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alergia saukuneTa mijnaze

amiran gamyreliZe

moxsenebis gegma

alergia 100 wlisaa alergologiis ganviTarebis ZiriTadi etapebi da miRwevebi me-20 saukuneSi da maTi winapirobebi ra codnaa dagrovili dReisTvis klinikur alergologiaSi ra iqneba 21-e saukuneSi

2006 wels alergia

100 wlis

gaxda

alergiis pirkesmieri gansazRvreba termin "alergiis" qveS pirke (1906 w.) gulisxmobda organizmis mier SeZenil specifikuri reagirebis unars, rogorc aweuli, ise daqveiTebuli reaqciis saxiT sxvadasxva ucxo agentebis (ara marto ucxo organizmebisa da organuli produqtebis, aramed martivi qimiuri nivTierebebisa da agreTve fizikuri faqtorebis ) ganmeorebiT moqmedebaze

alergiis Tanamedrove gansazRvreba

dReisTvis termin "alergiis" qveS igulisxmeba organizmis mxolod aweuli mgrZnobeloba im nivTierebebis mimarT, romlebic xasiaTdebian antigenuri (da maT gareSec) TvisebebiT alergia aris hipermgrZnobelobis reaqcia, romelic imunologiuri meqanizmebiTaa gaSvebuli. alergia SeiZleba iyos antisxeulebiT an ujredebiT gaSualebuli umravles SemTxvevaSi antisxeulebi, romelic tipiurad pasuxismgebelia alergiuli reaqciis ganviTarebaze, miekuTvneba IgE izotips da ganapirobebs IgE-iT gaSualebul alergias, Tumaca ara mxolod IgE gaSualebuli alergiuli reaqciebi gvxvdeba "alergiul" pirebSi

ZiriTadi alergiuli daavadebebi (alergozebi) riniti asTma atopiuri dermatiti medikamentozuri alergia kvebiTi alergia mweris nakbenze alergia anafilaqsiuri Soki kontaqturi dermatiti

alergiis nomenklatura

hipermgrZnobeloba

alergiuli hipermgrZnobeloba (imunologiuri meqanizmebi gansazRvrulia an didi albaTobaa) IgE-iT gaSualebuli

araalergiuli hipermgrZnobeloba (imunologiuri meqanizmebi gamoxatulia)

ara IgE-iT gaSualebuli

Johansson SGO et al. Allergy 2001 and JACI 2004

asTma

alergiuli asTma

araalergiuli asTma

IgE ganpirobebuli asTma

IgE ar ganpirobebuli alergiuli asTma

Johansson et al.

alergologiis ganviTarebis ZiriTadi saetapo TariRebi

Charles R. Richet (1850-1935) Paul J. Portier (1866-1962) anafilaqsiis aRmoCena (1902)

Nicholas-Maurice Arthus (1862-1945). "artusis reaqcia", rogorc pirvelad aRwerili lokaluri eqsperimentuli anafilaqsia, gamoxatuli adgilobriv nekrozul vaskulitSi

Paul Ehrlich (1854-1915). aRwera antisxeulebis formirebis gverdiTi jaWvebis Teoria, aRmoaCina poxieri ujredebi da eozinofilebi

Clemensvon Pirquet (1874-1929). Semoitana "alergiis" cneba, tuberkulinis kanis sinji da aRwra Sratis daaavadeba

Sir Henry H. Dale (1875-1968). gansazrvra hisaminis roli anafilaqsiaSi da nervuli impulsis qimiuri gadacema

(a) JeanMartin Charcot (1825-93). (b) Ernst V.von Leyden (1832-1910). aRweres nemsiseburi kristalebi asTmiT avadmyofTa naxvelSi, romelTac ewodaT Sarko-leidenis kristalebi

(a)Leonard Noon (1877-1913). (b)JohnFreeman (1877-1962). Semoitanes Tivis cxelebis imunoTerapia yvavilis mtvris eqstraqtiT

(a)OUo Carl W. Prausnitz (Giles) (1876-1963). (b)(b) Heinz Kiistner (1897-1963). kanis dauyovnebeli reaqciis pasiuri gadatana kanSida sinjiT alergiuli pacientis SratiT (reagini), e.w. "praustnic-kiustneris reaqcia" (P-K)

Arthur Fernandez Coca (1875-1959). Semoitana "atopiis" cneba

Mary Hewitt Loveless (1899-1991). xeli Seuwyo imunoTerapiis ganviTarebas; robert kukTan eTad aRwera mablokirebeli antisxeulebi, pirvelad gamoiyeneba mwerebis Sxami desensibilizaciisTvis

(a) Charles H. Kellaway (1889-1952) (b) Everton R. Trethewie (1913-84). pirvelad aRweres "anafilaqsiis neladmomqmedi nivTiereba"

Charles H. Blackley (18201900). mcenarebis yvavilis mtveris, rogorc Tivis cxelebis mizezis identifikacia

Francis M. Rackemann (1887-1973). Semoitana egzogenuri da endogenuri asTmis cneba

Henry Hyde Salter (1823-71). asTmis mizezebis aRwera da naxvelSi ujredebi (amJamad eozinofilebi)

(a) TamesF.Riley(1912-85). (b) Geoffrey B. West (1916-). aRmoaCines, rom poxieri ujredebis granulebi arian qsovilovani histaminis ZiriTadi Semcvelebi

Kimshige Ishizaka (1925-). Teruko Ishizaka (1926-). ganszRvres reagini, rogorc IgE.

K. Frank Austen (1928-). poxieri ujredebisa da mediatorebis, leikotrienebis bioqimiis pioneeri

Hans Bennich (1930-); Gunnar Johansson (1938-). imunoglobulin ND, rogorc IgE-is identificireba; videsTan erTad ganaviTara radio-alergo sorbentuli testis teqnika

Bengt 1. Samuelsson (1934-). SRS-A ­s, rogorc leikotrienebis identifikacia da qimiuri daxasiaTeba

Robin A. Coombs (1921-) aRwera antiglobulinuri (kumbsis) testi, jelTan erTad Semoitana alergiul reaqciaTa klasifikacia

Jack Pepys (1914-96). Termofiluri aqtinomicetis sokos, rogorc fermerebis filtvis mTavari xelSemwyobis aRmoCena; alergiuli alveolitebis, bronqopulmonuri aspergilozis da profesiuli asTmis etiologiisa da paTogenezis gansazRvra

Robert A. Cooke(1880-1960). Semoitna cilis azotovani erTeuli (PNU) alergenebis standartizaciisTvis; aRwera wamlismieri alergiis SemTxvevebi, memkvidruli fenomeni Tivis cxelebis dros, aRmoaCina "mablokirebeli antisxeulebi"

Roger E.e. Altounyan (1922-87). aRmoaCina sodiumis qromoglikati

Daniel Bovet

Philip Hench and Edward Kendall

1904 ­ Stolci ­ adrenalini 1950-60 ­ araseleqtiuri beta stimuliatori 1970 ­ sainhalacio kortikosteroidebi 1970-iani ­ seleqtiuri beta 2 stimulatorebi 1990-iani ­ pirveli antileikotrienuli preparatebi 2000-iani ­ samkurnalo monoklonuri antisxeulebi

Sir John Floyer (1649-1734). asTmis, rogorc multifaqtoruli daavadebis, daxasiaTeba gamowveuli mravali gamRizianebliT (Tambaqos moxmareba, mtveri, sakvebi, fizikuri varjiSi, garemo faqtorebi). asTmaSi memkvidrulobis rolis pirvelad aRwera

John Bostock (1773-1846). aRwera 'catarrhus aestivus', mogvianebiT ganisazRvra, rogorc Tivis cxeleba

Moses Maimonides (1135-1204). avtori cnobili traqtatisa 'Treatise on Asthma'

Thomas E. Willis (1621-75). bronquli inervaciis mniSvneloba asTmis dros; asTma rogorc nervuli daavadeba

Bernardino Ramazzini (1633-1714). mcxobelebSi profesiuli asTmis pirveli aRwera

alergiis zogierTi mniSvnlovani TariRebi (1)

Zv. w. aR. 28-e saukune Zv. w. aR. 2698 Zv. w. aR. 2641 Zv. w. aR. 375 Zv. w. aR. 41 Zv. w. aR. 25 ax. w. aR. 40 60 120 ­180 865 Shen Nung antiasTmuri wamlebis pirveli wyaroebi (efedrinis Semcveli mcenareebi), efedrinis Semcveloba dadginda mogvianebiT nei CingSi asTmis pirveli aRwera ("xmauriani sunTqva") uZvelesi traqtati Sinagani medicinaSi egviptis faraoni gardaicvala krazanis kbenis Sedegad (anafilaqsiuri Sokis pirvelad aRwerili SemTxveva) asTmis, egzemis, Txis rZisa da yvelis mimarT alergiis pirveli Semxvevebis aRwera cxenis mimarT mwvave alergiuli reaqciis pirvelad aRwera traqtatSi 'De medica` qoSinis, asTmisa da orTopneas aRwera klasikuri farmakologiis traqtatSi 'De Materia Medica` pirveli antiasTmuri wamlebi asTmis pirveli detaluri aRwera da sityva "asTmis" Semotana sparseTSi vardebiT gamowveuli sezonuri kataris aRwera

Huang Ti Menes Hippocrates Britannicus Aulus Celsus Pedanius Dioscorides Aretaeus of Cappadocia Rhazes

alergiis zogierTi mniSvnlovani TariRebi (2)

11351204 1306 1478 1565 1584 1682 1783 1802 1816 1819 Moses Maimonides John of Arderne Thomas Moore Leonardhus Botallus Johann Schenk Joan van Helmont Philipp Phoebus William Heberden Henri Laennec John Bostock sulTan saladinis eqimis mier asTmis traqtatis Seqmna antiasTmuri sirofis recepti marwvis miRebis Semdeg mefe riCard III-is kanis mwvave aSreveba paviaSi (italia) "vardebis cxelebis" aRwera cneba "idiosinkraziis" Semotana fsiqosomaturi asTmisa da sezonuri asTmis aRwera kanis qaviliTa da aqercvliT (atopiuri dermatiti?) Tivis cxelebis Sesaxeb monografia, pirveli epidemiologiuri kvleva zafxulis katarisa da asTmis aRwera, zogadi gacivebisagan maTi diferencireba stetoskopis Semotana; bronqospazmis, rogorc asTmis mniSvnelovani komponentis, identifikacia maRal sazogadoebaSi Tivis cxelebis pirveli 28 SemTxvevis aRwera

alergiis zogierTi mniSvnlovani TariRebi (3)

1837 1872 1872 1873-80 Johann Schoenlein Morrill Wyman Heinrich Quincke Charles Blackley revmatiuli purpuris pirveli aRwera aSS-Si Semodgomis kataris aRwera da ambroziasTan, rogorc mizezTan, identificireba angionevrozuli SeSupebis pirveli aRwera mcenaris yvavilis mtvris rolis eqsperimentuli demonstrireba Tivis cxelebis mizezad, mcenaris yvavilis mtvris pirveli daTvlebi revmatiuli purpuris meore aRwera kontaqturi dermatitis sadiagnostikod alergeniT kontaqtis testis aRmoCena Tirkmelzeda jirkvlis substanciis gamoyeneba Tivis cxelebisa da asTmis dros Sratis daavadebis pirveli aRwera difTeriis mimarT mimReblobis kanis sinji adamianis Tivis cxelebisa da WinWris cxelebis kavSiri eqsperimentul anafilaqsiasTan izolirebuli gluvi kunTis in vitro SekumSvis testi anafilaqsiis gansazRvrisaTvis

1882 1895 1900 1905 1905 1906 1909

Eduard Henoch Josef Jadassohn Solomon SolisCohen Bela Schik, C.Pirquet Bela Schick Wolff-Eisner William Schultz

alergiis zogierTi mniSvnlovani TariRebi (4)

1911 1912 1913 1914 1915 1922 1924 1924 1928 1927 Tomaso Casoni Oscar M. Schloss William Dunbar A.T. Waterhouse Warfield T.Longcope Fernand Widal Ko Kuei Shen Carl F.Schmidt F.T. Codham Storm van Leeuwen Thomas Lewis Echinococcus inficirebul pacientebSi kanis sinji sakvebis mimarT alergiis skarifikaciuli kanis sinji mcenareebis eqstraqciis meTodologia, alergenuli cilebis identifikacia anafilaqsiuri reaqcia mefutkreebSi futkris kbenis Semdeg cxovelTa organoebis eqsperimentuli dazianebebi ucxo cilis ganmeorebiTi Seyvanis Semdeg nazaluri polipebi, asTma da aspiinis autanloba efedrinis farmakologiis sistemuri kvlevebi sokoebis mimarT alergiis pirveli aRwera oTaxis mtvris mimarT sainhalacio alergiis aRwera WinWris ciebasa da histamibnis mimarT kanis sisxlZarRvovani reaqciebis msgavsebis aRwera (sisxlZarRvebis gafarToeba, qavili, siwiTle da lokaluri SeSupeba, rogorc triaduli pasuxi)

1932 1948

Wilhelm Loefler Andre filtvebis mfrinavi eozinofiluri infiltratis aRwera, romelic dakavSirebuli iyo askaridoziT infeqciasTan Essellier

alergiis zogierTi mniSvnlovani TariRebi (5)

1934 1937 1939 1941 1948 Mataso Masugi Daniel Bove Harry H. Donally Joseph Harkavy Malcolm H. Hargraves eqsperimentuli glomerulonefriti anti Tirkmliseuli antiSratiT antisistemuri preparatebis pirveli sinTzi sakvebi alergenebis gadacema dedis rZiT bronquli asTma rekurentuli eozinofiluri filtvebis infiltraciiT da poliserozitiT neitrofiluri leikocitebis mier fagocitirebuli nuklearuli masalis aRwera, romelic damaxasiaTebelia autoimunur/autoalergiuli daavadebebisTvis antinuklearuli antisxeulebiT (lupus erythematosus) revmatoiduli arTritis samkurnalod kortizonis gamoyeneba desensibilizaciis efeqturobis Sesafaseblad pirveli placeboTi kontrlirebadi klinikuri kvleva (alergenspecifikui imunoTerapia) hipo da agamaglobulinemiuri sindromebi, Timusis roli imunodeficitebSi eqsperimentuli autoalergiuli Tireoiditi; autoimunuri daavadebebis paTologia da kriteriumebi

1949 1954

Philip S.Hench Edward C. Kendall William Frankland Rosa Augustin Robert A.Good Ernest Witebsky

1956 1957

alergiis zogierTi mniSvnlovani TariRebi (6)

1960 1962 1963 1964 Bernard.B.Levine Alain L. de Weck Alain L. de Weck Charles W. Parker Frank J.Dixon Lawrence M. Lichtenstein Abraham G. OsIer T.E. King David Marsh Reindert Voorhorst Frederick Spieksma Bernard Halpern penicilinis mimarT alergiisas mTavari da aramTavari alergenebis aRwera penicilinis mimarT alergiis diagnostika kanis sinjiT sinTezuri penicilloy 1-pol yl ysine polimeriT antigen-antisxeulebis kompleqsebis roli daavadebebSi alegen-specifiuri histaminis gamoTavisuflebis testi

1964 1966 1967 1967

ambroziaSi mTavari alergenis identificireba balaxebis mTavari alergenebis identificireba Dermatophagoides-is tkipebis, rogorc oTaxis mtvris mTavari alergenebis wyaros, identificireba limfocitebis stimulaciis testi wamlismieri alergiebis diagnostikisTvis

qronikuli daavadebebis mizezebi

ZiriTadi socialekonomikuri, kulturuli, politikuri da garemo determinantebi cvalebadi riskfaqtorebi Sualeduri risk-faqtorebi ZiriTadi qronikuli daavadebebi

arajansaRi kveba hopodinamia Tambaqos moxmareba

ucvleli riskfaqtorebi

maRali sisxlis wneva maRali glukoza sisxlSi maRali lipidebi sisxlSi Warbi wona

gulis daavadebebi simsivne qronikuli respiratoruli daavadebebi diabeti insulti

globalizacia urbanizacia mosaxleobis dabereba

asaki memkvidreobiTi

alergiul daavadebaTa zrda me-20 saukuneSi

60%

50%

50% 40% 30% 20% 10%

30% - 35% 22% 14% 0% 3,5%

1958

17%

3%

1968

5%

1981

8%

0% 1926 1985 1987 1989 1995 2000 2050

qronikuli respiraciuli daavadebebi (CRD)

asTma COPD alergiuli riniti meoradi pulmonaruli hipertenzia profesiuli qronikuili respiraciuli daavadebebi qronikuli rinosinusiti postinfeqciuri qronikuli respiraciuli daavadebebi filtvis kibo da respiratoruli organoebis axalwarmolnaqmnebi filtvis emboliis garTulebebi filtvismieri guli Zilis apnoes sindromi filtvis fibrozebi sul > 1 miliardi

300 mln. (GINA, 2004) 80 mln. 400 mln. 25 mln. 25 mln. 50 mln. ar aris monacemebi ar aris monacemebi ar aris monacemebi ar aris monacemebi 100 mln. ar aris monacemebi

sikvdilianoba wamyvani daavadebaTa klasebis mixedviT msoflioSi

gulsisxlZarRvTa daavadebebi simsivneebi filtvis qr. obst. daavadeba da asTma sxva aragadamdebi daavad. travmebi da mowamvlebi gadamdebi daavad.

7,4%

2020

36,3%

18,1% 5,2%

10,8% 12,3%

15,1%

2002

29,2%

12,6%

11,5% 9,1% 4,7%

32,3%

1990

28,4%

12,5%

10,6% 10,1%

34,2%

0%

20%

40%

60%

80%

100%

2002 w. msoflioSi asTma 23-e adgilze iyo DALYs mixedviT

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 perinataluri mdgomareobebi (98,4 mln) 16 qveda sasunTqi gzebis infeqciebi aiv/Sidsi unipolaruli depresiuli darRvevebi diarea gulis iSemiuri daavadeba cerebrovaskularuli malaria sagzao SemTxvevebi tuberkulozi dedaTa mdgomareoba COPD (28 mln) Tandayolili anomaliebi wiTura Zaladoba 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TviTdazianebebi alkoholis borotad gamoyeneba cilovani kvebiTi darRvevebi travma Saqriani diabeti Sizofrenia osteoarTriti asTma (15,0 mln) RviZlis cirozi bipolaruli darRvevebi yivanaxvela anemiebi sggd traqeis/bronqis/filtvis kibo daxrCoba/moxrCoba

gayidvebis mixedviT 10 wamyvani produqti msoflio farmacevtul bazarze, 2003 ($ bill)

Lipitor Zocor Zyprexa Norvasc Erypo(Eprex/Procrit) Ogastro/Prevacid Nexium Plavix Seretide/advair Zoloft

0 2

10,3 6,1 4,8 4,5 4 4 3,8 3,7 3,7 3,4

4 6 8 10 12

Lipitor - Chl. Reducer Nexium - Antiulcerants Plavix - Platelet Agg Inhib Seretide - Antiasthmatic Zocor - Chl. Reducer Norvasc - Calcium Antag Ogastro - Antiulcerants Effexor- Antidepressant Enbrel - Antirheumatic Singulair-Antiasthmatic 2005

Gglobaluri iniciativebi

asTmis globaluri iniciativa (GINA) janmos iniciativa alergiuli rinitisa da misi asTmaze zemoqmedebis sferoSi (ARIA) GOLD ­ filtvis qronikuli obstruqciuli daavadebis globaluri iniciativa (COPD) GARD ­ sasunTqi gzebis daavadebaTa globaluri aliansi dokumentebi: EAACI ­ alergiisa da klinikuri imunologiis evropis akademia, AAAAI ­ amerikis alergiis, asTmisa da imunologiis, WAO ­ alergiis msoflio, UCB- alergiis instituti, GLORIA ­ alergiis globaluri resursebi da sxv.

asTmisa da alergiis msoflio dReebi

1998 wels mravali qveynis asTmis mowinave specialistebisa da GINA sponsorebis TanamSromlobiT dafuZnda asTmis msoflio dRe (maisis pirveli samSabaTi), romelic warmatebiT xorcieldeba da yovelwliurad sul ufro met monawileebs ikrebs 2003 da 2004 wlebSi asTmis msoflio dRis mTavari Tema iyo "asTmiT gamowveuli globaluri tvirTi" 2005 wels asTmis msoflio dRis mTavari Tema iyo "asTmasTan dakavSirebuli daukmayofilebeli saWiroebebi" 2006 wlis 2 maisis mTavari Tema igive 2005 wlis 8 ivliss dawesda da pirvelad aRiniSna alergiis msoflio dRe 2007 wlis 1 maiss asTmis msoflio dRis mTavari Tema aris "Tqven SegiZliaT gaakontroloT Tqveni asTma" 2007 wlis 4 dekemberi alergiis msoflio dRe

amerikis alergiis, asTmisa da amerikis alergiis, asTmisa da alergiis, imunologiis koleji imunologiis koleji

ACAAI ACAAI

amerikis alergologiis, asTmisa da amerikis alergologiis, asTmisa da alergologiis, imunologiis akademia imunologiis akademia

AAAAI AAAAI

alergiis msoflio organizacia alergiis msoflio organizacia

WAO WAO

amerikis gulmkerdis sazogadoeba amerikis gulmkerdis sazogadoeba

ATS ATS

amerikis filTvebis asociacia amerikis filTvebis asociacia

ALA ALA

alergiis alergiis saerTaSoriso saerTaSoriso kolegiumi kolegiumi

CIA CIA

evropis alergologiisa da evropis alergologiisa da klinikuri imunologiis akademia klinikuri imunologiis akademia

EAACI EAACI

evropis respiratoruli sazogadoeba evropis respiratoruli sazogadoeba

ERS ERS

amerikis gulis, filtvebisa da amerikis gulis, filtvebisa da gulis, sisxlis nacionaluri instituti sisxlis nacionaluri instituti

NHLBI NHLBI

amerikis alergiis da egzemur amerikis alergiis da egzemur daavadebaTa nacionaluri instituti daavadebaTa nacionaluri instituti

NIAID NIAID

asTmis saerTaSoriso sazogadoeba asTmis saerTaSoriso sazogadoeba

Interashma Interashma

alergiisa da asTmis Semswavleli organizaciebi da instituciebi

asTma da alergia evropis federacia asTma da alergia evropis federacia

EFAAA EFAAA

UCB Institute of Allergy UCB UCB Institute of Allergy UCB

alergiis instituti alergiis instituti

alergiuli riniti da misi zemoqmedeba asTmaze alergiuli riniti da misi zemoqmedeba asTmaze

ARIA ARIA

janmrTelobis msoflio organizacia janmrTelobis msoflio organizacia

WHO WHO

alergiisa da asTmis globaluri qseli alergiisa da asTmis globaluri qseli

GA2LEN GA2LEN

asTmis gl iniciativa asTmis gl iniciativa

GINA GINA

filtvebis qronikuli obstruqtuli filtvebis qronikuli obstruqtuli filtvis daavadeba iniciativa filtvis daavadeba iniciativa

GOLD GOLD

respiratirul daavadebaTa respiratirul daavadebaTa globaluri aliansi globaluri aliansi

GARD GARD

ALTANA ALTANA EAMG EAMG

MERCK Scharpand MERCK Scharpand Dohme Dohme

evropis alergenebis evropis alergenebis mwarmoebelTa jgufi mwarmoebelTa jgufi

Bühlmann Bühlmann Laboratories AG Laboratories AG

Nestle Nutrition Nestle Nutrition

alergiisa da asTmis sferoSi moRvawe ZiriTadi samedicino da farmacevtuli kompaniebi

NOVARTIS NOVARTIS

Pharmacia Diagnostics Pharmacia Diagnostics

Sanofi aventis Sanofi aventis

Schering Plough Schering Plough

Boehringer Boehringer Ingelhein Ingelhein

UCB Pharma UCB Pharma

Astrazeneca Astrazeneca

GlaxoSmithkline GlaxoSmithkline

specializacia evrogaerTianebis qveyanaSi

alergologia da klinikuri imunologia. moTxovna: 5 wlis ganmavlobaSi specializacia.

gadamzadebis 4 ZiriTadi modeli:

alergologia (alergia) rogorc calke specialoba (Svecia, espaneTi) alergologia rogors specialoba dakavSirebuli imunologiasa an klinikur imunologiasTan (italia, portugalia) alergologia rogorc sxvadasxva organoTa (filtgebi, yel-yur-cxviri) specialobebis subspecialoba (safrangeTi, germania) alergologia rogorc klinikuri imunologiis subspecialoba (Sveicaria)

alergologiis ganviTarebis ZiriTadi etapebi saqarTveloSi

1963-1964 1964-1974 1974 1976-1977 1981-1989 1988 1992 1992 2005 pirveli alergologiuri kabineti TbilisSi Tbilisis saxelmwifo samedicino institutSi alergologiis kursis SemoReba saqarTveloSi alergologiuri samsaxuris qselis Seqmna Tbilisis saxelmwifo samedicino institutSi alergologiuri kaTedris daarseba mecnierebaTa akademiis sistemaSi, alergologiis kvleviTi ganyofilebis daarseba qarTul-germanuli samecniero TanamSromloba alergiisa da asTmis kvlevis sferoSi alergiul daavadebaTa epidemiologiisa da imunogenetikis ganyofilebis daarseba Tbilisis saxelmwifo samedicino institutSi saqarTvelos asTmisa da alergiis klubis daarseba saqarTvelo gaerTianda evropis alergologiisa da klinikuri imunologiis akademiaSi saqarTvelo gaxda alergologiis msoflio organizaciis wevri

ukanaskneli 50 wlis manZilze alergiis SemTxvevebis mkveTri zrdis mizezebi

ratom izrdeba alergiis SemTxvevebis ricxvi? higienuri garemos cvla: naklebi infeqciebi meti antibiotikebi, gazrdili stresi naklebad infeqciuri da baqteriuli sakvebi kvebiTi Cvevebis cvlileba: naklebad fermentuli sakvebi (naklebad laqtikuri baqteriebi sakvebSi) Zalian mravalferovani sakvebi >> meti alergenebi 3-dan 6 cximovani mJavas Semcvel sakvebze gadasvla naklebi antioqsidantebi sakvebSi cxovrebis stilis Secvla naklebi dedmamiSvilebi, adamianTa jgufSi yofnis Semcireba qalaqSi cxovrebis gaxangrZliveba, naklebi kontaqtebi Sinaur cxovelebTan nawlavis floris cvlilebebi da TH1 da TH2 imunuri sistemis disbalansi warmoadgens yvela zemoT CamoTvlili mizezebis Sedegs

alergiuli reaqciebis paTfiziologia

antigeni lorwovani zedapiri

damuSaveba da warmodgena

farmakologiuri efeqti sisxlZarRvebi, sasunTqi sisxlZ gzebi da sxv. sxv. ujredebis infiltracia da akumulacia reformirebuli an axlad formirebuli mediatorebi klinikuri efeqti Tivis cxeleba asTma egzema anafilaqsia

citokinebi

GM-CSF, TNF GMTNF IL-8/9 stimulirebuli ILujredebis aqtivacia

antigenis warmodgena

IgE warmoqmna

poxieri ujredebis aqtivacia

mediatorebis gamoTavisufleba

klinikuri efeqti

anTeba asTma/alergiis dros: ujredebi da mediatorebi

anTebis ujredebi · poxieri ujredebi · eozinofilebi · Th2 ujredebi · bazofilebi · neitrofilebi · Trombocitebi · struqturuli ujredebi · epiTeluri ujredebi · endoTeluri ujredebi · fibroblastebi · kunTis ujredebi · nervebi

· · · · · · · · · · ·

mediatorebi histamini leikotrienebi prostanoidebi Trombocitebis aqtivaciis faqtori kininebi adenozinebi endoTelinebi azotis oqsidi citokonebi qemokinebi zrdis faqtorebi

efeqti · bronqospazmi · plazmis eqsudacia · lorwos sekrecia · AHR · struqturuli cvlilebebi

Source: Peter J. Barnes, MD

alergiis diagnostikis ZiriTadi komponentebi

anamnezi da fizikaluri gamokvleva

(simptomebis da eqspoziciis Sedareba)

diagnozis damadasturebeli testi

kanis sinji (priktesti, ksanSida) alergen-specifiuri IgE-is gamkvleva

provokaciuli testebi

oraluri, nazaluri, bronquli

alergenebis ZiriTadi jgufebi

cxoveluri alergenebi

sakvebi

mwerebi/ tkipebi

medikamentebi

sokoebi da baqteriebi

profesia/ hobi

parazitebi

mcenareebi

saneleblebi

55

60

Prick test

IC test

spirometriuli (FEV1) mrudebi

moculoba FEV1 janmrTeli asTmis mqone pacienti (bronqodilatoris miRebis Semdeg) asTmis mqone pacienti (bronqodilatoris miRebis win) 1 2 3 4 dro (wami) 5

SeniSvna: yoveli FEV1 mrudi

warmoadgens saukeTeso maCvenebels sami ganmeorebadi gazomvidan

alergen specifiuri IgE gansazRvris farTod gamoyenebuli meTodis ilustracia (ImmunoCAP® System)

pacientis IgE

ImmunoCAP-Tan ImmunoCAPSeerTebuli alergeni SekavSireba; SekavSireba; anti IgE fermenti

pacientis IgE antisxeuli dakavSirebulia immonoCAP antigenTan

fluorogenuli substrati

SekavSireba pacientis IgE-Tan IgE-

SekavSirebuli fermenti reagirebs fluorescentiis produqtis maformirebel substratze

naCvenebia roca naCvenebia roca SesaZlebelia SesaZlebelia

alergenis alergenis eliminacia eliminacia

usafrTxo usafrTxo efeqturi efeqturi advilad gamosayenebeli advilad gamosayenebeli

farmakoTerapia farmakoTerapia

alergiul daavadebaTa mkurnalobis ZiriTadi principebi

efeqturi efeqturi specialistis mier specialistis mier gamoiyeneba gamoiyeneba SeuZlia Secvalos SeuZlia Secvalos daavadebis bunebrivi daavadebis bunebrivi ganviTareba ganviTareba

imunoTerapia imunoTerapia

pacientis ganaTleba pacientis ganaTleba

yovelTvis naCvenebia yovelTvis naCvenebia

alergiis samkuranalo saSualebebi

adgilobrivi antihistaminurebi (azelastini, levokabastini) pirveli generaciis oraluri antihistaminurbi axali generaciis oraluri antihistaminurebi antialergiuli saSualebebi (kromoglikati da nedokromili) antiqolinerguli saSualebebi dekongestantebi antileikotrienuli preparatebi adgilobrivi kortikosteroidebi sistemuri kortikosteroidebi alergenspecifikuri ineqciuri imunoTerapia sublingvaluri-oraluri imunoTerapiis maRali dozebi adamianis monoklonuri antisxeulebi IgE-s winaaRmdeg, mag. omalizumabi amosaxveleblebi Zveli Taobis medikamentebi axali CvenebebiT (lidokaini, magneziumis sulfati da sxva)

histaminis, histaminis receptorebisa da H1 antihistaminuri preparatebis istoria

Tirkmelzeda jirkvali

1900

Adrenaline Isoprenaline Salbutamol Formoterol Salmeterol Cortisol Beclomethasone Budesonide Mometasone Fluticasone Ciclesonide

1999

P Barnes Berlin 1999

Symbicort Seretide

alergiuli rinitis magaliTze farmakoTerapiis modebis wertilebi

antihistaminebi

histamini leikotienebi prostaglandinebi bradikinini PAF dauyovnebeli rinitis simptomebi

· qavili · cxviridan gamonadeni · cxviris gaWedva

alergenis mocileba

poxieri ujredebi

Anti-IgE

IgE B ujredebi

IL-4

VCAM-1

alergeni

natriumis qromoglikati

steroidebi imunoTe rapia

T ujredebi (poxieri ujredebi)

IL-3, -5 GM-CSF

eozinofilebi

qronikuli rinitis simptomebi

· cxviris gaWedva · ynosvis dakargva · cxviris lorwovanis hipereaqtiuloba

imunoTerapia - desensibilizacia

ml

Th1 IL-2 INF- imunuri gadaxra? alergia? orive? IL-4 IL-5 IL-9

TCD4+

IT

Th2

t

mcenaris yvavilis mtveri kata oTaxis mtvris tkipebi mwerTa Sxamebi Zalian mcire monacemebia (Tumca damaimedebeli) ZaRlis bewvisa da sokovan alergenebTan dakavSirebiT

alergenebi, romelTa efeqturoba imunTerapiisas Seswavlilia ormagi, brma meTodiT

arasaineqcio an lokaluri imunoTerapia oraluri imunoTarapia sublingvaluri imunoTerapia lokaluri ­ nazaluri lokaluri bronquli imunoTerapia uaxlesi midgomebi axali imunoTerapiuli midgomebi aris amJamad kvlevis qveS: ­ liposomuri vaqcinacia ­ adiuvantebi ­ anti IgE kombinirebuli imunoTerapiasTan ­ peptiduri vaqcinebi ­ rekombinantuli alergenebi ­ dnm vaqcinebi

axali kortikosteroidebi axali bronqodilatatorebi mediatorebis antagonistebi imunomodilatorebi interleikinebis inhibitorebi TNF- inhibitori citokinebis inhibitorebi qemokinebis receptorebis inhibitorebi fosfodiesTeraza-4-is inhibitorebi

as Tm is / ax a le sa sa mku al i rgi S u rn is al al eb o eb i

transkrifciis faqtoris inhibitorebi kinazas inhibitorebi T-ujredebis adheziis blokatorebi antialergiuli medikamentebi vaqcinebi, imunoTerapia da imunostimulacia genuri Terapia

bronqodilatatorebis moqmedebis molekuluri meqanizmebi

2 adrenoreceptorebis, vazoaqtiuri intestinuli peptidis (VIP) da prostaglandin E2 (PGE2) receptorebis aqtivacia iwvevs adenilil ciklazis (AC) aqtivacias G-proteinis (Gs) saSualebiT da cAMP-is koncentraciis momatebas. igi aaqtiurebs protein kinaza A-s (PKA), romelic Semdeg afosforilebs sxvadasxva cilebs, rac iwvevs kalciumiT aqtivirebuli kaliumis arxebis (KCa) an maxi-K arxebis gaRebas, amcirebs fosfoinozitidis (PI) hidrolizs, imatebs Na+/K+ ATP-aza da mcirdeba miozinis msubuqi jaWvis kinazis (MLCK) aqtivoba, rasac mivyavarT sasunTqi gzebis gluvi kunTebis relaqsaciamde. damatebiT, 2adrenoreceptorebi SeiZleba SeuerTdnen pirdapir Gs-iT KCa-s. cAMP iSleba fosfodiesTeraziT (PDE), romelic inhibirdeba TeofiliniT da seleqtiuri PDE3 inhibitoriT, rac aseve asTmis Terapiis potenciuri

asTmis dros pro-anTebiTi citokinebis inhibitorebisaTvis sxvadasxva strategiebi

es moicavs citokinebis sinTezis inhibirebas (mag. kortikosteroidebi), transkrifciis faqtoris inhibirebas, romelic aregulirebs citokinebis eqspresias (mag. kalcineurinis inhibitorebi an oligonukleotidebis maketi), sekretirebuli citokinebis inhibicia mablokirebeli antisxeulebiT (mag. antiinterleikin (IL)-5 antisxeulebi), an xsnadi receptorebiT (mag. xsnadi IL-4 receptorebi), citokinebis receptorebis blokirebiT (mag. qemokinebis receptorebis antagonistebi), signalis gadacemis gzis blokirebiT (mag. P38 mitogenaqtivirebuli kinazis inhibitori), an transkrifciis faqtoris aqtivacia citokinebiT (mag. STAT6 inhibitorebi)

eozinofiluri anTebis inhibicia

arsebobs sxvadasxva strategiebi qsovilovani eozinofiluri anTebis inhibirebisTvis, esenia: imunomodulatorebi (mag. CyA, takrolimusi, mikofenolati, brequinari da tozilatis sulfati), proanTebiTi titokinebis inhibitorebi (mag. interleikin (IL)-4 da IL-5), molekulebis adheziis inhibicia (mag. gviani antigen-4, seleqtinebi, ujredSida adheziis molekula-1), eozinofilebze qemokinebis receptorebis blokireba (mag. qemokinis receptori-3 (CCR3)) da apoptozis gamowveva kortikosteroidebiT, lidokaini da p38 mitogenaqtivirebuli proteinazas (MAPK) inhibitorebi.

interleikin 13-is blokirebis efeqti asTmis dros

interleikin (IL)-13-s aqvs mravali efeqti alergiuli anTebisas asTmis dros, romelic moicavs imunoglobulin E-s (IgE) produqcias B limfocitebis mier, momatebul eqspresias dabali afinurobis receptorisa IgE-Tvis (FCRII, CD23) sxvadsxva anTebiT ujredebze, lorwos momatebul sekrecias sasunTqi gzebis epiTeliumidan. damatebiT, IL-13 iwvev steroidebis mimarT rezistentobas (albaT p38 mitogen-aqtiviebuli protein kinazas aqtivaciiT). IL-13 SeiZleba dablokirdes maRali afinobis xsnadi receptorebiT (shuIL-13R2), mablokirebeli antisxeulebiT an STAT6-is inhibitorebiT, romelic aseve aqtivirdeba IL4-iT.

qemokinebis receptorebis antagonistebi

mravali qemokini aris CarTuli asTmis paTofiziologiaSi. arsebobs sami mTavari qemokinis receptoris (CCR) samizne asTmis dros: CCR2, CCR3 da CCR4. CCR3 aris yvelaze warmatebuli mcire molekuluri inhibitorebis ganviTarebis TvalsazrisiT. damatebiT, mcire molekuluri inhibitorebi viTardebian amJamad CCR2 da CCR4-Tvis (magaliTad, INCB003344 CCR2-Tvis). eotaqsinebi, RANTES (gamoTavisufldeba aqtivirebuli normaluri T ujredebis mier) da monocitebis qemotaqsis protein-4 (MCP4) aaqtiveben CCR3, monocitebis qemotaqsiuri proteini 1-5 aaqtivebs CCR2, maSin, roca monocitebis mier gamoyofili qemokini (MDC) Timuss da aqtivaciaze damokidebuli qemokini (TARC) aaqtivebs CCR4 da CCR8, romlebic upiratesad ganlagebuli arian TH2 ujredebze.

fosfodiesteraza-4-is inhibitorebs aqvT farTo antianTebiTi moqmedebis speqtri asTmis dros?

fosfodiesTeraza-4 (PDE4) inhibitorebi amuxruWeben aqtivacias da procesebSi CarTvas mTavari anTebiTi ujredebisa, rogoricaa poxieri ujredebi, eozinofilebi, T limfocitebi, makrofagebi da neitorfilebi, aseve struqturuli ujredebis hiperplaziasa da hipertofias, rogoricaa sasunTqi gzebis gluvi kunTebis ujredebi, epiTeluri ujredebi da sensoruli da qolinerguli nergvebi

alergiuli pasuxis inhibitorebis strategiebi asTmis dros

imunoglobulini E-s (IgE) inhibireba SeiZleba omalizumabis (a) antisxeulebiT da dabali afinobis IgE receptorebiT anti-CD23-is saSualebiT (b). poxieri ujredebi SeiZleba daiblokos qromonebiT da furosemidiT (c), albaT qloridebis arxebze zemoqmedebiT da Syk kinazis inhibitorebiT, romelic amuxruWebs IgE receptorebis gaaqtivebis signalis gadacemis gzas (d). antigenis prezentacia SeiZleba daiblokos kostimulatoruli molekulebis inhibitorebiT (e), romelic moicavs B7.2, CD28 da romlebic ainducireben komastimulirebel molekulebs (ICOS) da citotoqsiur T limfocit antigen-4 (CTLA4). TH2 ujredebi, aseve pirdapir SeiZleba damuxruWdes interferon--Ti (IFN-), interleukini (IL)-12-iT da IL-18-iT (f).

axali kortikosteoidebi

msubuqi steroidebi da ciklozonidi disocirebuli kortikosteroidebi

axali bronqodilatatorebi vazoaqtiuri intestinuri peptidi prostaglandini E2 atriuli natriurezuli peptidi K+ arxebis gamRebi

mediatorebis antagonistebi

antihistaminebi leikotrienebis modifikatorebi prostaglandinebis antagonistebi endoTelinis antagonistebi azotis Jangis inhibitorebi adenozinis antagonistebi triptazis inhibitorebi

imunomodulatorebi sainhalacio ciklosporini takrolimusi rapamicini mofetinis mikofenolati (celcefti; roSi)

interleikinis inhibitorebi interferoni- IL-10 IL12 IL-8

citokinebis inhibitorebi anti-interleikini (IL)-4 anti-IL-5 anti-IL-13 anti-IL-9 anti-simsivnis-nekrozis faqtoris antisxeulebi

qemokinebis receptorebis inhibitorebi CCR3 CCR2 CCR4 antagonistebi

fosfodiesTeraza-4-is inhibitorebi cilomilasti roflumilasti

kinazas inhibitorebi CSAIDs magaliTad:

­ SB203580 ­ SB239063 ­ RWJ67657

T- ujredebis adheziis blokatorebi

mogvianebiTi antigen-4-is inhibitorebi seleqtini

antialergiuli medikamentebi qromonebi furosemidi inhibitorebis stimulatorebi anti-IgE anti-CD23

vaqcinebi, imunoTerapia da imunostimulacia specifikuri imunoTerapia T-ujredebis peptidebi vaqcinacia CpG oligonukleotidebi

genuri Terapia

mgrZnobelobis sawinaaRmdego oligonukleotidebi RNA interferencia

gmadlobT yuradRebisaTvis

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