukana Rru da Sua meatusi, am gamokvleviT nazaluri simptomebis mqone pacientTa mexuTedTan SesaZlebeli xdeba diagnozis dasma, Tumca alergiuli rinitis SemTxvevaSi nazaluri endoskopia mxolod sxva daavadebebis gamoricxvis SesaZleblobas iZleva87.

amonasunTq haerSi NO-s gansazRvris roli alergiuli rinitis diagnostikaSi Semdgom Seswavlas saWiroebs 88 , aRniSnuli kvleva informatiulia qveda sasunTqi gzebis eozinofiluri anTebis SemTxvevaSi, rodesac maCvenebeli momatebulia 89 (norma 5-20p.p.b bavSvebSi da 5-25p.p.b mozrdilebSi) da SesaZloa, damxmare iyos sasunTqi gzebis iseTi qronikuli daavadebebis SemTxvevaSi, rogoricaa karTageneris sindromi da cisturi fibrozi. Aam dros NO-s Semcveloba amonasunTq haerSi daqveiTebulia90.

nazalur nacxSi eozinofilebis kvleva alergiuli rinitis rutinul diagnostikur testebs ar miekuTvneba, misi gamoyeneba SesaZlebelia im SemTxvevebSi, rodesac anamneziT, fizikuri gamokvleviTa da specifikuri IgE-s gansazRvris Semdeg alergiuli rinitis diagnozi kvlev eWvis qveSaa (C );

cxviris provokaciuli testebi: rutinulad ar gamoiyeneba, SesaZlebelia Catardes histaminiT, metaqoliniT, alergenebiT, hipertonuli xsnariT an civi, mSrali haeris nakadiT. cxviris provokaciuli testebi tardeba mxolod specializebul alergologiur centrebSi, SesaZlebelia gamoiwvios asTmuri reaqcia, mniSvnelovania profesiuli rinitebis diagnostikaSi da im SemTxvevebSi, rodesac klinikuri istoriiT, fizikuri gamokvleviTa da specifikuri IgE-s gansazRvris Semdeg alergiuli rinitis diagnozi kvlev eWvis qveSaa.

gamosaxulebiTi kvleva: rinosinusitis dianozis dasadastureblad an gamosaricxad rekomendebuli kvlevaa kompiuteruli tomografia;

nazaluri biofsia - Cvenebaa dazianebis SemTxvevaSi granulaciisa da neoplaziis gamijvna, aseve, cilias ultrastruqturis paTologiis dadgena (C ).

40

mukociliaruli funqciis Sefaseba

ciliaruli disfunqciis sindromi iwvevs araefeqturi mukociliaruli klirensis Camoyalibebas da moicavs 2 mdgomareobas: pirvelad ciliarul disfunqcias, iSviaT genetikur paTologias, romelic aseve cnobilia uZravi cilias (immotile cilia) sindromis saxeliT, da meorad ciliarul disfunqcias, romelic gacilebiT ufro xSiria da gamowveulia mwvave an qronikuli infeqciebiT, iritaciuli rinitebiT, mravlobiTi qirurgiuli CareviT sinusebze. pacientebis 50%-s pirveladi ciliaruli disfunqciiT aReniSnebaT “situs inversus” –

karTageneris sindromi. skrining-testad gamoiyeneba saqarini 166 an teflonis (diupontis) testi. diagnozis saboloo dadastureba xdeba nazaluri bioptatis eleqtonul mikroskopiT analiziT.

b-2-transferinis gansazRvra nazalur sekretSi maRalmgrZnobiare meTodia cerebrospinaluri siTxis dinebis deteqciisaTvis.

nazaluri haeris nakadis obieqturi Sefaseba- rutinulad ar tardeba, informatiulia, rodesac dagegmili qirurgiuli Careva cxviris Zgidis gamrudebis an niJarebis hipertrofiis gamo, an alergenebiT an aspiriniT cxviris provokaciuli testis Sesafaseblad. nazaluri pik-floumetira, martivi, iafi da informatiuli gamokvlevaa 91 , aseve, SesaZlebelia Catardes rinomanometria, akustikuri rinometria.

7. mkurnaloba

zemo da qveda sasunTqi gzebis anTebiTi meqanizmis Sesaxeb informaciis matebam safuZveli Seqmna alergiuli rinitis marTvis Terapiuli strategiis gasaumjobeseblad. alergiuli rinitis axali klasifikacia saSualebas iZleva SemuSavdes gamarTlebuli inicialuri mkurnalobis strategia dafuZnebuli daavadebis xangrZlivobaze, simptomebis intensiurobaze da cxovrebis stilis Secvlaze92 .

alergiuli rinitis mkurnaloba moicavs:

1. pacientis ganaTlebas;

2. alergenebis eliminacias;

3. medikamentur Terapias;

4. imunoTerapias saWiroebisamebr;

5. qirurgiul mkurnalobas saWiroebisamebr.

41

garda amisa, mkurnalobis SerCevisas gasaTvaliswinebelia specialuri jgufebis Taviseburebebi, rogoricaa orsulebi, bavSvebi da asakovani pacientebi.

pacientis ganaTleba

samedicino personalis mier pacientis ganaTleba alergiis Sesaxeb aumjobesebs daavadeba-specifikr cxovrebis xarisxs 93 (C).

pacienti an mSoblebi (arasrulwlovani pacientis) informirebulni unda iyvnen daavadebis arsis, rinitis mizezebisa da meqanizmis, simptomebisa da SesaZlo mkurnalobis Sesaxeb;

miwodebuli unda iqnas informacia alergenebis Tavidan acilebis Sesaxeb da medikamenturi mkurnalobis Sesaxeb usafrTxoebisa da potenciuri gverdiTi moqmedebebis Sesaxeb informirebis CaTvliT;

mkurnalobis araefeqturoba SesaZloa gamowveuli iyos nazaluri spreisa da wveTebis moxmarebis araadekvaturi teqnikiT, amis gaTvaliswinebiT, aucilebelia medikamentebis moxmarebis wesebis kargad swavleba94 da Semowmeba;

mniSvnelovania, pacients miewodos informacia rinitis garTulebebis Sesaxeb, rogoricaa rinosinusiti da Sua yuris anTeba, aseva, komorbiduli mdgomareobebis Sesaxeb, magaliTad, asTma, nazaluri polipozi. pacientebi informirebulni unda iqnan aRniSnuli daavadebebis amocnobisa da mkurnalobis Sesaxeb;

pacientebs unda miewodoT informacia rinitis savaraudo gavlenis Sesaxeb maTi cxovrebis xarisxze da Terapiuli rekomendaciebis Sesrulebisas mosalodnel Sedegebze;

pacients unda aexsnas mkurnalobis mosalodneli Sedegebi da maT unda icodnen, rom qronikuli daavadebis SemTxvevaSi, rogoricaa alergiuli riniti, sruli gankurneba yovelTvis ar aris SesaZlebeli, da, SesaZloa, xangrZlivi mkurnaloba gaxdes saWiro.

42

alergenebis eliminacia

alergenebis eliminacia aumjobesebs pacientis cxovrebis xarisxs da daavadebis mimdinareobas, magram sakmaod rTulia Sesasruleblad.

or yvelaze gavcrelebul karSida alergenze, oTaxis mtvris tkipasa da Sinaur cxovelebze Catarebulma kvlevebma aCvenes, rom erTeuli RonisZiebebi alergenis Tavidan asacileblad araefeqturia, garkveeuli efeqti aqvs mxolod RonisZiebebis erTobliobas95. (ix cxrili 4);

cxrili #4

eliminaciuri RonisZiebebis zegavlena alergenebis koncentraciasa da klinikur simptomebze

RonisZieba alergenis

koncentaciaze gavlena

mtkicebuleba klinikuri efeqturobis Sesaxeb

oTaxis mtvris tkipa loginis hermetuli (gaumtari) gadasakravebi

ramdenadme mozrdilebTan araefeqturia (A) bavSvebTan ramdenadme (B)

TeTreulis recxva cxeli cikliT (55-60 celsiusze)

ramdenadme araefeqturia (A)

xaliCebis Canacvleba magari iatakiT, (xaliCebis aReba)

ramdenadme araefeqturia (A)

akaracidebi an taninis mJava susti araefeqturia (A) im sagnebis minimalizacia, romlebzec akumulirdeba mtveri

araefeqturia

araefeqturia (B)

vakuum-sawmendebis gamoyeneba integraluri HEPA

filtrebiT da ormagi rezervuarebiT.

susti araefeqturia (B)

rbili saTamaSoebis mocileba an cxeli wyliT recxva

araefeqturia araefeqturia (B)

katebis da ZaRlebis mocileba saxlidan

susti araefeqturia (B)

cxovelebis gayvana ZiriTadi sacxovrebeli oTaxebidan

susti araefeqturia (B)

haeris HEPA filtrebiani gamwmendebis gamoyeneba

araefeqturia (B)

43

cxovelebis dabana susti araefeqturia (B) xaliCebis Canacvleba magari iatakiT, (xaliCebis aReba)

araefeqturia araefeqturia (B)

vakuum-sawmendebis gamoyeneba integraluri HEPA

filtrebiT da ormagi rezervuarebiT.

araefeqturia araefeqturia (B)

alergenebis eliminaciuri RonisZiebebis erToblioba

ramdenadme ramdenadme (B)

pirebma, romelTac aqvT mcenaris mtverze alergia, unda SezRudon trigeruli mcenaris yvavilobis dros saxlidan gasvla, ar gaaRon fanjrebi qarian amindSi (B);

obis sokoze alergiis SemTxvevaSi rekomendebulia nestiani adgilebis Semcireba, dabinZurebuli nivTebis gatana saxlidan da qloris Semcveli maTeTrebeli xsnariT gluvzedapiriani nivTebis gawmenda svel wertilebSi (D);

iritantebiT (Tambaqos kvamli, formaldehidi) gamowveuli rinitis mkurnalobis saukeTeso gzaa gamaRizianebeli faqtorebis Tavidan acileba (B).

medikamenturi Terapia

zogadi rekomendaciebi

meore generaciis oraluri da intranazaluri H-1 antihistaminebi rekomendebulia alergiuli rinitisa da koniunqivitis samkurnalod rogorc mozrdilebSi, aseve bavSvebSi;

Tu meore generaciis antihistaminebi xelmisawvdomia, pirveli generaciis antihistaminebi ar aris rekomendebuli maTi gverdiTi movlenebis gamo;

topikuri H-1 antihistaminebi rekomendebulia alergiuli rinitisa da koniunqivitis samkurnalod;

intranazaluri glukokortikosteroidebi rekomendebulia alergiuli rinitis samkurnalod mozrdilebSi da bavSvebSi. es jgufi alergiuli rinitis samkurnalod yvelaze efeqturia;

intramuskuluri da oraluri glukokortikosteroidebis xangrZlivi kursi ar aris rekomendebuli maTi gverdiTi moqmedebebis gamo;

44

topikuri kromonebi rekomendebulia alergiuli rinitisa da koniunqivitis samkurnalod, maTi efeqturoba saSualoa, magram isini sruliad usafrTxoa;

montelukasti rekomendebulia sezonuri alergiuli rinitis samkurnalod mozrdilebSi da 6 Tveze ufros bavSvebSi;

intranazaluri ipratropiumi rekomendebulia alergiul rinitTan asocirebuli rinoreis samkurnalod;

intranazaluri dekongestantebis xanmokle kursi SesaZlebelia gamoyenebul iqnas Zlieri nazaluri obstruqciis mqone pacientebTan;

oraluri dekongestantebi (da maTi kombinacia oralur H-1 antihistaminebTan) SesaZlebelia gamoyenebul iqnas alergiuli rinitis mqone mozrdil pacientebTan, magram gasaTvaliswinebelia xSirad gverdiTi efeqtebis arseboba

alergiuli rinitis mkurnalobisas gaTvaliswinebuli unda iqnas: daavadebis simZime da xangrZlivoba, ramdenad misaRebia mkurnalobis meTodi pacientisaTvis, medikamentis efeqturoba, xelmisawvdomoba da fasi;

mkurnalobis dros gamoyenebuli unda iqnas safexurebrivi midgoma daavadebis simZimisa da xangrZlivobis mixedviT;

yvela pacientis saWiroebs individualur midgomas;

miuxedavad optimaluri farmakoTerapiisa, xSirad ver xerxdeba saSualo/mZime alergiuli rinitiT yvela pacientis simptomebis kontroli;

alergiuli rinitis dros samkurnalod gamoyenebuli medikamentebis miRebis gza ZiriTadad intranazaluri an oraluria;

Terapiuli efeqti grZeldeba mxolod medikamentis miRebis periodSi da ara misi Sewyvetis Semdeg. sxvadasxva medikamentebis SedarebiTi efeqturobis Semswavleli kvlevebis mixedviT intranazaluri glukokortikosteroidebi yvelaze efeqturia.

me-5 cxrilSi mocemulia alergiuli rinitis samkurnalod gamoyenebuli medikamentebis Sesaxeb detaluri informacia96 97.

45

cxrili #5 alergiuli rinitis samkurnalod

gamoyenebuli medikamantebis ganmartebani ARIA: ganaxlebuli 2008 w

jgufis dasaxeleba

generiuli dasaxeleba

moqmedebis meqanizmi

gverdiTi moqmedeba

komentari

oraluri H-1 anti-histaminebi

II generaciis cetirizini Acrivastine

Azelastine * Cetirizine

Desloratadine

Ebastine Fexofenadine

Levocetirizine*

Loratadine Mequitazine *

Mizolastine *

Rupatadine * I generaciis Chlorphenyramin

Clemastine

Dimethindene maleate

Hydroxyzine

Ketotifen Oxatomine kardiotoqsikuri Astemizole Terfenadine

H-1 receptorebis blokada

antialergiuli aqtivoba

axali generaciis preparatebis gamoyeneba SesaZlebelia 1-xel dReSi

ar iwvevs taqifilaqsias

II generaciis medikamentTa umetesobas ar axasiaTebs sedacia ar axasiaTebs antiqolinerguli efeqti ar aris kardiotoqsiuri akrivastins aqvs sedaciuri efeqti oralur azelastins axasiaTebs sedacia da aris mware I genereciis antihistaminebs axasiaTebT sedacia da/an antiqolinerguli efeqti

arCevis Terapiaa garda saSualo/mZime persistuli alergiuli rinitebisa.

II generaciis H-1 blokerebis gamoyeneba upiratesia maTi farmakokinetikisa da kargi usafrTxoeba/efeqturobis Sefardebis gamo gansxvavebiT I generaciis H-1 blokerebisagan, romelTa usafrTxoeba/efeqturobis Sefardeba ar aris sasurveli

swrafi efeqti (1 saaTze naklebi) nazaluri da okularuli simptomebis dros

zomieri efeqti aqvs cxviris gaWedvaze

kardiotoqsiuri medikamentebi (astemizoli, terfenadini) bevr qveyanaSi aRar gamoiyeneba.

lokaluri H-1 anti- histaminebi (i/n da i/o)

Azelastine *

Levocabastine *

Olopatadine

H-1 receptorebis blokada

antialergiuli aqtivoba - azelastini

umniSvnelo lokaluri adgilobrivi gverdiTi movlenebi

azelastinis SemTxvevaSi – zog pacientTan mware gemo

swrafi efeqti (30 wuTze naklebi) rogorc nazaluri, ise okularuli simptomebis SemTxvevaSi

nazaluri kortiko-steroidebi

Beclomethasone

dipropionate

Budesonide Ciclesonide *

Flunisolide *

Fluticasone propionate

Fluticasone

furoate * Mometasone

furoate

Triamcinolone acetonide*

mkveTrad amcirebs nazalur anTebas amcirebs nazalur hiperreaqtiulobas

mcire lokaluri gverdiTi movlenebi

SedarebiT farTo sazRvrebi sistemuri gverdiTi movlenebis ganviTarebisaTvis

bavSvTa asakSi ganixileba intranazaluri da sainhalacio preparatebis kombinacia

alergiuli rinitis yvelaze efeqturi mkurnalobaa, pirveli rigis arCevania saSualo/mZime persistuli alergiuli rinitis samkurnalod

efeqturia cxviris gaWedvis dros

efeqturia ynosvis aRsadgenad

efeqtis miRweva xdeba 6-12 saaTSi, magram maqsimaluri efeqti aRiniSneba mkurnalobidan ramodenime dReSi.

pacienti unda iyos informirebuli intranazaluri spreis moxmarebis wesebis Sesaxeb – kerZod mimarTos sprei lateralurad da ara medialurad (Zgidis gaswvriv).

46

cxrili #5 (gagrZeleba) alergiuli rinitis samkurnalod

gamoyenebuli medikamantebis ganmartebani ARIA: ganaxlebuli 2008w

jgufis dasaxeleba

generiuli dasaxeleba

moqmedebis meqanizmi

gverdiTi moqmedeba

komentari

oraluri/ i.m. gluko-kortiko-steroidebi

Dexamethasone

Hydrocortisone

Methyl-predisolone

Prednisolone

Prednisone* Triamcinolone

Deflazacort*

mkveTrad amcirebs nazalur anTebas

amcirebs nazalur hiperreaqtiulobas

xSiria sistemuri gverdiTi efeqtebi, gansakuTrebiT intramuskularuli preparatebis gamoyenebis SemTxvevaSi

depo ineqciebis gamoyenebis SemTxvevaSi SesaZloa lokalurad qsovilis atrofia

rodesac SesaZlebelia, upiratesoba eniWeba intranazalur glukokortikosteroidebs

oraluri/i.m. glukokortikosteroidebis mokle kursi SesaZloa saWiro gaxdes saSualo/mZime simptomebis SemTxvevaSi

lokaluri kromonebi poxieri ujredebis stabili zatorebi (i/n, i/o)

Cromoglycate

Nedocromil NAAGA*

moqmedebis meqanizmi naklebadaa cnobili

mcire lokaluri gverdiTi movlenebi

intraokularuli kromonebi Zalian efeqturia

intranazaluri kromonebi naklebad efeqturia da maTi efeqti xanmoklea

sruliad usafrTxoa

oraluri dekonges-tantebi

Ephedrine Phenylephrine

Phenyl

propanolamine

Pseudo-ephedrine

oraluri H-1

antihistamini – dekongestantis konbinacia Vibrocili

simpatomimetikuri medikamentebi

amcirebs cxviris gaWedilobis simptomebs

hipertenzia palpitacia daRliloba tremori agzneba insomnia Tavis tkivili Sardis Sekaveba glaukomisa da Tireotoqsikozis gamwvaveba lorwovani garsebis simSrale

oraluri dekongestantebi sifrTxiliT gamoiyeneba pacientebTan gulis daavadebiT.

oraluri H-1 antihistamini – dekongestantis konbinacia metad efeqturia, vidre maTi gamoyeneba cal-calke, Tumca gasaTvaliswinebelia gverdiTi movlenebi.

i/n dekonges- tantebi

Oxymethazoline

Xylomethazoline da sxva

simpatomimeturi medikamentebi

amcirebs cxviris gaWedilobis simptomebs

oraluri dekongestantebis msgavsi gverdiTi movlenebi, magram naklebi intnsivobis

gaxangrZlivebuli moxmarebis Sedegad (10 dReze meti) axasiaTebs Rhinitis medicamentosa – s ganviTareba

moqmedebs ufro swrafad da efeqturad, vidre oraluri dekongenstantebi

mkurnalobis xangrZlivoba limitirebulia – 10 dReze naklebi Rhinitis medicamentosa – s ganviTarebis saSiSroebis gamo.

i/n antiqoli-nerguli prepara- tebi

Ipratropium axdens mxolod rinoreis blokirebas

mcire lokaluri gverdiTi moqmedeba ar axasiaTebs sistemuri gverdiTi efeqtebi

efeqturia rinoreis SemTxvevaSi rogorc alergiuli, aseve araalergiuli pacientebisaTvis

47

cxrili #5 (gagrZeleba) alergiuli rinitis samkurnalod

gamoyenebuli medikamantebis ganmartebani ARIA: ganaxlebuli 2008w

jgufis dasaxeleba

jgufis dasaxeleba

jgufis dasaxeleba

jgufis dasaxeleba

jgufis dasaxeleba

CysLT antagonistebi antileikotreinebi leikotreinis inhibitorebi

Montelukast

Pranlukast* Zafirlukast*

CysLT receptorebis blokada

saukeTeso tolerantoba

efeqturia rinitebisa da asTmis dros

efeqturia rinitis yvela simptomisa da, aseve, okularuli simptomebis dros

SeniSvna * ar aris registrirebuli

rinitis samkurnalod rekomendebulia safexurebrivi midgoma romelic dafuZnebulia alergiuli rinitis klinikur simptomebze (ARIA 2008).

msubuqi intermisiuli alergiuli riniti: oraluri H-1

antihistamini, an intranazaluri H-1 blokeri, an dekongestantebi an LTRA;

saSualo/mZime intermisiuli alergiuli riniti: intranazaluri glukokortikosteroidi (beklometazoni 300-400mkg. dReSi, an sxva kortikosteroidi eqvivalenturi doziT). saWiroebis SemTxvevaSi 1 kviriani mkurnalobis Semdeg unda daematos oraluri H-1 antihistamini an oraluri glukokortikosteroidi;

msubuqi pesistuli alergiuli riniti: oraluri H-1

antihistamini an intranazaluri glukokortikosteroidi dabali doziT (beklometazoni 100-200mkg. dReSi, an sxva kortikosteroidi eqvivalenturi doziT);

saSualo/mZime persistuli alergiuli riniti: intranazaluri glukokortikosteroidis maRali doza (beklometazoni 300-400mkg. dReSi, an sxva kortikosteroidi eqvivalenturi doziT), Tu simptomebi Zlieria, mkurnalobis dasawyisSive unda dainiSnos oraluri H-1 antihistamini an oraluri glukokortikosteroidis xanmokle kursi.

safexurebrivi midgomis gaTvaliswinebiT alergiuli rinitis medikamenturi marTvis algoriTmi mocemulia suraTze #6

48

oraluri H-1 antihistaminebi

alergiuli rinitis samkurnalod upiratesoba eniWeba meore generaciis antihistaminebs pirveli generaciis antihistaminebTan SedarebiT am ukanasknelTa gverdiTi movlenebis gaTvaliswinebiT. pirveli generaciis antihispaminebs axasiaTebT mniSvnelovani sedacia da antiqolinerguli efeqti. meore generaciis antihistaminebs aRniSnuli moqmedeba ara aqvT, an axasiaTebT minimalurad (B).

meore generaciis antihistaminebs Soris mniSvnelovani gansxvavebaa maTi sedaciuri efeqtis mixedviT. feqsofenidini, loratadini da desloratadini ar iwveven sedacias rekomendebul dozebSi; loratadinma da desloratadinma SesaZlebelia gamoiwvios sedacia rekomendebul dozebze maRali doziT miRebis SemTxvevaSi. ceterizinma da intranazalurima azelastinma SeiZleba gamoiwvios sedacia rekomendebul dozebSi (A).

bavSvebSi oraluri H-1 antihistaminebi usafrTxo da efeqturia.

oraluri antihistaminebi efeqturia simptomebisTvis, romlebic inducirebulia histaminiT: rinorea, cemineba, cxviris qavili, Tvalis simptomebi, magram naklebad efeqturia cxviris gaWedvis samkurnalod. ar axasiaTebs taqifilaqsiis ganviTareba.

topikuri (intranazaluri) H-1 antihistaminebi

intranazaluri H-1 antihistaminebi SeiZleba CaiTvalos pirveli rigis samkurnalo medikamentad alergiuli da araalergiuli rinitebisaTvis (A);

intranazaluri H-1 antihistaminebi alergiuli rinitis samkurnalod aris iseve, an metad efeqturi, rogorc oraluri H-1 antihistaminebi (A).

itranazaluri H-1 antihistaminebis gamoyenebisas aRiniSneba sistemuri absorbcia, ris gamoc SesaZlebelia aRiniSnos sedacia da kanis testebze reaqciis daTrgunva (A);

intranazalur H-1 antihistaminebs gaaCniaT klinikurad mniSvnelovani efeqti cxviris gaWedvis SemTxvevaSi (A);

alergiuli rinitis samkurnalod intranazaluri glukokortikosteroidebi metad efeqturia, vidre oraluri an intranazaluri H-1 antihistaminebi (A).

49

intranazaluri da oraluri glukokortikosteroidebi

intranazaluri glukokortikosteroidebi yvelaze efeqturi medikamentebia alergiuli rinitis simptomebis kontrolisaTvis (A);

kvlevebis mixedviT, intranazaluri glukokortikosteroidebi sezonuri alergiuli rinitis mkurnalobaSi ufro efeqturi aRmoCnda, vidre antihistaminisa da liekotrienis antagonistis kombinacia (A);

sezonuri alergiuli rinitis dros intranazaluri glukokortikosteroidebis saWiroebis SemTxvevaSi gamoyeneba (mxolod Civilebis arsebobis dros) simptomebis mniSvnelovan Semcirebas iwvevs (B), magram saWiroebis SemTxvevaSi gamoyeneba SeiZleba ar iyos iseve efeqturi, rogorc xangrZlivi gamoyeneba (D);

sxvadasxva intranazaluri kortikosteroidebis efeqturobis Sedarebisas klinikuri pasuxi mniSvnelovnad gansxvavebuli ar yofila (C);

intranazaluri glukokortikosteroidebi gamoiyeneba rinitis zogierTi sxva, araalergiuli formis samkurnalodac (A);

intranazaluri glukokortikosteroidebis gamoyeneba rekomendebuli dozebiT ar aris asocirebuli klinikurad mniSvnelovan sistemur gverdiT efeqtebTan (A);

intranazaluri glukokortikosteroidebis lokaluri gverdiTi moqmedeba Cveulebriv minimaluria, SesaZlebelia nazaluri iritacia da sisxldena, Zalzed iSviaTad SesaZlebelia cxviris Zgidis perforacia (B).

oraluri kortikosteroidebis xanmokle, 5-7 dRiani kursis gamoyeneba mizanSewonilia pacientebTan Zalian mZime an arakupirebadi alergiuli rinitiT, an mniSvnelovani nazaluri polipozis samkurnalod. alergiuli riniti dros monoTerapia oraluri kortikosteroidebiT ar aris gamarTlebuli imis gaTvaliswinebiT, rom erTjeradi xanmokle kursi araefeqturia simptomebis kontrolisaTvis, xolo xangrZlivi gamoyeneba ukunaCvenebia gverdiTi movlenebis gamo (D).

oraluri da topikuri dekongestantebi.

oraluri dekongestantebi, rogoricaa fsevdoefedrini da fenilefrini, warmoadgenen alfa-adrenergul agonistebs da efeqturad amcireben cxviris gaWedvas, magram aseve iwveven gverdiT

50

efeqtebs, rogoricaa insomnia, agznebadoba da gaRizianebadoba, kankali (A);

oraluri da topikuri dekongestantebi sifrTxiliT unda iqnas gamoyenebuli patara bavSvebTan da asakovan pacientebTan, aseve, nebismieri asakis pacientebTan, romelTac aqvT gulis iSemiuri daavadebis, ariTmiis, cerebrovaskuluri daavadebis, hipertenziis, Sardis buStis yelis obstruqciis, glaukomisa an hiperTireozis klinikuri anamnezi (C);

topikuri dekongestantebi SesaZlebelia dainiSnos xanmokle kursiT, an epizoduri Terapiis saxiT cxviris gaWedvis samkurnalod, magram gaumarTlebelia maTi daniSvna regularuli xmarebisaTvis imis gaTvaliswinebiT, rom aris rhinitis medicamentosa-s ganviTarebis riski (C);

Rhinitis medicamentosa-s ganviTarebas iwvevs oraluri dekongestantebis 10 dReze meti vadiT gamoyeneba

51

suraTi 7 alergiuli rinitis medikamenturi marTvis algoriTmi.

SeafaseT pacienti 2-4 kviraSi

blokada - daamateT oral-uri dekongesta-nti an kortiko-steroidi

alergiuli rinitis diagnozi anamnezi/klinika/rinoskopia

efqturia

persistuli intermisiuli

gamoikvlieT asTmis arseboba, gansakuTrebiT pacientebSi mZime da/an persistuli rinitiT

nebismieri rigiTobiT oraluri H-1 blokerebi an i/n H-1 blokerebi, da/an dekongestantebi, an LLTRA

saSualo/ mZime

msubuqi

nebismieri rigiTobiT oraluri H-1 blokerebi an i/n H-1 blokerebi, da/an dekongestantebi, an intranazaluri ks, an LTRA, an kromonebi

persistuli rinitis SemTxvevaSi SeafaseT pacienti 2-4 kviraSi

mkurnalobis araefeqturobis

SemTxvevaSi – erTi safexuriT zemoT,

gaumjobesebis SemTxvevaSi –

gaagrZeleT 1 Tve igive sqemiT

saSualo/mZime

miTiTebuli rigiTobiT intranazaluri kortikosteroidi, an H-1 blokeri an LTRA,

safexuriT qvemoT da gaagrZeleT mkurnaloba 1 Tve

gadaxedeT diagnozs, SeafaseT mkurnalobis teqnikuri Sesruleba, ifiqreT infeqciaze an sxva mizezebze

gazardeT i/n kortikosteroidis doza.

rinorea – daamateT ipratropiumi cemineba-qavili daamateT H-1 blokeri

mkurnaloba arefeqturia –referali specialistTan

msubuqi

ara efeqturia

rekomendebulia alergenebisa da gamaRizianeblebis arideba koniunqirtis SemTxvevaSi daamateT: oraluri H-1 blokerebi, an i/o H-1 blokerebi, an i/o kromoni, an fiziologiuri xsnari. ganixileT kanis specifikuri tesebisa da imunoTerapiis Catarebis sakiTxi

52

intranazaluri kromolini

intranazaluri kromolini zog pacientTan efeqturia alergiuli rinitis prevenciisa da mkurnalobisaTvis da axasiaTebs minimaluri gverdiTi movlenebi. misi efeqturoba, kortikosteroidebTan SedarebiT, bevrad naklebia, misi SedarebiTi efeqturoba LT

antagonistebTan da antihistaminebTan ar aris Seswavlili (A).

intranazaluri antiqolinerguli saSualebebi

intranazaluri antiqolinerguli saSualebebi efeqturia rinoreis samkurnalod, magram ara aqvs gavlena sxva nazalur simptomebze, xasiaTdeba minimaluri gverdiTi movlenebiT, rac gamoixateba nazaluri membranebis simSraliT (A).

ipratropium bromidisa da kortikosteroidis nazaluri formis erTdrouli gamoyeneba ufro efeqturia, vidre am ori medikamentis cal-calke administrireba. amavdroulad, maTi gverdiTi moqmedebebis sixSire an siZliere ar izrdeba (A).

oraluri L CysLT antagonistebi (antileikotreinebi)

oraluri CysLT antagonistebs, monoTerapiis saxiT an antihistaminTan erTad, aqvT dadasturebuli efeqturoba alergiuli rinitis mkurnalobaSi (A).

oraluri antileikotreinebi xasiaTdeba maRali usafrTxoebis maCvenebliT, misi gamoyeneba nebadarTulia 6 Tvis asakidan.

montelukastis efeqturoba alergiuli rinitis simptomebis kontrolisaTvis aRemateba H-1 antihistaminebis efeqturobas da CamorCeba nazaluri glukokortikosteroidebis efeqturobas98.

fiziologiuri xsnari

fiziologiuri xsnariT cxviris Rrus sanacia iafi da martivi meTodia da, zog SemTxvevebSi, efeqturia.

medikamentebis efeqturoba alergiuli rinitis calkeul simptomebze mocemulia me-6 cxrilSi

53

cxrili 6 medikamentebis efeqturoba alergiuli rinitis

calkeul simptomebze cemi-

neba rino- rea

nazal-uri obstruqcia

cxvi- ris qavili

Tvalis simpto-mebi

antihistamini

oraluri ++ ++ + +++ ++

nazaluri ++ ++ + ++

Tvalis wveTebi 0 0 0 +++

cxrili 6 (gagrZeleba) medikamentebis efeqturoba alergiuli rinitis

calkeul simptomebze

medikamenti cemi neba

rino rea

nazaluri obstruqcia

cxvi ris qavili

Tvalis simptomebi

kortikosteroidi

nazaluri +++ +++ +++ ++ ++

kromonebi

nazaluri + + + +

Tvalis wv. 0 0 0 0 ++

dekongestantebi

nazaluri 0 0 ++++ 0 0

oraluri 0 0 + 0 0

antiqolinerguli 0 ++ 0 0 0 antileikotreini 0 + ++ 0 ++

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cxrili 7 mtkicebulebebis done alergiuli rinitis samkurnalod

gamoyenebuli saSualebebis efeqturobis Sesaxeb

ARIA 2007

medikamenti/intervencia sar wmmar par mozrdi

lebi bavSvebi mozrdi

lebi bavSvebi

oraluri H-1 antihistamini A A A A A

nazaluri H-1 antihistamini

A A A A A**

nazaluri kortikosteroidi

A A A A A**

nazaluri kromonebi A A A A

LTRA A A

(>6 welze)

A A**

kanqveSa imunoTerapia A A A A A**

sublingvaluri/nazaluri imunoTerapia

A A A B A**

alergenebis eliminacia D D A* B*

sar – sezonuri alergiuli riniti wmmar – wlis manZilze mimdinare alergiuli riniti par – persistuli alergiuli riniti

*- ar aris efeqturi mTels populaciaSi

**eqstrapolirebulia sar/wmmar –ze Catarebuli kvlevis Sedegebi

imunoTerapia

alergenebiT imunoTerapia efeqturi meTodia alergiuli rinitis samkurnalod (A).

saqarTveloSi Catarebuli kvlevis Sedegebis mixedviT asTmisa da alergiuli rinitis/rinokoniunqtivitis mqone pacientebTan imunoTerapiis Sedegad mniSvnelovnad mcirdeba simptomebi da sxva medikamenturi Terapiis saWiroebis sixSire, aseve, umjobesdeba daavadeba-specifikuri cxovrebis xarisxi99 .

imunoTerapia unda Catardes mxolod specializebul alergologiur klinikaSi.

alergenebiT imunoTerapiam SesaZlebelia moaxdinos axali sensibilizaciis prevencia da asTmis ganviTarebis prevencia pacientebTan alergiuli rinitiT (B).

55

imunoTerapiis Cveneba – kanqveSa an sublingvaluri imunoTerapiis Cvenebaa:

1. gamovlenilia alergiuli rinitis gamomwvevi mxolod 1 an 2 jgufis alergenebi;

2. farmakoTerapia da alergenebis eliminacia araefeqturia;

3. aRiniSneba bronquli asTmis ganviTarebis maRali riski.

kanqveSa imunoTerapiis SemTxvevaSi sistemuri gverdiTi moqmedebebis riski metia, vidre sublingvaluri imunoTerapiis SemTxvevaSi. oraluri antihistaminebis daniSvna imunoTerapiamde amcirebs sistemuri gverdiTi movlenebis sixSires da siZlieres (B).

anti-IgE antisxeuli – omalizumabi:EboWavs kompleqsis warmoqmnis saSualebiT Tavisufal IgE-s, axdens misi ureTierqmedebis blokirebas poxier ujredebTan da bazofilebTan, aqveiTebs sisxlSi Tavisufali IgE-s cirkulacias 100 . omalizumabi efeqturia alergiuli rinitisa da asTmis simptomebis kontrolisaTvis. omalizumabis iSviaT, magram potenciuriad mZime gverdiT moqmedebas warmoadgens anafilaqsiuri reaqcia (pacientTa 0,1% kvlevis mixedviT), ris gamoc omalizumabis ineqcia unda Catardes mxolod specializebul alergologiul dawesebulebaSi da pirveli 3 ineqciis Semdeg pacienti unda imyofebodes eqimis dakvirvebis qveS 2-2 saaTi, xolo Semdgomi ineqciebis dros 30-30 wT.

xarjTefeqturobis gaTvaliswinebiT, omalizumabi rutinulad alergiuli rinitis samkurnalod rekomendebuli ar aris101.

qirurgiuli mkurnaloba

alergiuli rinitis dros qirurgiuli mkurnaloba naCvenebia komorbiduli daavadebebis arsebobis SemTxvevaSi, rogoricaa cxviris obstruqcia Zgidis mZime gamrudebis, wina niJaris hipertrofiis, adenoidebis hipertrofiis an refraqteruli sinusitebis dros (C).

referalis Cveneba

specialistTan – alergologTan, otorinolaringologTan, ofTalmologTan referalis Cvenebebia:

1. gadawyvetileba Catardes alergodiagnostika (kanis testebi da/an Sratis specifikuri Ig-E-s gansazRvra) alergenis identifikaciisa da mkurnalobis Semdgomi taqtikis gansasazRvrad (imunoTerapiis CaTvliT) – referali alergologTan;

56

2. komorbiduli daavadebebi: asTma, cxviris Rrus polipozi, atopiuri dermatiti, urtikaria, angioedema, anamnezSi anafilaqsiuri Soki, medikamenturi hipermgrZnobeloba (gansakuTrebiT aspirinisa da sxva aass-is mimarT) – referali alergologTan;

3. qronikuli an rekurentuli baqteriuli rinosinusiti, rekurentuli Sua yuris anTeba, nazaluri polipebi, csviris Zgidis gamrudeba, cxviris refraqteruli obstruqcia – referali otorinolaringologTan;

4. Tvalis problemebi – referali alergologTan da/an ofTalmologTan;

5. nebismieri Zlieri alergiuli reaqcia, romelic iwvevs pacientis an misi mSoblebis SeSfoTebas – referali alergologTan;

6. medikamenturi Terapia efeqturi ar aris da simptomebi persistirebs 3 Tveze meti – referali alergologTan.

gansakuTrebuli mdgomareobebi

orsuloba

orsulobis dros cxviris fiziologiuri cvlilebebis gamo xSirad viTardeba orsulTa riniti.

orsulTa rinitis aris cxviris gaWedva, romelic aRmocendeba orsulobis dros respiraciuli traqtis infeqciis sxva niSnebis gareSe, ar aris cnobili alergiuli mizezi da srulad alagdeba mSobiarobidan 2 kviris ganmavlobaSi. orsulTa riniti SesaZloa daiwyos gestaciis nebismier vadaze da aReniSneba 5 orsulidan 1-s102.

alergiuli rinitis mimdinareoba SesaZlebelia gamwvavdes orsulobis dros, magram naklebad mosalodnelia orsulobis periodSi alergiuli rinitis ganviTareba.

medikamenturi Terapiis daniSvnisas orsulobis periodSi aucilebelia misi usafrTxoebis profilis gaTvaliswineba.

pirveli trimestri, rodesac mimdinareobs organogenezi, yvelaze kritikuli periodia, rodesac medikamentebma SeiZleba gamoiwvios kongenitaluri malformacia (D);

adamianebze Catarebulma sakmaod didi raodenobis observaciulma kvlevebma aCvenes, rom meore generaciis antihistaminebis usafrTxoeba iseTivea, rogorc pirveli generaciis antihistaminebisa (C);

57

oraluri antihistaminis daniSvnisas arCevani unda SeCerdes pirveli generaciis preparatebidan qlorfeniraminze, xolo meore generaciis antihistaminebidan – loratadinze an cetirizinze (B);

oraluri dekongestantebi ar aris naCvenebis pirvel trimestrSi, topikuri dekongestantebis xanmokle gamoyeneba oralur dekongestantebTan SedarebiT, metad usafrTxoa pirvel trimestrSi (C);

alergiuli rinitis kromoliniT mkurnaloba usafrTxoa orsulobis periodSi (C);

alergiuli rinitis montelukastiT mkurnaloba usafrTxoa orsulobis periodSi (B);

intranazaluri kortikosteroidebis gamoyeneba nazaluri simptomebis samkurnalod, maTi usafrTxoeba/efeqturobis profilis gaTvaliswinebiT, SesaZlebelia orsulobis periodSi (C);

orsulobis periodSi imunoTerapiis iniciacia araa rekomendebuli, dawyebuli imunoTerapia SeiZleba gagrZeldes orsulobis periodSi, magram dozis eskalaciis gareSe (C). gasaTvaliwinebelia, rig evropul qveynebSi orsulobis periodSi imunoTerapia wydeba.

pediatriuli aspeqtebi

intermisiuli alergiuli riniti ar aris damaxasiaTebeli 2 wlamde asakisaTvis, misi sixSire maRalia ZiriTadad saskolo asakSi.

mkurnalobis taqtika igivea, rac mozrdilebSi.

oraluri antihistaminis miReba sasurvelia simptomebis arsebobisas an mosalodneli simptomebis dros. dRis simptomebis kontrolireba xdeba ufro efeqturad, rodesac antihistamini iniSneba mTeli sezonis ganmavlobaSi (mcenaris mtvriT inducirebuli alergiis dros) nacvlad saWiroebis mixedviT gamoyenebisa103.

intranazalur kortikosteroidebs, gansakuTrebiT mometazons, gaaCniaT kargi usafrTxoebis maCveneblebi: minimaluria sistemuri absorbcia da ar aris mtkicebulebebi, rom igi iwveven zrdis Seferxebas (A).

montelukasti gamoiyeneba 6 Tvis asakidan.

58

asakovani pacientebi

nazaluri simptomebis mqone xanSiSesul pacientebTan mniSvnelovania medikamenturi anamnezis gaTvaliswineba, raTa gaTvaliswinebul iqnes iatrogenuli rinitis arseboba (agf inhibitorebi, beta-blokerebi, aspirini da a.S.).

medikamenturi midgoma igivea, mxolod sifrTxiliT gamoiyeneba dekongestantebi.

intranazaluri glukokortikosteroidebis gamoyeneba xanSiSesul pacientebTan ar aris asocirebuli motexilobis riskis matebasTan104.

prevencia

pirveladi prevencia – dedaTa da bavSvTa kveba: ZuZuTi kveba, rigi kvlevebis mixedviT, amcirebs alergiuli daavadebebis ganviTarebis risks bavSvebTan, romelTac ara aqvT alergiis ojaxuri anamnezi.

alergiis ganviTarebis maRali riskis mqone axalSobilebTan, romelTa eqskluziuri ZuZuTi kvebac SesaZlebeli ar aris, rekomendebulia hidrolizirebuli da ara Zroxis rZis Semcveli formuliT kveba, aris mtkicebulebebi, rom hidrolizirebuli formuliT kveba amcirebs Zroxis rZeze alergiis ganviTarebas105.

soioze damzadebuli formula ar aris rekomendebuli alergiis maRali riskis mqone axalSobilebTan an sakvebis autanlobisas106.

yvela bavSvs 6 Tvis asakidan unda mieces naxevradmyari sakvebi, magram atopiis maRali riskis mqone bavSvebTan ar aris rekomendebuli Zroxis rZis produqtebis damateba 12 Tvemde (gamoyenebuli unda iqnas formula 2), aseve ar aris rekomendebuli 12 Tvemde araqisis, nigozis an Txilis micema, kvercxis – 24 Tvemde, Tevzis da zRvis produqtebis micema 36 Tvemde 107 , Tumca, gasaTvaliswnebelia, rom srulfasovani damatebiTi kveba bavSvis fizikuri da gonebrivi ganviTarebis erT-erTi mTavari determinantia da dietologiuri SezRudvebi didi sifrTxiliT unda iyos miRebuli108.

ar aris mtkicebuleba, rom maRali riskis mqone orsulebTan hipoalergiuli dietis daniSvna amcirebs bavSvTan an dedasTan atopiis risks 109 . amave kvleviT, aris monacemebi, rom laqtaciis periodSi atopiis maRali riskis mqone dedebis hipoalergiuli dieta amcirebs bavSvTan atopiuri egzemis ganviTarebis risks.

oTaxis mtvris tkipa: karSida alergenebs didi roli aqvT asTmisa da rinitis ganviTarebaSi, magram rigi kvlevebiT dadasturebulia, rom asTmisa da alergiis pirveladi prevencia alergenebis eliminaciis gziT efeqturi ar aris, savaraudod, daxvewili

59

meTodologiis ararsebobis gamo. asTmisa da alergiis pirveladi prevenciis Temaze mravali kvleva mimdinareobs.

meoreuli prevencia – alergiuli rinitis meoreuli prevencia gulisxmobs daavadebis droul gamovlenas, amavdroulad asTmis kontrols (arsebobis Sefasebas) alergiuli rinitis arsebobis dros.

mesameuli prevencia – alergiuli rinitis mesameuli prevencia ZiriTadad warmodgenilia alergenebis eliminaciiTa da imunoTerapiiT. kvlevebis mixedviT, alergiuli rino-koniunqtivitis mqone pacientebSi imunoTerapia amcirebs asTmis ganviTarebis risks110.

8. eTikur-samarTlebrivi sakiTxebi

alergiuli rinitis marTvaSi udidesi mniSvneloba aqvs pacientis ganaTlebas da mis srul informirebas daavadebis SesaZlo mimdinareobisa da garTulebebis Sesaxeb. aseve, gasaTvaliwinebelia pacientis arCevani mkurnalobis formis SerCevisas.

9. praqtikaSi adaptaciis da protokolis SemuSavebis

rekomendaciebi

rekomendaciebi gaidlainis implementaciis Sesaxeb

gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi

alergiuli riniti sakmaod gavrcelebuli problemaa, misi marTva pirveladi jandacvis doneze ar aris dakavSirebuli did danaxarjebTan, rac SesaZlebels gaxdis ojaxis eqimTa imformirebis Semdeg realurad iqnes gamoyenebuli gaidlainSi rekomendebuli midgomebi.

mosalodneli barierebi gaidlainis danergvis procesSi

alergiuli riniti pacientebis, da, samwuxarod, xSirad eqimebis mierac ar aRiqmeba seriozul daavadebad, ris gamoc am daavadebis marTva araadekvaturia. umetes SemTxvevaSi pacienti alergiuli rinitis gamo daniSnulebas pirdapir afTiaqSi Rebulobs da eqimamde ar midis.

60

gaidlainis implementaciis rekomendebuli meTodebi

gaidlainebis gavrceleba/xelmisawvdomobis uzrunvelyofa

gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT, asociaciis veb-gverdi, saministro da a.S.

gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba.

ganaTleba da treiningi

gaidlainis integrireba saojaxo medicinis diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi, maT Soris moklevadiani (gadamzadebis) programaSi;

gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba; aRniSnuli programebi xelmisawvdomi unda gaxdes Sesabamisi specialobis eqimebisa da sxva samedicino personalisaTvis.

saxelmwifo sasertifikacio gamocda;

gaidlainze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~

sadazRvevo kompaniebis informireba:

sadazRvevo kompaniebma unda gaiTvaliswinoT erovnuli gaidlainiT gaTvaliswinebuli sakiTxebi resursebis ganawilebisa da xarisxis monitoringis procesSi.

61

klinikuri praqtikis auditis kriteriumebi

Sefaseba rinoskopia; asTmis arsebobisa da

kontrolis Sefaseba; mkurnaloba medikamenturi

mkurnalobisas safexurebrivi midgomis gaTvaliswineba;

vizualuri analogiis SkaliT dinamikis Sefaseba;

referalis kriteriumebis dacva;

pacientis ganaTleba miewoda Tu ara saganmanaTleblo masala.

10. gaidlainis miRebis xerxi/wyaro

gaidlaini warmoadgens sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.

11. alternatiuli gaidlaini

alternatiuli gaidlaini ar arsebobs.

62

12. mtkicebulebis done, rekomendaciebis xarisxi da

gamoyenebuli literatura

mtkicebulebis done da rekomendaciebis xarisxi

mtkicebulebebi doneebi

Shekelle guride for level of evidance (from Shekelle at al111)

Ia. mtkicebuleba miRebuli randomizebuli kontrolirebuli kvlevebis metaanaliziT

Ib. mtkicebuleba miRebuli minimum 1 randomizebuli kontrolirebuli kvleviT

IIa. mtkicebuleba miRebuli minimum 1 kontrolirebuli kvleviT randomizaciis gareSe

IIb. mtkicebuleba, miRebuli minimum 1 sxva saxis (nawilobriv eqsperimentuli - quisi-experimental) kvleviT

III. mtkicebuleba, miRebuli araeqsperimentuli aRwerilobiTi kvleviT, rogoricaa mag. SedarebiTi kvlevebi

IV. mtkicebulebebi eqspertTa komitetis angariSis an avtoritetTa klinikuri gamocdilebis safuZvelze

rekomendaciis xarisxebi A dafuZnebulia I donis mtkicebulebaze

B dafuZnebulia II donis mtkicebulebaze an I donis mtkicebulebis eqstrapolirebaze

C dafuZnebulia III donis mtkicebulebaze an I an II donis mtkicebulebis eqstrapolirebaze

D dafuZnebulia IV donis mtkicebulebaze an I, II, III donis mtkicebulebis eqstrapolirebaze

13. gamoyenebuli literatura

gaidlainis mosamzadeblad, garda qvemoT miTiTebuli literaturuli wyaroebisa, gamoynebuli iqna Semdegi gaidlainebi:

Allergic Rhinitis and its Impact on Asthma (ARIA) 2008,

Allergic rhinitis management pocket reference 2008, World Organization of

Family Doctors (Wonca), Global Primary Care education, International Primary

Care Respiratory Group (IPCRG), European Federation of Allergy and Airway

Diseases Patients Association (EFA), Allergic Rhinitis and its Impact on Asthma

(ARIA) Based on the ARIA 2008 and the IPAG handbook, in collaboration with

WHO, GA2LEN** and AllerGen.

The diagnosis and management of rhinitis: An updated practice parameter

American Academy of Allergy, Asthma & Immunology (AAAAI); the American

College of Allergy, Asthma and Immunology (ACAAI); and the Joint Council of

Allergy, Asthma and Immunology (JCAAI) 2008.

BSACI (British Society of Allergy and Clinical Immunology) guidelines for the

management of allergic and non-allergic rhinitis, 2008

63

Allergic Rhinitis: University of Michigan Health System Guidelines for Clinical

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14. avtorTa jgufi

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier

avtorebi:

nino kiknaZe (ojaxis eqimi), maia goTua (alergologi), qeTevan juReli (ojaxis eqimi), Tamar meliqiZe (ojaxis eqimi), qeTevan xecuriani (ojaxis eqimi), guram kiknaZe (redaqtori), givi javaSvili (redaqtori).

eqspertebi:

saqarTvelos alergologiisa da klinikuri imunologiis asociacia;

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.