1

danarTi 2

Tambaqos wevis mitoveba da

prevencia

klinikuri mdgomareobis marTvis saxelmwifo standarti

(protokoli)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 24 agvistos

# 283/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

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Tambaqos wevis mitoveba da prevencia (protokoli)

1. nikotinuri damokidebuleba

definicia

damokidebulebis medicinis amerikis sazogadoebis mier damokidebulebis daavadebebi ganimarteba, rogorc paTologiuri procesi, romelic xasiaTdeba specifikuri fsiqoaqtiuri nivTierebebis moxmarebis gagrZelebiT miuxedavad gamowveuli mavne fizikuri, fiziologiuri da/an socialuri Sedegebisa.

nikotinuri damokidebuleba aris swrafva Tambaqos produqtebis mimarT, romelic gamowveulia Tambaqos Semadgeneli ZiriTadi fsiqoaqtiuri ingredientis- nikotinis moqmedebiT. nikotini fizikurad da fsiqologiurad miCvevas iwvevs. sigaretisgan, sigarisgan da Cibuxisgan gamonabolqvi nikotinis garda Seicavs 4000-mde qimiur nivTierebas, romelTaganac 40-ze meti cnobilia, rogorc kibos gamomwvevi (kancerogeni).

nikotinuri damokidebuleba niSnavs, rom pirs ar SeuZlia Sewyvitos Tambaqos moxmareba miuxedavad im zianisa, romelsac Tambaqos weva ayenebs. damokidebulebis damaxasiaTebel niSnebs miekuTvneba Tambaqos moxmarebis gagrZeleba miuxedavad gacnobierebisa, ra samedicino problemebi moaqvs mowevas, aRkveTis simptomebis ganviTareba moxmarebis Sewyvetisas da Tavis danebebis warumatebeli mcdelobebi. regularuli mwevlebis umravlesobas miesadageba Tambaqos damokidebulebis diagnostikuri kriteriumebi daavadebaTa saerTaSoriso klasifikaciis me-10 gadasinjvis – dsk-10 an fsiqikuri daavadebebis diagnostikuri da statistikuri saxelmZRvanelos me-4 ganaxlebuli gamocemis - DSM-IV-s mixedviT.

saqarTveloSi narkologiuri daavadebebis diagnostirebisTvis gamoiyeneba dsk me-10 gadasinjva, romlis mixedviTac, nikotinuri damokidebulebis qveS igulisxmeba fsiqikuri da qceviTi aSlilobebi, romlebic nikotinis miRebiTaa gamowveuli da zustdeba kodiT F17.

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gamoyenebuli Semoklebebi

dsk-10 – daavadebaTa saerTaSoriso klasifikacia, me-10-e

gadasinjva

DSM‐IV 

– fsiqikuri daavadebebis diagnostikuri da statistikuri saxelmZRvanelos me-4 ganaxlebuli gamocema

nCT – nikotinCanacvlebiTi Terapia

2. daavadebis diagnozi

skriningi

zogadsaeqimo praqtikaSi yvela pacients unda hkiTxoT, eweva Tu ara Tambaqos da regularulad SeavsoT Tambaqos mowevis statusis amsaxveli dokumenti. mtkicebulebebi adasturebs, rom klinikuri skrininguli sistemebi, romlebic Tambaqos mowevis Sesaxeb SekiTxvebs Seicavs, aseve samaxsovroebi (kompiuteruli an baraTebiT) mniSvnelovnad zrdis klinikuri intervenciebis sixSires (mtkicebulebis xarisxi A).

ojaxis eqimebs SeuZliaT Seafason maTi pacientebis mowevis qceva ramdenime wuTSi specialuri kiTxvarebis meSveobiT: CAGE kiTxvari mowevisTvis, “4 Cs” testi da Fagerström testi nikotinze damokidebulebis simZimis Sesafaseblad (ix. danarTebi 1, 2 da 3). maT SeuZliaT SearCion Sefasebis am kiTxvarebidan erTerTi maTgani, romelsac ukeT moirgeben praqtikaSi da gamoiyeneben mkurnalobis individualuri gegmis SesamuSaveblad.

sadiagnozo kriteriumebi

saqarTveloSi narkologiuri daavadebebis diagnostirebisTvis gamoiyeneba dsk me-10 gadasinjva, romlis mixedviTac, nikotinuri damokidebulebis qveS igulisxmeba fsiqikuri da qceviTi aSlilobebi, romlebic nikotinis miRebiTaa gamowveuli da zustdeba kodiT F17.

damokidebulebis sindromi dsk me-10 gadasinjvis mixedviT ismeba, Tu 1 wlis manZilze 6 niSnidan aReniSneba 3 an meti:

fsiqoaqtiuri nivTierebis miRebis kompulsiuri survili;

tolerantoba;

kontrolis dakargva nivTierebis miRebisas, misi moxmarebis dawyebis, damTavrebis an moxmarebis xasiaTis TvalsazrisiT;

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aRkveTis sindromis formireba;

moxmarebis gagrZeleba miuxedavad damRupveli Sedegebisa;

alternatiuli interesebis progresuli ukuganviTareba fsiqoaqtiuri nivTierebis miRebis sasargeblod.

gamoiricxeba: 1. Tambaqoze damokidebuleba warsulSi (Z87.82), Tambaqos moxmareba (sxvagvarad dauzustebeli) (Z72.0); 2. Tambaqos moxmareba (moweva) fexmZimobis, Sobadobis da fexmZimobis Semdgom (puerperul) periodSi (daaxlovebiT 6 kvira) (O99.33-); nikotinis toqsikuri efeqti (T65.2-).

nikotinuri damokidebulebis sindromis Semdgomi dazusteba Tambaqos nawarmis mixedviT xdeba kodebiT:

F17.2 nikotinuri damokidebuleba;

F17.2 1 nikotinuri damokidebuleba, sigareti;

F17.22 nikotinuri damokidebuleba, Tambaqos ReWva;

F17.29 nikotinuri damokidebuleba, Tambaqos sxva produqtebi.

damokidebulebis simZimis gansazRvra Fagerström testis meSveobiT (ix danarTi 3) daexmareba eqimebs mkurnalobis Semdgomi taqtikis SemuSavebaSi., mag. saWiroa Tu ara nikotinuri CanacvlebiTi Terapiis CarTva mkurnalobaSi. damatebiTi kiTxvarebi SeiZleba gamoyenebul iqnas pacientis cvlilebisTvis mzaobis Sesafaseblad.

3. simptomebi da niSnebi

Tambaqos moxmarebiT gamowveuli mwvave intoqsikacia1

a. unda akmayofilebdes mwvave intoqsikaciis (F1x.0) zogad kriteriumebs: gardamavali mdgomareoba fsiqoaqtiuri nivTierebis (am SemTxvevaSi, nikotinis) miRebis Sedegad, rac iwvevs cnobierebis, kognituri funqciebis, aRqmis, emociebis, qcevis da sxva fsiqofiziologiuri funqciebisa da reaqciebis moSlas.

b. adgili unda hqondes disfunqciur qcevas an perceptualur (aRqmis) moSlilobas, romelic dadasturebulia sul cota, erT-erTi qvemoTCamoTvliliT:

1. insomnia;

2. eqscentruli sizmrebi;

3. guneb-ganwyobis labiloba;

4. derealizacia;

5. personalur funqcionirebaSi xelis SeSla.

1 mwvave nikotinuri intoqsikacia - F17.0

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g. saxeze unda iyos, sul mcire, erTi niSani qvemoTCamoTvlilTagan:

1. gulisreva an pirRebineba;

2. oflianoba;

3. taqikardia;

4. gulis ariTmiebi.

Tambaqos aRkveTis mdgomareoba2

a. unda akamyofilebdes aRkveTis mdgomareobis (F1x.3) zogad kriteriumebs (ix. ZiriTadi terminebis ganmartebani)

b. saxeze unda iyos romelime ori niSani qvemoTCamoTvlilTagan:

1. ltolva Tambaqos mimarT (an nikotinis Semcveli sxva produqtis mimarT);

2. diskomforti an sisuste;

3. SfoTva;

4. disforiuli ganwyoba;

5. gaRizianebadoba an mousvenroba;

6. insomnia;

7. gazrdili mada;

8. xvelis gaxSireba;

9. piris dawyluleba;

10. yuradRebis koncentraciis gaZneleba.

Tambaqos moxmarebis samedicino Sedegebi

Tambaqos moxmarebis moklevadiani uaryofiTi Sedegebi vlindeba sigaretis mowevisTanave – gulis cemis gaxSireba, arteriuli wnevis zrda, yelis lorwovani garsis gaRizianeba, naxSirJangis sisxlSi SeRweva, filtvebSi kancerogenebis moxvedra, haeris mowamvla, Tvalis lorwovani garsis gaRizianeba.

Tambaqos moxmarebiT gamowveuli sxva uaryofiTi Sedegebia: tuCis, enis, sasis, saylapavi milis lorwovani garsis dazianeba (rac iwvevs gemovnebis SegrZnebis klebas), mSrali xvela, piris Rrus infeqciebi, gamonayari saxeze, kbilis minanqris dazianeba, normaluri sunTqvis darRveva, gamZleobis, mexsierebis da mxedvelobis daqveiTeba, sxvadasxva daavadebebis mimarT organizmis brZolisunarianobis Sesusteba.

2 F17.3

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4. mkurnaloba

konsultireba da fsiqosocialuri rekomendaciebi

aucilebelia, rom pirveladi jandacvis profesionalebma Caataron xanmokle intervenciebi (10 wuTze<) Tambaqos momxmareblebTan.

rCeva mowevis Sewyvetis Taobaze

klinicistebma aucileblad unda urCion yvela mwevel pacients, Sewyviton moweva, radgan mtkicebulebebma aCvena, rom eqimis rCeva zrdis mowevis Tavis danebebis sixSires (mtkicebulebis xarisxi A).

am mxriv daxmarebis strategia Sejamebulia e.w. `5A~-s wesSi.

pacientis mier Tambaqos wevis Sewyvetis xelSewyobis sqema:

1. gamokiTxeT (Ask): yoveli vizitis dros moaxdineT mwevelebis identifikacia. danergeT sistema, romlis mixedviTac yvela pacients yvela vizitisas gamokiTxavT Tambaqos wevis Sesaxeb da SeavsebT Sesabamis dokumentacias;

2. urCieT (Advise): dabejiTebiT urCieT yvela mwevels Tambaqos wevis Sewyveta. rCeva gasagebi, damajerebeli da uSualo unda iyos;

3. SeafaseT (Assess): gansazRvreT, surs Tu ara mwevels Tambaqos wevis Sewyveta hkiTxeT yvela mwevels, surs Tu ara scados Tambaqos wevis Sewyveta axla (anu uaxloesi 30 dRis manZilze);

4. daexmareT (Assist):

pacientebisTvis, vinc mzadaa mowevas Tavi daanebos:

daexmareT pacients Tambaqos wevis Sewyvetis gegmis SedgenaSi; CautareT praqtikuli konsultaciebi; uzrunvelyaviT socialuri mxardaWera; saWiroebis SemTxvevaSi urCieT farmakoTerapia; miawodeT damxmare masalebi;

pacientebisTvis, vinc mzada ar aris mowevas Tavi daanebos:

ganixileT pacientTan erTad mowevisTvis Tavis danebebis upiratesobebi, aseve masTan dakavSirebuli siZneleebi; miawodeT saganmanaTlebo masalebi; urCieT, ar moswios ojaxis wevrebis TandaswrebiT, raTa ar gaxdnen pasiuri mwevlebi; daarwmuneT Tqvens mzaobaSi, daexmaroT; SeekiTxeT pacients mowevisadmi misi damokidebulebis Sesaxeb yoveli Sexvedrisas.

5. dagegmeT (Arrange): dagegmeT pacientze Semdgomi dakvirveba vizitebis an satelefono kontaqtebis gziT.

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skriningis savaraudo Sedegebi Sesabamisi intervenciebis mimarTulebebiT da Tambaqoze damokidebulebis mkurnalobis modelebi sqematurad gamosaxulia algoriTmebSi (sqemebi 1, 2):

sqema 1. algoriTmi Tambaqos moxmarebis mkurnalobisTvis

surs pacients Tavis danebeba?

moixmarda pacienti odesme Tambaqos?

Caatare Sesabamisi mkurnaloba

gaaZliere motivacia

Tavis dasanebeblad

imuSave recidivis prevenciaze

waaxalise abstinencia

ki ara ki ara

ara ki

moixmars pacienti amJamad Tambaqos?

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sqema 2. Tambaqos moxmarebisa da damokidebulebis mkurnalobis modeli (algoriTmi) (Treating Tobacco Use and Dependence: 2008 Update) zogadi

populacia

pacienti imyofeba jandacvis sitemaSi

Ask –SeekiTxeT yvela pacients Tambaqos moxmarebis Sesaxeb

(skriningi)

pirveladi prevencia

Advice – urCieT Tavis danebeba

Assess – SeafaseT pacientis mzaoba mowevis Sewyvetis Taobaze

Assist – gauwieT asistireba Tambaqos moxmarebis SewyvetaSi

Arrange – dagegmeT Semdgomi kontaqti

recidivis prevencia

gaaZliereT Tavis danebebis motivacia

ara

aqvs moiaxmars

adre moixmarda ara

kvlav ar surs Tavis danebeba

gauCnda Tavis danebebis survili

abstinenti

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klinikuri Carevis intensiuroba

minimaluri intervencia _ 3 wuTze naklebi xangrZlivobisac ki _ zrdis Tavis danebebis sixSires. yvela mwevels unda SesTavazoT minimaluri intervencia mainc, imis miuxedavad, SemdgomSi Cautardeba Tu ara mas intensiuri intervencia (mtkicebulebis xarisxi A).

arsebobs myari doza-damokidebuli kavSiri erTi-erTze konsultaciis xangrZlivobasa da mkurnalobis warmatebul Sedegebs Soris. intensiuri Carevebi ufro efeqturia, vidre naklebad intensiuri, amitom sadac SesaZlebelia isini unda gamoiyenoT (mtkicebulebis xarisxi A).

mkurnalobis individualuri (erTi-erTze) seansebi 4 da meti raodenobiT gansakuTrebiT efeqturia Tavis danebebis sixSiris gazrdis TvalsazrisiT. amitom, klinicistebi unda ecadon, 4-jer mainc Sexvdnen pacients TambaqosaTvis Tavis danebebis procesis ganmavlobaSi, Tuki es SesaZlebelia (mtkicebulebis xarisxi A).

fsiqosocialuri mkurnalobis formati

proaqtiuri satelefono konsultireba, jgufuri konsultireba da individualuri konsultireba _ yvela es forma efeqturia da unda gamoyenebuli iqnas Tambaqos mowevis Sewyvetis intervencebis dros (mtkicebulebis xarisxi A).

sxvadasxva formatiT Catarebuli Tambaqos mowevis Sewyvetis intervenciebi zrdis Tavis danebebis sixSires da rekomendebulia (mtkicebulebis xarisxi A)

gamovlinda, rom specialuri masalebi _ beWduri an kompiuteruli _ efeqturia da exmareba adamianebs mowevis SewyvetaSi. amitom klinicistebma unda uzrunvelyon TviT-daxmarebis masalebis miwodeba im pacientebisTvis, visac mowevis Sewyveta surs (mtkicebulebis xarisxi B).

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medikamenturi mkurnaloba

Tambaqos Sewyvetis medikamenturi mkurnalobisaTvis sadReisod arsebobs 7 ZiriTadi pirveli rigis medikamenti – bupropion-SR, nikotinis Semcveli saReWi rezini, nikotin-inhalatori, nikotinis Semcveli nazaluri sprei, nikotinis Semcveli plastiri, rimonabandi da vareniklini da 2 ZiriTadi meore rigis preparati – klonidini da notriptilini.

aRniSnuli preparatebi gamoiyeneba rogorc monoTerapiis saxiT, ise 2-is an metis kombinaciiT. Cveulebriv, Tambaqos moxmarebis SewyvetisaTvis medikamenturi mkurnaloba gamoiyeneba rogorc erT-erTi komponenti mkurnalobis mTlian kursSi, vinaidan medikamentebi ZiriTadad amsubuqebs aRkveTis simptomebs da amgvarad aadvilebs mis mowevis Sewyvetas.

pirveli rigis medikamentebi

bupropioni

bupropioni-SR (gaxangrZlivebuli moqmedebis) antidepresantia. amcirebs nikotinis aRkveTis sindroms. ar Seicavs nikotins. moqmedebs tvinis im receptorebze, romlebic nikotinis “moTxovnaze” arian pasuxismgebelni.

igi SeiZleba gamoyenebul iqnes rogorc monoTerapiis (erTi preparatiT mkurnaloba) saxiT, aseve nikotin Camnacvlebel saSualebebTan kombinaciaSi (nikotinis Semcvel plastirTan, an xanmokle moqmedebis nikotinis Semcvel saReW rezinTan da nikotinis Semcvel abebTan erTad).

dozireba: preparatis miReba unda daiwyos mowevis Sewyvetamde erTi an ori kviriT adre. iniSneba mzardi doziT - 1 abi (150 mg) dReSi erTxel, diliT, sami dRis ganmavlobaSi, Semdeg erTi abi 2-jer dReSi. tableti unda gadaiylapos da ar daiReWos. preparatis miRebis xangrZlivoba Seadgens 7-12 kviras. Tu pacientma ver miaRwia SesamCnev efeqts, me-7 kviridan mkurnaloba wydeba.

gverdiTi movlenebi: gverdiTi movlenebi: gverdiTi movlenebi: gverdiTi movlenebi: Zilis darRveva (insomnia), piris simSrale.

ukuCveneba: apopleqsia, alkoholizmi, qala-tvinis mZime tramva, kvebiTi aSlilobebi (anoreqsia, bulemia).

bupropioni SR mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

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nikotinCanacvlebiTi Terapia

a) nikotinis Semcveli saReWi rezini

warmoadgens swrafad moqmed nikotinis Semcvel saSualebas. nikotini Seiwoveba piris Rrus lorwovani garsidan.

dozireba: dReSi erT kolof sigaretze metis mowevisas 4 mg-iani, xolo erT kolofze naklebis- 2 mg-iani nikotinis Semcveli saReWi rezini.

ar SeiZleba dReSi 24 saReW rezinze metis daReWva. preparatis gamoyenebis xangrZlivoba Seadgens 1-3 Tves.

gverdiTi movlenebi: cudi gemo pirSi, xaxisa da piris Rrus lorwovanis gaRizianeba (wyluli), slokini, gulisreva, taqikardia.

ukuCveneba: orsuloba, ZuZuTi kveba, ariTmia, stenokardia, infarqti, 18 welze naklebi asaki, aramweveloba, alergia.

nikotinis saReWi rezini mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

mZime mwevelebSi umjobesia daniSnos 4 mg-iani nikotinis saReWi rezini 2 mg-ianis nacvlad (mtkicebulebis xarisxi B).

b) nikotin-inhalatori

preparati warmoadgens Txel plastikur tumbos, nikotinis kartrijiT. misi inhalacia iZleva sigaretis mowevis simulacias, radganac nikotinis orTqli grovdeba pirSi da ar aRwevs filtvebamde.

dozireba: mkurnaloba iwyeba 6-16 inhalaciiT dReSi 3 Tvis manZilze. Semdeg doza mcirdeba safexureobrivad.

mkurnalobis xangrZlivoba: 6 Tve.

gverdiTi movlenebi: xvela, xaxisa da piris Rrus lorwovanas gaRizianeba, diskomforti kuWis areSi.

ukuCveneba: instruqciis mixedviT miRebisas ukuCveneba ar gaaCnia.

nikotinis inhalatori mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

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g) nikotinis tabletebi

nikotinis Semcveli preparatebis SedarebiT axali formaa. arsebobs misi 2 da 4 mg-iani formebi.

dozireba: dozis SerCeva xdeba imis mixedviT, Tu gaRviZebidan ramden xanSi ewevian sigarets. pirveli 6 kviris ganmavlobaSi - 1 tableti yovel 1-2 sT-Si, me-7-9 kviras 1 tableti 2-4 sT-Si, xolo me-10-12 kviras 1 tableti yovel 4-8 sT-Si.

nikotinis tabletebis miRebis rekomendaciebi: kursis dawyebisTanave unda Sewydes nikotinis gamoyeneba, miRebamde 15 wT-iT adre pacientma ar unda miiRos sakvebi da siTxe, ar daReWos da gadaylapos igi, unda wuwnos daaxloebiT 20-30 wT-is ganmavlobaSi. ar gamoiyeneba 5 tabletze meti 6 sT-is ganmavlobaSi, an 20 tabletze meti dRis ganmavlobaSi. tabletebis miReba wydeba 12 kviris mere. ar unda gagrZeldes misi miReba, Tu am periodis manZilze pacienti paralelurad agrZelebs nikotinis miRebas da/an iyenebs nikotinis Semcvel sxva preparatebs.

gverdiTi movlenebi: mousvenari Zili, gulisreva, xvela, Tavis tkivili, slokini, Seberiloba.

nikotinis sawuwni tabletebi mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi B).

d) nikotinis Semcveli nazaluri sprei

sprei momentalurd aqrobs aRkveTis simptomebs, radgan cxviris lorwovani garsidan swrafad Seiwoveba sisxlSi. aseve iZleva nikotinis survilis regulirebis saSualebas da praqtikulia mosaxmarad.

dozireba: 8-40 doza dReSi.

miRebis xangrZlivoba: 3-6 Tve. ar aris rekomendirebuli 6 Tveze meti xniT gamoyeneba.

gverdiTi movlenebi: cxviris Rrusa da xaxis lorwovani garsis gaRizianeba, riniti, cremldena, xvela, cemineba. SeiZleba gamoiwvios SeCveva.

ukuCveneba: asTma, alergia, cxviris polipi, sinusiti.

nikotinis nazaluri sprei mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

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e) nikotinis Semcveli plastiri

plastiri ikvreba diliT mSral, sufTa, naklebad Tmian kanze kisrisdan welis donemde. Zilis win rekomendirebulia plastiris moSoreba.

dozireba: sxeulis masis mixedviT plastiris gamoyeneba unda daiwyos maRali dozidan – 15mg/16 sT-iani plastiriT yovel dRe 8 kviris ganmavlobaSi; Semdeg doza mcirdeba 10mg/16 sT-mde 2 kviris ganmavlobaSi, bolos 5 mg/16sT-iani 2 kvira. E

mZime mwevelebSi efeqturia preparatis kombinireba nikotinis Semcvel inhalatorTan an saReW rezinasTan.

gverdiTi movlenebi: kanis gaRizianeba (siwiTle, qavili), Tavbrusxveva, taqikardia, insomnia (Zilis darRveva, ucnaur sizmrebi), Tavis tkivili, gulireva, Rebineba, diskomforti muclis areSi.

ukuCveneba: plastiris gamoyenebis periodSi akrZalulia sigaretis moweva.

nikotinis plastiri mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

vareniklini

vareniklini axali preparatia, moqmedebs tvinis nikotinis receptorebze da iwvevs, erTi mxriv, imgvari fizikuri siamovnebis gancdas, romelsac mweveli mowevisas ganicdis, da meores mxriv, aRkveTis sindromis Semcirebas.

gverdiTi movlenebi: Tavis tkivili, gulisreva, Rebineba, mSfoTvare Zili, uCveulo sizmrebi, Seberiloba, gemos Secvla.

araa Seswavlili misi moqmedeba sxva nikotinis Semcvel preparatebTan kombinaciaSi.

vareniklini mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa da pacentebs unda urCioT misi gamoyeneba (mtkicebulebis xarisxi A).

citizini

nikotinCanacvlebiT Terapiis (nCT) SedarebiT axali formaa mcenareuli warmoSobis citizini, romlis Terapiuli efeqti efuZneba imas, rom mowevis fonze is iwvevs nikotinis dozis gadaWarbebis arasasiamovno efeqts, rac aiZulebs mwevels Seamciros moweuli sigaretis raodenoba an gadaagdos igi.

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dozireba: pirveli sami DdRis ganmavlobaSi iniSneba 1 abi 6-jer dReSi, yovel 2 saaTSi. Tu am xnis ganmavlobaSi rezultati ar SeiniSneba, mkurnaloba unda ganaxldes 2-3 Tvis Semdeg, xolo dadebiTi rezultatis SemTxvevaSi kursi grZeldeba Semdegi sqemiT:

me-4-12 dRis CaTvliT – 1 tableti yovel 2,5 sT-Si (sul dRe-RameSi 5 tableti);

me-13-16 dRis CaTvliT – 1 tableti yovel 3 sT-Si (sul 4 tableti).

me-17-20 dRis CaTvliT – 1 tableti yovel 5 sT-Si (sul 3 tableti).

21-25-e dRes – 1 tableti 6-8 sT-Si (sul 2 tableti dReSi).

gverdiTi movlenebi: Tu kursis mimdinareobisas dozireba sworadaa daculi, gverdiTi movlenebi sustadaa gamoxatuli. SesaZloa gamovlindes gemosa da madis Secvla, piris simSrale, gulisreva da Rebineba, Sekruloba, Tavis tkivili, gaRizianebadoba, wnevis momateba, taqikardia.

ukuCveneba: arteriuli hipertenzia, gamoxatuli aTerosklerozi, sisxldena msxvili kalibris sisxlZarRvebidan, filtvebis SeSupeba, momatebuli mgrZnobeloba im nivTierebebis mimarT, romelsac Seicavs aRniSnuli preparati.

rekomendebuli ar aris orsulebsa da meZuZur qalebSi.

rimonabanti

rimonabanti warmoadgens kanabinoid-1 receptoris blokers.

sigaretis gadagdeba rTuli procesia da xSirad mas Tan sdevs wonaSi mateba. rimonabanti aadvilebs sigaretis gadagdebis process da amasTanave xels uSlis Warbi wonis ganviTarebas Semdegi meqanizmiT: moqmedebs tvinis endokanibanoidur sistemaze, kerZod, CB-1 receptorebze, romlebic pasuxismgebelni arian nikotinisa da sakvebisadmi ltolvaze. rimonabanti amcirebs ra maT aqtivobas, sxeulidan wamosul impulsebze tvini adekvaturad ver reagirebs, Sesabamisad, organizmi naklebad ganicdis SimSils da nikotinisadmi ltolvas.

dozireba: Wamis Semdeg 120 mg-iani tableti dReSi erTxel.Aar SeiZleba tabletis daReWva da daqucmaceba.

gverdiTi movlenebi: gulis reva, Rebineba, Zilis darRveva.

ukuCveneba: meore tipis diabeti, gulis daavadebebi, orsuloba, ZuZuTi kveba.

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meore rigis preparatebi

II rigis medikamentebs miekuTveneba iseTi medikamentebi, romelTa efeqturobis mtkicebulebebi arsebobs, magram maTi roli nikotindamokidebulebis mkurnalobaSi ufro SezRudulia, vidre I rigis preparatebisa, radgan potenciuri gverdiTi efeqtebis albaToba ufro maRalia. II rigis preparatebi gamoiyeneba konkretul SemTxvevebSi maSin, rodesac I rigis preparatebi (calke an kombinaciaSi) araefeqturi aRmoCnda an isini winaaRmdegnaCvenebia.

klonidini

klonidini moqmedebs nervul sistemaze da SesaZloa Seamsubuqos aRkveTis simptomebi sxvadasxva saxis damokidebulebis dros, maT Soris Tambaqos moxmareba, alkoholizmi, opioidebze damokidebuleba. es medikamenti aucileblad eqimis mier unda dainiSnos. TviTmkurnaloba saxifaToa.

dozireba: 0,15-0,75 mg dReSi 3-10 kviris ganmavlobaSi.

gverdiTi movlenebi: piris simSrale, Zilianoba, Tavbruxveva, sedacia.

ukuCveneba: hipotenzia.

klonidini mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa. is miRebuli unda iyos eqimis meTvelyureobis qveS, rogorc II rigis medikamenti nkotindamokidebulebis samkurnalod (mtkicebulebis xarisxi A).

nortriptilini

nortriptilini meore Taobis tricikluri antidepresantia. amcirebs aRkveTis sindroms da amgvarad, mwevelobis Sewyveta advildeba.

dozireba: 75-100 mg dReSi, 12 kviris ganmavlobaSi.

gverdiTi movlenebi: sedacia, piris simSrale, orTostatuli hipotenzia, araregularuli da momatebuli guliscema, zogierTi seqsualuri problema. alkoholis momxarebam SesaZloa gaaZlieros es movlenebi.

ukuCveneba: ariTmia, miokardiumis infarqtis reabilitaciis periodi.

nortriptilini mowevis sawinaaRmdego efeqturi samkurnalo saSualebaa. is miRebuli unda iyos eqimis meTvelyureobis qveS, rogorc II rigis medikamenti nikotindamokidebulebis samkurnalod (mtkicebulebis xarisxi A).

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medikamentebis kombinacia

pirveli rigis medikamentebis zogierTi kombinacia sakmaod efeqturi aRmoCnda mowevis sawinaaRmdego mkurnalobisas. amitom, klinicistebma unda ganixilon am kombinaciebis gamoyenebis sakiTxi. es kombinaciebia:

grZelvadiani gamoyeneba (>14 kviraze) nikotinis plastiris + sxva romelime nCT (saReWi rezini an aerozoli);

nikotinis plastiri + nikotinis inhalatori;

nikotinis plastiri + bupropion SR (mtkicebulebis xarisxi A).

dagrovda sakmarisi odenobis saTanado statiebi, medikamentebis 5 kombinaciis efeqturobis Sesafaseblad placebosTan SedarebiT. mxolod nikotinis plastiri + bupropionis kombinaciam miiRo saTanado dadastureba amerikis kvebisa da wamlis saagentos mier (FDA). es kombinaciebi iyo:

nikotinis plastiri + bupropion-SR;

nikotinis plastiri + nikotinis inhalatori;

nikotinis plastiri (xangrZlivi moqmedebis) + romelime nCT;

nikotinis plastiri + nortriptilini;

nikotinis plastiri + meoradi generaciis antidepresantebi.

ra ar aris rekomendebuli Tambaqos moxmarebis SewyvetisaTvis

Tambaqos wevis mitovebisTvis ar aris rekomendebuli Semdegi wamlebis da midgomebis gamoyeneba3:

antidepresantebi (bupropion-SR da nortriptilinis garda);

serotoninis ukuCaWeris inhibitorebi (SSRI);

anqsiolitikebi/benzodiazepinebi/beta-blokerebi;

opioidebis antagonistebi/naltreqsoni;

vercxlis acetati;

mekamilamini;

medikamentebis xangrZlivi gamoyeneba;

nCT gul-sisxlZaRvTa sistemis paTologiis mqone pacientebSi.

gansakuTrebuli populaciebi

am gaidlainSi aRwerili efeqturi intervenciebi efeqturi aRmoCnda sxvadasxva populaciaSi gamoyenebisas. mravali kvleva Catarda Tambaqos momxmareblebis sxvadasxva jgufebze. aqedan gamomdinare,

3 Ggaidlainis “Treating Tobaco Use and Dependence: 2008 update” eqspertTa paneli

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mowodebuli intervenciebi rekomendebulia yvela Tambaqos momxmareblisTvis, garda im SemTxvevebisa, rodesac medikamenti ukunaCvenebia an specifikuri populaciebisa, romlebSic am medikamentebis gamoyenebis efeqturoba ar dadasturda – orsulebi, pirebi, romlebic Tambaqos ara mosawevis formiT iyeneben, msubuqi mwevelebi da mozardebi (mtkicebulebis xarisxi B).

bavSvebi da mozardebi

klinicistebma unda hkiTxon bavSvebs da mozardebs Tambaqos moxmarebis Sesaxeb da kargad auxsnan maT, Tu ra mniSvnelovania Tambaqos mowevisgan Tavis Sekaveba (mtkicebulebis xarisxi C).

konsultireba efeqturi aRmoCnda mozardebis mkurnalobisTvis, amitom mozard mwevelebs unda Cautardes intervencia konsultirebiT, romlis mizania mowevis Sewyveta (mtkicebulebis xarisxi B). pasiuri mweveloba mavnea bavSvebisTvis. efeqturi aRmoCnda mweveli mSoblebisTvis Tambaqos mowevis Sesaxeb konsultireba pediatriul dawesebulebebSi _ gaizarda mwevel mSoblebSi Tavis danebebis sixSire. amitom, pasiuri mwevelobisgan bavSvebis dasacavad, klinicistebi unda SeekiTxon mSoblebs Tambaqos moxmarebis Sesaxeb, urCion maT mowevis Sewyveta da SesTavazon daxmareba (mtkicebulebis xarisxi B).

msubuqi mwevelebi

saWiroa msubuqi mwevelebis identificireba, dabejiTebiT rCeva, daanebon Tavi mowevas da mowevis Sewyvetisken mimarTuli intervenciebis (konsultireba) Catareba (mtkicebulebis xarisxi B). 

momxmareblebi, romlebic Tambaqos mosawevis formiT ar iyeneben

saWiroa maTi identificireba da dabejiTebiT rCeva, daanebon Tavi Tambaqos gamoyenebas; aseve aucilebelia intervenciebis (konsultireba) Catareba (mtkicebulebis xarisxi A). stomatologebma unda Cautaron mokle konsultireba yvela momxmarebels, romlebic Tambaqos mosawevis formiT ar iyeneben (mtkicebulebis xarisxi A).

saWiroa sigaris, Cibuxis mwevlebis da sxva ara sigaretis formiT Tambaqos momxmareblebis identificireba, dabejiTebiT rCeva, daanebon Tavi mowevas. aucilebelia mowevis Sewyvetisken mimarTuli intervenciebis (konsultireba) Catareba (mtkicebulebis xarisxi C).

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orsuli mwevelebi

radgan moweva seriozul risks warmoadgens orsulisa da nayofisTvis, rekomendebulia yvela mweveli orsuli qalisTvis, rodesac ki SesaZlebelia, erTi-erTze fsiqosocialuri intervenciis SeTavazeba, romelic scildeba mxolod martivi

rCevis farglebs (mtkicebulebis xarisxi A). rogorc nayofisTvis, aseve dedisTvis bevrad ukeTesia orsulobis adreul vadaze Tambaqos mowevis Sewyveta, magram orsulobis nebismier perodSi Tavis danebebas mainc moaqvs dadebiTi Sedegebi. amitom klinicistebma orsulebs unda SesTavazon Tambaqos sawinaaRmdego efeqturi RonisZiebebi, pirveli prenataluri vizitidan dawyebuli, mTeli orsulobis ganmavlobaSi

(mtkicebulebis xarisxi B).

wonaSi momateba

im pacientebisTvis, romlebic Relaven mowevis Sewyvetis Semdeg wonaSi momatebis Taobaze, yvelaze gamarTlebulia bupropion SR an nCT (kerZod, nikotinis saReWi rezini an nikotinis sawuwni abi). dadgenilia, rom es preparatebi aferxeben wonis matebas mowevis

Sewyvetis Semdeg (mtkicebulebis xarisxi B).

5. reabilitacia / meTvalyureoba

yvela pacienti, romelic itarebs Tambaqoze damokidebulebis mkurnalobas, unda Sefasdes mkurnalobis damTavrebis Semdeg da yoveli momdevno vizitis dros. (1) pacientebi, romlebmac warmatebiT daanebes Tavi mowevas, unda waaxalison klinicistebma, xolo maT, visac problemebi aqvT mowevis SewyvetasTan dakavSirebiT, klinicistebma unda SesTavazon daxmareba/asistireba. (2) pacientebi, romlebmac ver SeZles Tavis danebeba, unda Sefasdnen, aqvT Tu ara ganmeorebiTi mcdelobis survili (mtkicebulebis xarisxi C).

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6. marTvis sqema

qvemoTmocemul gaidlainSi mowodebulia mowevis Sewyvetis specifikuri intervenciebi amJamad Tambaqos momxmareblebisTvis samizne

mosaxleoba sakvanZo sakiTxebi rekomendaciebi da mtkicebulebis xarisxi sixSire

yvela pacienti 12 wlis da zeviT (warsuli mowevis statusis miuxedavad)

Tambaqos mwevelobis statusis (arasodes mouwevia, yofili mweveli, amJamad eweva) da tipis (iyenebs Tambaqos yvela formiT, Cibuxi, Tambaqos ynosva, sigara) dadgena

SeekiTxeT: CawereT mwevelobis statusi pacientis samedicino baraTSi

yovel amulatoriul vizitze da stacionarSi Sesvlisas.

yvela amJamad Tambaqos momxmarebeli/ mweveli pacienti

Tambaqos mowevis Sewyvetis xelSemwyobi intervencia

surs mowevis Sewyveta ar surs mowevis Sewyveta yovel prevenciul vizitze, an ufro xSirad, Tu eqimi CaTvlis saWirod.

Advise – urCieT mowevis Sewyveta Assess – SeafaseT pacientis survili, Tavi daanebos Tambaqos

Assist – daexmareT daadginos Sewyvetis TariRi. miawodeT masalebi TviTdaxmarebis Taobaze, SesTavazeT referali Tambaqos mitovebis programaSi, SesTavazeT farmakologiuri mkurnalobis variantebi:

a. nikotinCanacvlebiTi Terapia b. bupropioni c. vareniklini (chartix)

Arrange – organizeba gaukeTeT Semdgom meTvalyureobas, piradad an telefoniT. gaiTvaliswineT referali qceviTi Terapiis specialistTan:

o Sewyvetis TariRidan I kviris ganmavlobaSi;

o Sewyvetis TariRidan I Tvis ganmavlobaSi.

Relevance – aqtualoba: hkiTxeT pacients, ramdenad aqtualuria piradad misTvis mowevis Sewyveta

Risks _ riski: sTxoveT pacients, CamoTvalos ra potenciuri uaryofiTi Sedegebi aqvs mowevas

Rewards - sargebeli: sTxoveT pacients, CamoTvalos ra potenciuri sargebeli aqvs Tambaqos wevis mitovebas

Roadblocks – barierebi: sTxoveT pacients, Camoayalibos Tambaqos wevis mitovebis Semafexebeli faqtorebi

Repetition – gameoreba: kvlav SeaxseneT pacients, rom mas SeuZlia wevis mitoveba

gansakuTrebuli garemoebebi: orsuli mwevelebi: dedisa da nayofisTvis seriozuli riskis arsebobis gamo, mwevel orsulebs unda SesTavazoT Tambaqos wevis mitovebis programaSi monawileoba. hospitalizirebuli mwevelebi: eqimebma unda Cautaron aseT pacientebs saTanado farmakoTrapia da konsultireba saavadmyofoSi yofnis periodSi, nikotinis aRkveTis simptomebis Sesamcireblad da daexmaron mwevelebs Tavi daanebon Tambaqos. mwevelebi, Tanmxlebi fsiqiatriuli daavadebebiT: nikotinis aRkveTis simptomebma SeiZleba daamZimon depresia anamnezSi afeqturi aSlilobis mqone pacientebSi. Tambaqos wevis Sewyvetam SeiZleba Secvalos zogierTi fsiqotropuli preparatis farmakokinetika. eqimebma xSiri monitoringi unda gauwion fsiqotropuli medikamentebis gverdiT efeqtebs mwevelebSi/Tambaqos momxmareblebSi, romlebic cdiloben Sewyviton moweva.A

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7. danarTebi

skriningis instrumentebi nikotinuri damokidebulebis gamosavlenad da damokidebulebis simZimis gansasazRvravad

danarTi 1. CAGE kiTxvari, danarTi 2. “4 Cs” testi, danarTi 3. Fagerstrom-is testi

danarTi 1. CAGE kiTxvari, modificirebuli mowevis qcevis Sesafaseblad

kiTxvebi: interpretacia

odesme Tu

C: gifiqriaT, rom Tqven unda SeamciroT an gaakontroloT Tqveni moweva, magram gqoniaT siZneleebi?

dadebiTi pasuxi romelime 2 SekiTxvaze aris pozitiuri skriningi da sasurvelia dasazusteblad Semdgomi SekiTxvebis dasma moxmarebuli Tambaqos raodenobis, xangrZlivobis da Tanmxlebi uaryofiTi Sedegebis Taobaze.

A: gauRizianebixarT an gaubrazebixarT xalxis kritikas Tqveni mowevis Taobaze an rCevas, rom Tavi daaneboT mowevas?

G: Tavi gigrZniaT cudad an damnaSaved mowevis an sxva ramis gamo, rac gaakeTeT mowevisas?

E: mogiweviaT Tvalis gaxelisTanave diliT 1/2-1 saaTis ganmavlobaSi?

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danarTi 2. “4 C”-s testi

dafuZnebulia DSM-IV sadiagnozo kriteriumebze da 4 punqtisgan Sedgeba:

1. kompulsia – intensivoba, romliTac swrafva nivTierebis moxmarebis mimarT Trgunavs pacientis fiqrebs, grZnobebs da gansjis unars;

2. kontroli – xarisxi, romliTac pacients SeuZlia (an ar SeuZlia) fsiqoaqtiuri nivTierebebis moxmarebis gakontroleba, rakiRa daiwyo;

3. Semcireba – qimiuri nivTierebis moxmarebis Semcirebis Sedegebi; aRkveTis simptomatika;

4. Sedegebi – uaryofa an zianis miReba, romelic gamoiwvia fsiqoaqtiuri nivTierebis moxmarebam.

SekiTxvebi TiToeuli am punqtis Sesaxeb SeiZleba daisvas Semdegi saxiT:

nikotinuri damokidebulebis Sefaseba “4 C” testis meSveobiT

kompulsia – Compulsion

odesme Tu mogiweviaT imaze ufro meti, vidre apirebdiT? odesme Tu Tu giTqviaT uari Tqvens movaleobebze imis gamo, rom

eweodiT an mowevis saSualeba mogcemodaT?

kontroli – Control

gigrZvniaT odesme saWiroeba, gagekontrolebinaT ramdens eweviT, magram advilad ver migiRweviaT amisTvis?

odesme dapireba migiciaT, rom SewyvitavT mowevas da imave dResve giyidiaT kolofi sigareti?

Semcireba (da aRkveTis simptomebi) – Cutting down (and withdrawal symptoms)

odesme gicdiaT mowevisTvis Tavis danebeba? ramdenjer? ramdeni xniT? gqoniaT odesme romelime am simptomTagan, roca raRaca droiT

usigaretod darCenilxarT: agzneba, SfoTva, gaRizianeba, koncentraciis gaZneleba, emociuri labiloba?

Tu asea, simptomebi qreboda sigaretis mowevis Semdeg?

Sedegebi – Consequences

ramdeni xania iciT, rom moweva vnebs Tqvens organizms? Tu gaagrZelebT mowevas, rogor ggoniaT, ramden xans icocxlebT? rom SegeZloT mowevisTvis Tavis danebeba dResve samudamod, rogor

ggoniaT, ramden xans icocxlebdiT?

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danarTi 3. Fagerstrom-is nikotindamokidebulebis Sesafasebeli testi

1. gaRviZebidan ramden xanSi eweviT pirvel sigarets? • 60 wuTis Semdeg (0) • 31-60 wuTSi (1) • 6-30 wuTSi (2) • 5 wuTis manZilze (3)

2. Znelia TqvenTvis TavSekaveba adgilebSi, sadac moweva akrZalulia?

• ara (0) • diax (1)

3. romeli sigaretisTvis geZnelebaT yvelaze metad uaris Tqma?

• diliT pirvelis (1) • nebismieri danarCenis (0)

4. ramden Rer sigarets eweviT dReSi?

• 10 an naklebi (0) • 11-20 (1) • 21-30 (2) • 31 da meti (3)

5. gaRviZebidan pirvel saaTebSi ufro mets eweviT, vidre dRis manZilze dasvenebis dros?

• ara (0) • diax (1)

6. eweviT imis miuxedavad, rom ise avad xarT, rom dRis umetesi nawili wevxarT sawolSi?

• ara (0) • diax (1) jamuri qula: ------------------------

interpretacia:

0-2 Zalian susti damokidebuleba 3-4 susti damokidebuleba 5 saSualo xarisxis damokidebuleba 6-7 Zlieri damokidebuleba 8-10 Zalian Zlieri damokidebuleba

klinicistis rekomendebuli pasuxi:

5 qulaze dabali: “Tqveni nikotinze damokidebulebis xarisxi jer kidev dabalia. Sasurvelia, imoqmedoT axla, sanam damokidebulebis xarisxi gaizrdeba.”

5 qula: “Tqveni nikotinze damokidebuleba saSualo simZimisaa. Tu ar SewyvetT mowevas mokle xanSi, Tqveni damokidebulebis xarisxi gaizrdeba seriozuli avadobis niSnulamde.”

5 qulaze meti: “Tqveni nikotinze damokidebulebis xarisxi maRalia. Tqven ver akontrolebT mowevas, is gakontrolebT Tqven! rodesac Tqven miiRebT gadawyvetilebas, mowevis Sewyvetis Sesaxeb, Cven SegviZlia visaubroT nikotinCanacvlebiT Terapiaze an sxva medikamentebis Taobaze, raTa davamarcxoT Tqveni midrekileba.”

wyaro: Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionaire. Br J Addict. 1991; 86: 1119-1127.

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8. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli

`Tambaqos wevis mitoveba da prevencia~.