Tambaqos wevis mitoveba da prevencia

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danarTi 1

Tambaqos wevis mitoveba da prevencia

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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

1. daavadebis ganmarteba, terminologia

nikotinuri damokidebuleba

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. es yvelaze didi gavlenis mqone damokidebulebis gamomwvevi preparatia msoflioSi da misi moxmareba asocirebulia janmrTelobisTvis bevr seriozul riskTan.

toqsikur efeqtebi ZiriTadad dakavSirebulia ara nikotinTan, aramed Tambaqos SemadgenlobaSi Semavali sxva niTierebebTan. es nivTierebebia:

benzopireni – Seicavs manqanis gamonabolqvi;

kupri – kibos gamomwvevi nivTiereba;

acetoni – saRebavis mosacilebeli qimiuri nivTiereba;

kadmiumi – gamoiyeneba eleqtroenergis akumulatorebSi;

dariSxani – sawamlavi.

sigaretisgan, sigarisgan da Cibuxisgan gamonabolqvi Seicavs 4000-mde qimiur nivTierebas, romelTaganac 40-ze meti cnobilia, rogorc kibos gamomwvevi (kancerogeni). mwevelebs gulis paTologiis, insultis da kancerogenuli daavadebebis ganviTarebis mniSvnelovnad maRali maCvenebeli aqvT.

sigaretis moweva, roca is Cvevad iqceva, Seesabameba nivTierebebze damokidebulebis samedicino kriteriumebs.

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.

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ZiriTadi terminebis ganmartebani

mwvave intoqsikacia – mdgomareoba, romlis drosac saxezea fsiqoaqtiuri nivTierebis axlaxan miRebis aSkara simptomebi da niSnebi, rac gamoixateba cnobierebis, kognituri funqciebis, aRqmis, emociebis, qcevis da sxva fsiqofiziologiuri funqciebis darRvevebSi.

nivTierebis araswori gamoyeneba (misuse) – nivTierebis (mag., narkotikebis) gamoyeneba gansxvavebulad, vidre gamowerilia, rogoricaa araswori dozebiT miReba an dozebs Soris intervalebSi damatebiT miReba.

nivTierebebis saxifaTo moxmareba (hazardous use) – nivTierebebis (mag., narkotikebis) moxmareba, roca izrdeba momxmareblis janmrTelobisTvis damRupveli Sedegebis ganviTarebis riski.

nivTierebebis mavned moxmareba (abuse) – nivTierebebis (mag., narkotikebis) gamoyeneba, romelic safrTxes uqmnis momxmarebels an sxva pirs; an gamoyeneba sxva mizniT, vidre am nivTierebis daniSnulebaa; an aralegaluri narkotikis gamoyeneba1.

nivTierebis sazianod moxmareba (harmful use) – dsk-me-10-s mixedviT, fsiqoaqtiuri nivTierebebis moxmareba, romelic safrTxes uqmnis janmrTelobas. ziani SeiZleba iyos fizikuri an fsiqikuri.

tolerantoba – ucvleli doza aRar iwvevs sasurvel efeqts an igive efeqtis misaRwevad saWiroa nivTierebis dozis gazrda.

damokidebuleba narkotikul nivTierebaze – aRkveTis sindromis (fsiqologiuri da/an fizikuri simptomebi) ganviTareba nivTierebis moxmarebis Sewyvetisas (aseve, ix. Tavi “daavadebis diagnozi”).

msubuqi mweveli – piri, romelic dReSi 10 Rerze naklebs eweva. SesaZlebelia, yoveldRiurad arc eweodes (eqspertTa jgufis SeTanxmeba).

1 DSM-IV-is mixedviT Tambaqos mavned moxmareba ar aris calke gamoyofili da klasificirebulia mxolod nikotinuri damokidebuleba kodiT 305.1; nikotinuri aRkveTa kodiT – 292 da nikotinis moxmarebiT gamowveuli daavadebebi (sxvagvarad dauzustebeli) kodiT – 292.9

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pasiuri moweva (meoradi moweva, garemoTi ganpirobebuli anu ekologiuri moweva) – individi CaisunTqavs kvamls ara uSualod sigaretis, sigaris an Cibuxis moqaCvis Sedegad, aramed maTi wvis Sedegad garemoSi gamoyofil gamonabolqvs da kvamls, romelic mwevelis filtvebidan amonasunTq haerSia. am nazavs uneburad isunTqavs aramweveli. dabinZurebul haeri sigaretis Caqrobis Semdeg ramdenime saaTis Semdegac ki SeiZleba gaxdes mravali daavadebis ganviTarebisa Tu gamwvavebis mizezi, maT Soris kibos, respiratoruli infeqciebisa da asTmisa.

jvaredini tolerantobis unaris mqone narkotiki/nivTiereba – narkotiki, romelic amsubuqebs aRkveTis simptomatikas im nivTierebasTan msgavsi moqmedebis gamo, romelzec damokidebuli iyo pacienti (mag. benzodiazepinebi jvaredin- tolerantulia alkoholTan).

aRkveTis sindromi – niSnebi da/an simptomebi, romlebic viTardeba Cveuli nivTierebis miRebis Sewyvetis an misi raodenobis swrafi Semcirebis Sedegad.

detoqsifikacia – nivTierebis gamodevna pacientis organizmidan TandaTanobiTi Semcirebis gziT an miRebis Sewyvetis gziT. SesaZloa, saWiro gaxdes jvaredin-tolerantuli nivTierebebis miReba pacientis komfortuli an usafrTxo mdgomareobisaTvis.

gamoyenebuli Semoklebebi

dsk me-10-e – daavadebaTa saerTaSoriso klasifikacia,

me-10-e gadasinjva

DSM‐IV

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

DALY

– sicocxlis ganmavlobaSi Sromis uunarobis wlebi (The disability‐adjusted life‐year)

janmo – jandacvis msoflio organizacia

cns – centraluri nervuli sistema

smi – sxeulis masis indeqsi

nCT – nikotinCanacvlebiTi Terapia

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2. epidemiologia

monacemebi msofliosTvis

Tambaqos moxmareba erTerTi yvelaze didi saSiSroebaa janmrTelobisTvis. jandacvis msoflio organizaciis- janmo-s monacemebiT, msoflioSi daaxloebiT 1.3 bilioni regularuli mwevelia 15 wlis da ufrosi asakis. mwevelebis 4/5 dabal da saSualo Semosavlebis qveynebSi cxovroben.

globalurad iTvleba, rom TiTqmis 5-jer meti mamakaci eweva, (48%) vidre qali (10%). gansxvavebuli monacemebia CineTSi, sadac 63% mamakacebis eweva SedarebiT 3.8%-Tan mweveli qalebisa.

es saerTaSoriso monacemebi sqesTa darRveuli balansis Sesaxeb damaxasiaTebelia Tambaqos epidemiis adreuli safexurebisTvis da ufro metad gamoxatulia ganviTarebad qveynebSi. mogvianebiT, arsebuli sxvaoba qalebsa da mamakacebs Soris amoivseba, radgan meti qalebi iwyeben mowevas, zrdian ra qalebSi Tambaqos mowevasTan dakavSirebuli daavadebebis tvirTs.

globalurma kvlevam axalgazrdebis mier Tambaqos moxmarebis Sesaxeb (The Global Youth Tobacco survey) aCvena, rom mowevis sixSire daaxloebiT erTnairia axalgazrda gogonebsa da biWebSi msoflios bevr qveyanaSi. radgan es mozardebi gaizrdebian, mosalodnelia, rom qalTa populaciis 20% mowevs 2025 wlisaTvis.

globalurad, Tambaqos produqtebis moxmareba izrdeba, Tumca maRali Semosavlis mqone qveynebSi- mcirdeba. bolo wlebSi Tambaqos moxmarebaze uari Tqva Crdilo amerikisa da dasavleT evropis bevrma qveyanam, magram gaizarda misi moxmareba sxva qveynebSi, gansakuTrebiT- aziaSi. TiTqmis 30% msoflios mwevlebisa aris CineTSi. daaxloebiT 300 milioni Cineli mwevelia, rac mTeli aSS-s mosaxleobis tolfasia. epidemia inacvlebs ganviTarebadi qveynebisaken. msoflioSi mwevelTa 80% dabali da saSualo Semosavlis mqone qveynebis macxovrebelia.

Tambaqo erTerTi yvelaze mosafrTxilebeli sikvdilis mizezia msoflio maStabiT. me-20-e saukuneSi 100 milioni adamiani gardaicvala Tambaqos moxmarebis Sedegad. amJamad, 5.4 milioni adamiani kvdeba yovelwliurad msoflioSi Tambaqos moxmarebis Sedegad - saSualod, 1 adamiani yovel 6 wamSi da yoveli 10 mozrdili adamianidan 1-is sikvdilis mizezi Tambaqos moxmareba xdeba. Tambaqo mwevelebis naxevarze metis sikvdilis mizezia. is warmoadgens risk-faqtors 8-dan 6 daavadebisa, romlebic sikvdilis wamyvan mizezebis ricxvSia msoflio maStabiT.

Tambaqos moxmarebisagan gamowveuli garTulebebiT gacilebiT meti adamiani iRupeba vidre erTianad aRebuli Sidsis, avtokatastrofebis, mkvlelobebis, TviTmkvlelobebis, infeqciuri daavadebebis, sxva narkotikuli nivTierebebis moxmarebis Sedegad.

gardacvlil onkologiur avadmyofTa 30% Tambaqos moixmarda, filtvis kibos dros ki mwevelTa xvedriTi wili 80%-s aRwevs.

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aSS-is pediatriis akademiisa da fondi `memkvidreoba~-s mier Catarebuli gamokvlevebiT, Tambaqos moxmarebiT gamowveuli avadobis tvirTi ZiriTadad bavSvebze modis. TiTqmis naxevari msoflioSi mosaxle bavSvebisa isunTqavs Tambaqos gamonabolqviT mowamlul haers. e.w. meoradi moweva seriozul safrTxes uqmnis bavSvTa janmrTelobas. aq igulismeba mcire wona dabadebisas, uecari sikvdilis sindromi, asTma da Suayuris anTebebi bavSvebSi, rasac emateba Tambaqos mwevelTa garemoSi gazrdili bavSvebis mier SemdgomSi Tambaqos moxmarebis maRali procenti.

sayovelTaod cnobilia mowevis uaryofiTi zegavlena gulis iSemiuri daavadebisa da sxva aTerosklerozuli daavadebebis ganviTarebis riskze. moweva pasuxismgebelia im sikvdilobis 50%-ze, romelic SesaZlebeli iyo agvecilebina Tavidan.Aaqedan naxevari kardio-vaskularul daavadebebze modis, sadac didi wili aqvs gulis iSemiur daavadebas. Tu moweva dawyebulia 15 wlamde asakSi, momavalSi gulis iSemiuri daavadebebis ganviTarebis riski gansakuTrebiT maRalia. uaxlesi monacemebiT pasiuri mowevac zrdis koronarul da sxva masTan dakavSirebul daavadebaTa risks. meoradi moweva yovelwliurad TiTqmis 50,000 sikvdilis mizezia aramwevel mozardebSi aSS-Si da aqedan daaxloebiT 3,400 filtvis kibos xarjze modis, xolo 22,700-69,699- gulis daavadebebze.

Tambaqos moxmarebis ekonomikuri xarjebi gamaognebelia. Tambaqos moxmarebiT gamowveuli daavadebebis mkurnalobaze gaweul uzarmazar xarjebTan erTad (pirdapiri xarjebi), Tambaqos moxmarebasTan dakavSirebuli sikvdilianoba mizezia uzarmazari ekonomikuri perspeqtivis danakargisa (arapirdapiri xarjebi) mas Semdeg, rac naxevari am sikvdilis SemTxvevebisa modis saukeTeso produqtiul wlebze.

globaluri ekonomikuri danakargi Tambaqos moxmarebasTan dakavSirebiT ar aris gansazRvruli arasruli monacemebis gamo, magram cnobilia, rom es xarjebi ramodenime aseul bilion dolars Seadgens yovelwliurad.

nikotinuri damokidebuleba, rogorc qronikuli daavadeba

nikotinuri damokidebuleba qronikuli daavadebis Tvisebebis matarebelia. nikotinis momxmarebelTa mxolod mcire nawili Tu axerxebs miaRwios myar abstinencias pirvelive cdaze. momxmarebelTa umravlesoba wlebis manZilze momxmareblad rCeba da meordeba tipiuri cikli mravaljeradi remisia-recidivis periodebisa. epidemiologiuri monacemebi miuTiTeben, rom aSS-Si dRevandeli monacemebiT arsebuli 45 milioni mwevelidan 70%-ze mets surs mowevisTvis Tavis danebeba da daaxloebiT 44% acxadebs, rom yovelwliurad aqvs Tavis danebebis mcdeloba. samwuxarod, umravlesoba aseTi mcdelobebisa warumatebelia. ase, mag. 2005 wels 19 milioni mozrdili adamianis mcdeloba, Tavi daenebebinaT mowevisaTvis, savaraudod, mxolod 4-7%-isTvis damTavrda warmatebiT. statistikuri monacemebi SemaSfoTebelia rogorc mwevelebisaTvis, aseve klinicistebisTvis.

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monacemebi saqarTvelosTvis

Tambaqos moxmareba saqarTveloSi sazogadoebrivi jandacvis erT-erT umTavres problemas warmoadgens. sxvadasxva sabaziso kvlevebis monacemebiT, sadReisod Tambaqos moixmars qveynis mosaxleobis daaxloebiT 37-40%. mamakacebs Soris mwevelia 50-65%, xolo qalebs Soris 16-22%. Zalze sayuradReboa mdgomareoba mozardebs Soris. skolis moswavleebis 22,1% mwevelia, xolo qalebs Soris mwevelobis progresi katastrofulia – igi bolo 16 wlis ganmavlobaSi TiTqmis 6-jer gaizarda (m.S. Tambaqos moxmarebis gavrceleba gazrdilia orsulebSi).

sxvadasxva kvlevebiT dadasturda, rom saqarTvelos mosaxleobis umetesi nawili imyofeba Tambaqos permanentuli da intensiuri zemoqmedebis qveS. saqarTveloSi Tambaqos masiur moxmarebas biWebi iwyeben 10-11 wlis asakidan, gogonebi 12-13 wlis asakSi. Tu isini gaagrZeleben Tambaqos moxmarebas, CamouyalibdebaT Tambaqosadmi Zlieri damokidebuleba, rac mravali saxis garTulebis winapirobaa.

Tambaqos moxmarebis sixSire rogorc mamakacebSi, aseve qalebSi yvelaze maRalia 26-59 wlis asakobriv jgufSi, isini ewevian mTeli moxmarebuli sigaretis 60,5%-s. maTze modis sigaretis SeZenaze daxarjuli mTeli Tanxis ori mesamedi. monacemebi saqarTveloSi Tambaqos moxmarebis prevalentobaze mocemulia cxrilSi #1.

cxrili. №1

Tambaqos moxmarebis prevalentoba saqarTvelos mosaxleobaSi 2003-2005 wlis gamokvlevebiT

indikatori (Tambaqos moxmarebis) %, weli

prevalentoba 13-15 wlis mozardebSi (orive sqesi) 24.6 (2003)

prevalentoba 13-15 wlis mozardebSi (qalebi) 13.6 (2003)

prevalentoba 13-15 wlis mozardebSi (mamakacebi) 36.4 (2003)

prevalentoba 15≥ wlis mozrdilebSi (orive sqesi) 31.9 (2005)

prevalentoba 15≥ wlis mozrdilebSi (qalebi) 6.3 (2005)

prevalentoba 15≥ wlis mozrdilebSi (mamakacebi) 57.1 (2005)

wyaro: Core Health Indicators (WHO): http://apps.who.int/whosis/database/core/core_select_process.cfm#

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daavadebis tvirTi:

daavadebis tvirTi populaciaSi SeiZleba ganvixiloT, rogorc sxvaoba amJamindel janmrTelobis mdgomareobasa da idealur situacias Soris, romlis drosac yvela cxovrobs xandazmul asakamde, daavadebebisa da invalidobis gareSe. am sxvaobis ar adreuli gardacvaleba, invalidoba da garkveuli risk-fatorebi, romlebic xwls uwyoeben daavadebis ganviTarebas. yovelive amis analizis Sedegad konkretdeba daavadebis tvirTi populaciaSi. sicocxlis ganmavlobaSi araqmediTunarianobis wlebi (DALY) aris jamuri maCvenebeli avadobis, invalidobis da sikvdilianobis gavlenisa populaciis janmrTelobaze.

kardiovaskuluri daavadebebis da neirofsiqiatriuli kondiciebis wilze modis daavadebis tvirTis yvelaze maRali procenti orive sqesis wamomadgenlebaSi saqarTvelos mosaxleobaSi. vinaidan sikvdilianoba neirofsiqiatriuli kondinciebis Sedegad mcirea, am SemTxvevaSi daavadebis tvirTis did wili invalidobaze modis.

2001 wlis monacemebiT, saqarTveloSi mowevaze modis daavadebis tvirTis sul cota 9% da 516 sikvdili 100 000 kacze.

ZiriTadi risk-faqtorebi:

cxrilSi №2 naCvenebia pirveli 10 risk-faqtori maTi Sesabamisi wvliliT daRmavali principiT daavadebis tvirTis CamoyalibebaSi mamakacebsa da qalebSi saqarTvelos populaciaSi. DALY-s mixedviT, maRali arteriuli wneva da Tambaqos aris daavadebis tvirTis mTavari faqtorebi saqarTvelos mamakacTa populaciaSi, xolo maRali arteriuli wneva da maRali sxeulis masis indeqsi (smi)- qalTa populaciaSi. saqarTveloSi wlis ganmavlobaSi Tambaqos mavne zemoqmedebis Sedegad gul-sisxlZarRvTa paTologiebiT avaddeba 100 aTasamde Tambaqos momxmarebeli.

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cxrili N#2

wamyvani risk-faqtorebi, rogorc daavadebis tvirTis mizezebi saqarTveloSi, gamoTvlili DALY–is mixedviT (2002)

mamakacebi qalebi

risk-faqtorebi totaluri

DALY (%) risk-faqtorebi

totaluri DALY (%)

1 maRali arteriuli wneva

24.4 maRali arteriuli wneva

22.4

2 Tambaqo 15.1 maRali smi1 13.3

3 maRali qolesterini 12.8 maRali qolesterini 11.0

4 maRali smi1 10.7 fizikuri inertuloba 5.6

5 alkoholi 9.9 xilisa da bostneulis simwire racionSi

5.4

6 xilisa da bostneulis simwire racionSi

6.3 daucveli sqesobrivi kontaqti

2.8

7 fizikuri inertuloba 5.6 Tambaqo 2.5

8 aralegaluri narkotikebi

3.8 aralegaluri narkotikebi

1.4

9 tyvia 2.0 alkoholi 1.2

10 qalaqis haeris gamonabolqvi

1.1 tyvia 1.1

1smi – sxeulis masis indeqsi

wyaro: Background data from WHO (2003c)

janmos monacemebiT, ,,pasiuri wevis“ Sedegad saqarTveloSi yovelwliurad saSualod 4000 udanaSaulo adamiani iRupeba. e.i. Tu Tambaqos mwevelebi, sakuTar TavTan erTad zians ayeneben garSemomyofebsac, gansakuTrebiT ojaxis wevrebs.

saqarTveloSi ,,pasiuri wevis" mizeziT yovelwliurad avaddeba 82000 aramweveli. Tambaqos nebismieri momxmarebeli aavadebs misTvis yvelaze pativsacem xalxs.

TambaqoTi gamowveuli avadoba da sikvdilianoba xels uwyobs saqarTveloSi ekonomikuri krizisis ganviTarebas. amave dros, did zians ayenebs ojaxis biujets.

prognozi

Tu saswrafo zomebi ar iqneba miRebuli, 2030 wlisTvis 8 milioni adamiani gardaicvleba yovelwliurad. 2030 wlisTvis, Tambaqos moxmarebis mizeziT gardacvlilTa 80% ganviTarebadi qveynebis wilze mova. 21-e saukuneSi am gaTvlebiT 1 miliardi adamianis gardacvalebaa mosalodneli.

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TandaTan, qalebsa da mamakacebs Soris arsebuli sxvaoba Semcirdeba, radgan mwevel qalTa raodenoba izrdeba, rac iwvevs qalebSi Tambaqos mowevasTan dakavSirebuli daavadebebis tvirTis zrdas.

saqarTveloSi qalebSi mwevelTa raodenoba imdenad maRalia, rom Tu saswrafod ar SeCerda es procesi, mosalodnelia axali katastrofa sazogadoebrivi jandacvisaTvis.

gamokvlevebiT dadginda, rom saqarTvelos mosaxleobis im nawilis xarjze, romelic amJamad 0-19 asakobriv jgufSi erTiandeba, mwevelebs 800 aTasi adamiani moemateba, romelTagan 400 aTasi daiRupeba Tambaqos mavne zemoqmedebis Sedegad; maT Soris 200 aTasi daiRupeba saSualo asakSi, amdenive xanSiSesulobis asakSi. 35 wlis asakis qarTvel mamakacebs Soris 5-dan erTi Tambaqosagan gamowveuli problemebiT gardaicvleba.

3. etiopaTogenezi

mwevelobis dawyebasa da mis SenarCunebaze moqmedi ZiriTadi faqtorebia socialuri, interpersonaluri da personaluri zegavlenebi:

socialuri zegavlena: reklama, fasi, xelmisawvdomoba, TanatolTa zewola, TviTSefaseba da sxv.

interpersonaluri zegavlena: ojaxis wevrebi, megobrebi, popularuli adamianebi, maswavleblebi da sxv.

personaluri zegavlenebi: warmodgenebi, ra SeuZlia gamoiwvios mowevam. mag. wonis kontroli, damSvideba, TviTdajerebis momateba, siamovneba, momxibvleloba da a.S.

zemoT moxseniebuli faqtorebi sxvadasxva intensiurobiT moqmedeben mwevelobis sxvadasxva etapze.

nikotinis Tviseba, gamoiwvios miCveva da fizikuri simptomebi, aixsneba nikotinis kavSiriT cns-Si qolinergul da nikotinur receptorebTan, Tirkmelzeda jirkvlis tvinovan SresTan, nerv-kunTovan sinafsebTan da vegetatiur gangliebTan. tvinSi nikotinis yvelaze didi SekavSirebis adgilebi aRiniSneba hipoTalamusSi, hipokampSi, TalamusSi, Sua tvinSi, tvinis ReroSi, qerqSi, zolian sxeulsa da mezolimbur dofaminergul neironebSi. mezolimburi sistemis dofaminerguli neironebis stimulacia da neiroadaptacia ganapirobebs nikotinis mimarT midrekilebas, damokidebulebis, tolerantobis da aRkveTis sindromis ganviTarebas. siZneleebi, romlebic mowevis Tavis danebebasTanaa dakavSirebuli, sigaretis mowevis moTxovnileba da SeuCerebeli moweva SeiZleba iyos tvinis zemoT aRniSnuli ubnebis neiroadaptaciis Sedegi.

nikotinis moqmedeba nervuli sistemis danarCen nawilebze orfaziania: Tavdapirvelad aRiniSneba stimulacia, romelsac mosdevs Sekaveba. vegetatiuri gangliebi nikotinis moqmedebis pirveladi samizneebia. mcire dozebSi xdeba gangliebis stimulireba, xolo did dozebSi stimulaciis xanmokle fazis Semdeg dgeba gangliuri blokadis faza. nerv-kunTovan sinafsebSi stimulaciuri komponenti minimaluria dofaminergul sistemasTan SedarebiT.

11

4. klinikuri simptomatika

Tambaqos moxmarebiT gamowveuli mwvave intoqsikacia2

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.

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

1. gulisreva an pirRebineba;

2. oflianoba;

3. taqikardia;

4. gulis ariTmiebi.

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, saylapavis 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.

nikotini zemoqmedebs tvinze, rac droebiT sasiamovno gancdebs iwvevs. es efeqti adamians ubiZgebs Tambaqos Semdgomi moxmarebisken da sabolod, formirdeba damokidebuleba. amasTan, Tambaqos moxmarebis Sewyveta iwvevs aRkveTis simptomatikas, gaRizianebisa da SfoTvis CaTvliT. nikotinis moxmarebasTan mWidrod asocirebuli daavadebebis nusxa mocemulia cxrilSi #3.

2 mwvave nikotinuri intoqsikacia - F17.0

12

cxrili #3

wiTeli droSis diagnozebi

nikotinis moxmarebasTan mWidrod dakavSirebuli daavadebebi

sasunTqi sistema emfizema, qronikuli bronqitebi, asTma da filtvebis qronikuli obstruqciuli daavadebebi

gul-sisxlZarRvTa sistema gulis iSemiuri daavadeba

cns insulti

kancerogenuli daavadebebi filtvebis, yelis, saylapavis, mkerdis, Sardis buStis kibo

sxva qronikuli tkivilis sindromi

nayofis wonis Semcireba

Tambaqos aRkveTis mdgomareoba3

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.

mowevis Sewyvetam SeiZleba zegavlena iqonios sxva wamlebis metabolizmze citoqrom P450 (CYP450) sistemis meSveobiT. es sistema warmoadgens RviZlis enzimuri sistemebidan erTerTs, romelic pasuxismgebelia bevri medikamentis metabolur gardaqmnaze (daSlaze) inaqtiur Semadgenel komponentebad. rac ufro maRalia CYP450 sistemis mimarT afiniteti, miT ufro swrafad xdeba nivTierebebis an maTi Semadgeneli nawilebis daSla. zog komponents SeuZlia sxva dabalafinitetiani wamlebis metabolizmis procesis Seneleba da amrigad, am medikamentis an misi komponentis SeCereba sxeulSi.

3 F17.3

13

nikotinuri detoqsikaciis dros zogierT medikamentis metabolizmi icvleba. maT ricxvSia: Teofilini, kofeini, tacrini, imipramini, haloperidoli, pentazocini, propranololi, flekainidi da estradioli. ufro xSirad, es efeqtebi xanmoklea. nikotini aseve amcirebs beta-blokerebis unars, Seamciros sisxlis wneva da guliscemis sixSire da amcirebs benzodiazepinebis sedaciis unars, iseve rogorc opioidebis tkivilgamayuCebel unars. fsiqotropul medikamentebis metabolizmze nikotinuri aRkveTis zegavlena Sejamebulia cxrilSi #4.

cxrili #4

mowevis Sewyvetis zegavlena sisxlSi fsiqotropuli medikamentebis koncentraciaze

abstinencia zrdis sisxlSi am nivTierebebis Semcvelobas

abstinencia ar zrdis sisxlSi am nivTierebebis Semcvelobas

abstinenciis efeqti sisxlSi nivTierebis koncentraciaze naTeli aris aris

klomipramini

klozapini

dezipramini

dezmeTildiazepami

doqsepini

flufenazini

haloperidoli

imipramini

oqsazepami

nortriptilini

propranololi

amitriptilini

qlordiazepoqsidi

eTanoli

lorazepami

midazolami

triazolami

alprazolami

qlorpromazini

diazepami

14

5. daavadebis diagnozi

skriningi

Tambaqos moxmareba unda ganixilebodes, rogorc seriozuli samedicino problema da mis gamovlenasa da marTvas samedicino personalma, gansakuTrebiT, ojaxis eqimebma da pirveladi jandacvis sxva profesionalebma, jerovani yuradReba unda dauTmos.

pirveladi jandacvis eqimma anamnezuri monacemebis Sekrebisas aucileblad unda gansazRvros pacientis mier Tambaqos moxmarebis faqti.

ojaxis eqimebs SeuZliaT nikotinuri damokidebulebis diagnostireba, Sefaseba da mkurnaloba sakmaod SezRudul droSi ofisSi vizitebis dros. amisTvis maT unda Seafason pacientebis mowevasTan dakavSirebuli qceva ramdenime wuTSi, specialuri kiTxvarebis meSveobiT. CAGE kiTxvari mowevisTvis (modificirebuli cnobili alkoholizmis CAGE kiTxvarisagan) da “4 Cs” testi mowodebulia diagnozis dasasmelad standartul kriteriumebze dafuZnebiT (ix. danarTebi 1 da 2). klinicistebs SeuZliaT SearCion Sefasebis kiTxvarebidan erTerTi maTgani, romelsac ukeT moirgeben praqtikaSi da gamoiyeneben mkurnalobis individualuri gegmis SesamuSaveblad.

yvela pacients unda hkiTxoT, eweva Tu ara Tambaqos da regularulad SeavsoT Tambaqos moxmarebis statusis amsaxveli dokumenti. mtkicebulebebi adasturebs, rom klinikuri skrininguli sistemebi, rogoricaa vitaluri niSnebis gafarToveba, romlebic Tambaqos moxmarebis Sesaxeb SekiTxvebs Seicavs (cxrili #5), aseve samaxsovroebi (kompiuteruli an baraTebiT) mniSvnelovnad zrdis klinikuri intervenciebis efeqturobas (mtkicebulebis xarisxi A).

cxrili #5

Tambaqos momxmareblebis identificirebis strategia

RonisZieba strategia implementaciisTvis

danerge sistema, romlis mixedviTac yvela pacienti klinikaSi yoveli vizitisas gamokiTxuli iqneba Tambaqos moxmarebis Sesaxeb, rac saTanadod iqneba dokumentirebuli

`gaafarToveT~ vitaluri niSnebi da CarTeT Tambaqos moxmareba sasicocxlo niSnebi sisxlis wneva: _________________ pulsi: __________ wona: ________ temperatura: ___________________ sunTqvis sixSire: _______________ Tambaqos moxmareba (Semoxaze erTi): 1. aJamad moixmars; 2. warsulSi moixmarda; 3. arasodes mouxmaria

15

rekomendacia: sistematurad gamoavlineT Tambaqos momxmareblebi yoveli vizitisas. ganmeorebiTi gamokiTxva ar aris aucilebeli im mozrdili pirebis SemTxvevaSi, visac arasdros gausinjavs Tambaqo, an visac mravali wlis manZilze aRar mouxmaria da romelTa Sesaxebac informacia naTlad aris asaxuli samedicino CanawerebSi (rekomendaciis xarisxi A).

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;

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 iqnes pacientis cvlilebisTvis mzaobis Sesafaseblad.

diferenciuli diagnozi

klinicistebisTvis cnobili unda iyos, rom aRkveTis simptomatikam SeiZleba moaxdinos fsiqiatriuli daavadebebis, gansakuTrebiT, SfoTvis da depresiis imitacia.

16

nikotinuri aRkveTis simptomatikis sxva magaliTebs, romelTa aRreva SeiZleba moxdes sxva fsiqiatriul daavadebebSi, miekuTvneba:

Zilis REM4 fazis gazrda;

insomnia (uZiloba);

gaRizianeba;

mousvenroba;

wonis mateba.

6. mkurnaloba

gaidlainis 10 ZiriTadi rekomendacia

am rekomendaciebis ZiriTadi mizania, klinicistebma mkacrad urCion Tambaqos momxmarebel pacientebs, Caitaron konsultacia da medikamenturi mkurnaloba Tambaqoze damokidebulebis Taobaze.

1. Tambaqoze damokidebuleba qronikuli daavadebaa, rac xSirad saWiroebs ganmeorebiT intervenciebs da mravaljerad mcdelobebs Tambaqos moxmarebis Sesawyvetad. arsebobs efeqturi mkurnalobis meTodebi, romelTa Catarebis Sedegad abstinenciis xangrZlivoba SeiZleba mniSvnelovnad gaizardos.

2. arsebiTia, rom klinicistebis da jandacvis sistemis mier Tanmimdevrulad moxdes Tambaqos moxmarebis identificireba da dokumentireba; aseve, Tambaqos yvela momxmareblis mkurnaloba, romelic jandacvis sistemaSi xvdeba.

3. Tambaqoze damokidebulebis mkurnaloba efeqturia farTo populaciebisTvis. klinicistebma unda waaxalison TiToeuli pacientis mcdeloba, Sewyvitos Tambaqos moxmareba am gaidlainSi mowodebuli konsultaciebisa da medikamenturi mkurnalobis daxmarebiT.

4. Tambaqoze damokidebulebis xanmokle mkurnaloba efeqturia. klinicistebma Tambaqos mwevel yvela pacients unda SesTavazon xanmokle mkurnaloba mainc, romelic am gaidlainSia mowodebuli, rogorc mkurnalobis efeqturi meTodi.

5. individualuri, jgufuri da satelefono konsultacia efeqturia da maTi efeqturobis xarisxi izrdeba mkurnalobis intensiurobasTan erTad. Konsultaciis qvemoT mocemuli 2 komponenti gansakuTrebiT efeqturia da klinicistebma isini unda gamoiyenon moxmarebis Sewyvetis msurveli pacientebis konsultirebisas:

praqtikuli konsultacia (problemis gadaWra/unar-Cvevebis gamomuSaveba);

socialuri mxardaWeris aRmoCena, rogorc mkurnalobis nawili.

4 REM – Rapid Eye Movement: tvalis swrafi moZraoba (Zilis faza)

17

6. Tambaqos damokidebulebis samkurnalod mowodebulia mravali efeqturi medikamenti da Tambaqos moxmarebis Sewyvetis mcdelobebisas pacientebs klinicistebma unda urCion am medikamentebis gamoyeneba garda im SemTxvevebisa, roca maTi miReba ukunaCvenebia, an roca arasakmarisi mtkicebulebebia garkveul populaciebSi ama Tu im medikamentis efeqturobis Sesaxeb (mag. fexmZime qalebSi, aramwevel Tambaqos momxmareblebSi, msubuq mwevelebSi, da mozardebSi).

Semdegi Svidi pirveli rigis medikamenti (5 nikotinis da 2 ara-nikotinis) realurad zrdis mowevis abstinenciis xangrZlivobas (xangrZliv vadiani abstinencia):

1. bupropioni – Bupropion SR;

2. nikotinis saReWi rezini;

3. nikotinis inhalatori;

4. nikotinis tableti;

5. nikotinis nazaluri sprei/pulverizatori;

6. nikotinis salbuni/plastiri;

7. vareniklini.

klinicistebma agreTve unda ganixilon am gaidlainSi mowodebuli medikamentebis efeqturad miCneuli kombinaciebis gamoyenebis sakiTxi.

7. konsultireba da medikamentebi efeqturia nikotinze damokidebulebis samkurnalod, magram maTi kombinacia ufro efeqturia, vidre cal-calke romelime maTgani. amitom, eqimebma unda urCion pacientebs, mimarTon orive meTods.

8. telefoniT konsultacia (mowevis Sewyvetis xazi) efeqturia sxvadasxva mosaxleobaSi da farTo gavrceleba hpova. amitom eqimebma da jandacvis servisebma unda uzrunvelyon pacientebisaTvis aseTi xazebis xelmisawvdomoba.

9. Tu Tambaqos momxmarebeli amJamad ar aris mzad mowevis Sewyvetis mcdelobisTvis, klinicistma unda gamoiyenos motivaciuri mkurnaloba, rac am gaidlainis mixedviT efeqturadaa miCneuli SemdgomSi aseTi mcdelobebis gazrdis TvalsazrisiT.

10. nikotindamokidebulebis mkurnaloba klinikurad efeqturic aris da xarjTefeqturic sxva daavadebebis samkurnalo intervenciebTan SedarebiT. am mkurnalobis xarjebis dafarva sadazRvevo kompaniebis mier zrdis Tambqos moxmarebis Sewyvetis sixSires.

konsultireba da fsiqosocialuri rekomendaciebi

Tambaqos wevis Sewyveta xangrZlivi da rTuli procesia. strategia TiToeul pacientTan dakavSirebiT gansxvavebulia da individualurad unda SemuSavdes.

18

Tambaqos momxmareblebis 70% eqimTan yovelwliurad midis. aucilebelia, rom pirveladi jandacvis profesionalebma Tambaqos momxmareblebTan Caataron xanmokle intervenciebi (10 wuTze naklebi).

randomizirebuli kontrolirebadi kvlevebis sistemuri mimoxilvebisa da meta-analizis Sedegad (Bala M., Lesniak W., 2007) dadginda, rom nikotinuri damokidebulebis arafarmakologiuri mkurnalobis meTodebi, rogoricaa martivi rCeva, individualuri da jgufuri konsultaciebi mowevis Sewyvetis albaTobas da mowevisgan TavSekavebas 12≥ Tvis manZilze 1.5-2-jer zrdian. amasTan, 30 pacientis intensiuri mkurnalobis Sedegad daaxloebiT 1 anebebs Tavs mowevas, xolo martivi rCevisas – 60-dan 1 mweveli.

2008 wlis sistemuri mimoxilvis mixedviT (Stead LF et al., 2008), sadac ganxiluli iyo 1972-dan 2007 wlamde Catarebuli 41 kvleva, romelSic CarTuli iyo 31, 000 mweveli, dadginda, rom 17 kvlevis mixedviT, mokle rCevis Sedegad mniSvnelovnad izrdeba mowevis Sewyvetis maCvenebeli, rCevis ar micemasTan an Cveul movlasTan SedarebiT (fardobiTi riski 1.66, sarwmunoebis intervali 95% 1.42-dan 1.94-mde). 11 kvlevidan, sadac ufro intensiuri intervenciebi iyo Catarebuli, efeqti ufro maRali iyo (fardobiTi riski 1.84, 95% sarwmunoebis intervali 1.60-dan 2.13-mde); Tumca, ar iyo statistikuri sxvaoba intensiuri da minimaluri intensivobis intervenciebis qvejgufebs Soris. intensiuri intervenciisa minimalur rCevasTan pirdapiri Sedareba intensiuri rCevis mcired upiratesobaze metyvelebs (fardobiTi riski 1.37, 95% s.i. 1.20-dan 1.56-mde). pirdapiri Sedareba aseve miuTiTebs momdevno vizitebis mcire upiratesobas.

rekomendaciebi Tambaqos moxmarebis Sewyvetis Sesaxeb Sejamebulia cxrilSi #6.

19

cxrili #6

rekomendaciebi Tambaqos moxmarebis Sewyvetis Taobaze

sakvanZo SekiTxva pasuxi rekomendaciis xarisxi

da mtkicebulebis done

ra asakidanaa mizanSewonili Tambaqos moxmarebaze skriningis dawyeba?

12 wlis Semdeg yvela pacients unda hkiTxoT Tambaqos moxmarebis Sesaxeb.

rekomendaciis xarisxi A, mtkicebulebis done I

rodis unda Sewydes skriningi mwevelobis statusis dasadgenad?

asaki, romlis zemoTac hipertenziaze skriningi kargavs Tavis mniSvnelobas jer-jerobiT dadgenili ar aris.

ar moipoveba

ra periodulobiT unda moxdes pacientis mwevelobis statusis Sefaseba?

gamoiyeneT pacientTan kontaqtis yvela SesaZlebloba da hkiTxeT mas Tambaqos moxmarebis Taobaze.

rekomendaciis xarisxi C, mtkicebulebis done

III

romel pacientebSia yvelaze maRali Tambaqos moxmarebasTan asocirebuli garTulebebis aRmocenebis riski da rodisaa mowevis Sewyvetis mosalodneli sargebeli maqsimaluri?

orsulebi; rekomendaciis xarisxi

A, mtkicebulebis done I

mcire asakisa da Cvil bavSvTa mSob-lebi;

pacientebi mentaluri problemebiT;

pacientebi, romelTac aReniSnebaT damokidebuleba sxva nivTierebebis mimarTac;

pacientebi TambaqosTan asocirebuli daavadebebiT;

pacientebi diabetiT an sxva kardio-vaskuluri risk-faqtorebiT

dabali socio-ekonomikuri klasis pirebi


III

ra meodebi unda gamoviyenoT skriningisaTvis?

mwevelobis statusis gansazRvra rutinuli anamnezis aucilebeli komponenti unda iyos;


mwevelebis identificirebas aiolebs samedicino dokumentaciaSi Tambaqos moxmarebis aRsaniSnavad specialuri seqciis SemoReba, romelsac samedicino personali pacientTan kontaqtis dros Seavsebs.


III

ramdenad efeqturia eqimis mier mweveli pacientis konsultireba, Tambaqos mox-marebis Sewyvetis Taobaze?

pirveladi jandacvis eqimis mier pacientis konsultireba, Tundac erT rutinul konsultaciaze bevrad ufro efeqturia, vidre am faqtis saerTod ugulebelyofa.


konsultireba sakmaod efeqturia im SemTxvevaSi, rodesac pacienti sakmarisad motivirebuli da momzadebulia mowevis Sesawyvetad, xolo samedicino personali mas mowevis Sewyvetis `rTul~ periodSi qmediT daxmarebas SesTavazebs.


20

sakvanZo SekiTxva pasuxi rekomendaciis xarisxi

da mtkicebulebis done

rodis unda gaigzavnos pacienti specializebul dawesebulebaSi, sadac mas Tambaqos mowevis Sewyvetis specifikur programas SesTavazeben?

mZime mweveli, romelsac aReniSneba fsiqologiuri da fizikuri damokidebu-leba da, romelic sakmarisad moti-virebulia amisaTvis.


III

ra SemTxvevaSia rekomendebuli nikotin CanacvlebiTi Terapia?

pacientebSi, romlebsac aReniSnebaT nikotinze fizikuri damokidebuleba.


III

rogor SeiZleba Sefasdes, mzadaa Tu ara pacienti Tavi daanebos Tambaqos mowevas?

es pacientis mimarT keTilganwyobili da araganmsjeli damokidebulebiT SeiZleba moxerxdes, mag. "rogor fiqrobT, iqneb mowevisTvis Tavi dagenebebinaT?~


saWiroa Tu ara aramwevelebis konsultireba pasiuri mwevelobis Taobaze?

marTalia, pasiuri mwevelobis Taobaze aramwevelebis konsulitirebis efeqtu-robis damadasturebeli mecnieruli faq-tebi ar arsebobs, magram Tu gaviT-valiswinebT pasiuri mwevelobis mavneobas, amis Taobaze pacientis konsultireba udavod sasargeblo unda iyos, gansakuTrebiT orsulebisa da Cvili da mcire asakis bavSvebisaTvis.


III;


(orsulebSi)

prevenciuli RonisZiebebis sargebeli da riski

Tambaqos mowevis Sewyveta amcirebs kibos, gulis iSemiuri daavadebis, filtvis qronikuli obstruqciuli daavadebisa da insultis risks. Tambaqos mowevis prevencia raime riskTan dakavSirebuli ar aris.


III

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);

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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.

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

sqeima 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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intervenciebis efeqturobisTvis mniSvnelovania cvlilebisTvis mzaobis stadiis dadgena. intervenciis mizani sxvadasxva iqneba pacientis cvlilebisadmi mzaobis mixedviT. mizani SeiZleba iyos pacientis codnis gaRrmaveba pacientis qcevis uaryofiTi Sedegebis Sesaxeb, an misi qcevisadmi gaorebuli damokidebulebis gaRrmaveba, an pacientis daxmareba, SeimuSavos gegma, rogor Secvalos sakuTari qceva.

mowodebulia (Prochaska & DiClemente) cvlilebis mzaobis koncefcia, romelic moicavs Semdeg stadiebs:

gaanalizebis, gaTvicnobierebis wina stadia – e.w. ~bednieri momxmareblebi~. am jgufis wevrebi ar arian Sewuxebulebi Tavisi qceviT (Tambaqos weviT). maTTvis pozitiuri motivebi gadawonis negatiurs da amitom yuradRebas ar aqceven an ar sjeraT, rom maTi qceva sazianoa.

gaanalizebis stadia – am jgufis pacientebs gaorebuli damokidebuleba aqvT Tambaqos wevasTan dakavSirebiT. maT siamovnebT Tambaqos weva, miuxedavad imisa, rom mas problemebi moaqvs da sazRaurTanaa dakavSirebuli. am jgufis pacientebs surT problemebis Semcireba, magram Tambaqos wevis garZeleba.

gadawyvetilebis stadia – am jgufis pacientebs gadawyvetili aqvT imoqmedon – Seamciron an Sewyviton Tambaqos weva. dgamen sacdel nabijebs.

moqmedebis stadia – axorcieleben konkretul qmedebebs da cdiloben danergon cvlilebebi.

SenarCuneba – am jgufis wevrebma warmatebiT Secvales Tavisi qceva da sakmarisi droc gavida, rom Tavi igrZnon eqs-problemur momxmareblebad. iTvleba, rom es stadia saSualod, mavne Cvevis mitovebidan 12-18 Tvis Semdeg dgeba.

recidivi – mravali imaTgan, vinc gadawyvita konkretul qmedebaze gadasvla, isev icvlis Sexedulebas da ubrundeba Tambaqos wevas. recidivis Semdeg isini ubrundebian wina safexurebs.

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).

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fsiqosocialuri mkurnalobis formati

proaqtiuri satelefono konsultireba, jgufuri konsultireba da individualuri konsultireba _ yvela es forma efeqturia da unda gamoyenebuli iqnes 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).

Semdgomi dakvirveba - Sefaseba da procedurebi:

yvela pacienti, romelic itarebs Tambaqoze damokidebulebis mkurnalobas, unda Sefasdes mkurnalobis damTavrebis Semdeg da yoveli momdevno vizitis dros. (1) pacientebi, romlebmac warmatebiT daanebes Tavi mowevas, waxalisebuli unda iqnen klinicistis mier, 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).

konsultirebis da qceviTi Terapiis tipebi:

gansakuTrebiT kargi SedegebiT (TambaqosTvis Tavis danebebis maRali sixSiriT) gamoirCeva konsultirebis da qceviTi Terapiis Semdegi ori tipi: (1) mwevelebisTvis praqtikuli treningis Catareba (problemis mogvarebis unar-Cvevebi/unar-Cvevebze treningi), da (2) mxardaWera da gamxneveba, rogorc mkurnalobis Semadgeneli nawili. konsultirebis es ori tipi CarTuli unda iyos mowevis Sewyvetis intervenciebSi (mtkicebulebis xarisxiBB).

konsultirebis da medikamenturi mkurnalobis kombinacia

konsultirebis da medikamenturi mkurnalobis kombinacia ufro efeqturia, vidre TiToeuli maTgani cal-calke. amitom, sadac SesaZlebelia, mowevis Sewyvetis msurvel pacientebs unda gauwioT konsultirebac da medikamenturi mkurnalobac (mtkicebulebis xarisxi A).

arsebobs myari uTierTkavSiri medikamentur mkurnalobasTan kombinirebul konsultirebis raodenobasa da mowevis Sewyvetis warmatebis albaTobas Soris. amitom, SesaZleblobis farglebSi, klinicitebma unda Caataron ramdenime konsultacia medikamentur mkurnalobasTan erTad (mtkicebulebis xarisxi A).

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pacientebi, visac amJamad ar surs mowevis Sewyveta

pacientebi, romelTac ara aqvT amJamad survili mowevas Tavi daanebon, SesaZlebelia, aqvT informaciis nakleboba im mavne zegavlenis Sesaxeb, romelsac moweva axdens janmrTelobaze da im dadebiTi mxareebis Sesaxeb, rac moaqvs mowevisTvis Tavis danebebas, aqvT Tavis danebebis SiSi an warumatebeli mcdelobebi warsulSi.

aseTma pacientebs SeiZleba reqcia hqondeT motivaciur intervenciebze, romlebic dafuZnebulia motivaciuri intervius principebze.

motivaciuri interviu aris direqtiuli, klientze-orientirebuli konsultacia, romelic mimarTulia arsebuli qcevis Secvlisaken da gulisxmobs klientis daxmarebas gaaanalizos da daZlios orWofoba da miaRwios garkveuli problemuri qcevebis myar cvlilebas.

motivaciis gaZlierebis Terapia aris sistematuri intervenciis meTodi cvlilebebis misaRwevad. is dafuZnebulia motivaciuri fsiqologiis principebze da miznad isaxavs gamoiwvios swrafi, Sinaganad-motivirebuli cvlilebebi. mkurnalobis aRniSnuli strategia uSualod gamojanmrTelebas ar iwvevs, magram exmareba pacients gadawyvetilebis miRebasa da sakuTari Zalebis mobilizebaSi, raTa Secvalos arasasurveli qceva (Tambaqos wevasTan dakavSirebuli).

arsebobs mtkicebulebebi, rom motivaciuri interviu efeqturia mowevis Sewyvetis mcdelobebis gazrdis TvalsazrisiT. Tumca, ar aris naTeli, ramdenad warmatebulia abstinenciis SenarCunebis TvalsazrisiT im pirebSi, romlebic motivirebulni arian, Tavi daanebon mowevas.

motivaciuri interviuirebis ZiriTadi principebi:

Develop – gamoavlineT Seusabamoba saqcielsa da miznebSi;

Avoid – moerideT kamaTs;

Roll – rweva (lavireba) rezistentobasTan erTad (pacienti pirdapiri wyaroa gadawvetilebebis da gamosavlis moZebnaSi, Tavs nu moaxvevT Tqvens azrebs);

Express – gamoxateT empaTia;

Support – mxari dauWireT TviTaqtivobas;

efeqturia motivaciuri intervenciebi, rac zrdis imis albaTobas, rom pacients momavalSi gauCndeba survili da eqneba Tavis danebebis mcdeloba. ase rom, klinicistebma unda gamoiyenon motivaciuri meTodebi im pacientebis konsultirebisas, romelTac amJamad ara aqvT mowevisTvis Tavis danebebis survili (mtkicebulebis xarisxiBB).

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,

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nikotinis Semcveli plastiri, rimonabandi da vareniklini da 2 ZiriTadi meore rigis preparati – klonidini da notriptilini.

2008 wlis meta-analizis mixedviT (Eisenberg MJ et al., 2008), Sedarebul iqna 7 nebaTarTuli farmakologiuri intervencia nikotindamokidebulebis samkurnalod. ganixiles 69 placebo-kontrolirebadi, ormagi-brma meTodiT Catarebuli randomizebuli kontrolirebadi kvleva sul 32 908 pacientiT. 6 intervencia 7-dan CaiTvala placeboze efeqturad: vareniklini, nikotinis nazaluri sprei, bupropioni, transdermaluri nikotini, nikotinis abi da nikotinis saReWi rezini. nikotinis inhalatoris maCvenebeli Sansebis Tanafardobis mixedviT aRemateboda placebos (2.17), Tumca es rezultati ar iyo gadamwyveti, radgan sarwmuno intervali moicavda erTeuls (95% sarwmuloebis intervali 0.95-5.43). kvlevam daadgina, rom vareniklinis

efeqturoba aRemateba bupropionisas (OR 2.18, 95% CrI 1.09‐4.08). mkvlevarebi askvnian, rom vareniklini, bupropioni da danarCeni 5 nikotinis CanacvlebiTi Terapia aris placeboze efeqturi mowevis Tavis danebebis TvalsazrisiT 6-dan 12 Tvemde.

aRniSnuli preparatebi gamoiyeneba rogorc monoTerapiis saxiT (erTi medikamentiT mkurnaloba), ise 2-is an metis kombinaciiT. umjobesia mkurnaloba eqimis daniSnulebiT. meore rigis preparatebi iniSneba im SemTxvevaSi, roca pirveli rigis preparatebi ver gamoiyeneba maTi ukuCvenebis an gverdiTi movlenebis gamo, an maTi moxmareba araefeqturi gamodga.

Cveulebriv, Tambaqos moxmarebis SewyvetisaTvis medikamenturi mkurnaloba gamoiyeneba rogorc erT-erTi komponenti mkurnalobis mTlian kursSi; medikamentebi ZiriTadad amsubuqebs Tambaqos gadagdebis Semdgom simptomebs da amgvarad aadvilebs mis Sewyvetas, magram mTlianobaSi mowevis gadagdebisaTvis mxolod preparatebis miReba sakmarisi ar aris.

rekomendaciebi calkeuli medikamentebis Sesaxeb:

pirveli rigis medikamentebi

pirveli rigis medikamentebs miekuTvneba iseTi medikamentebi, romlebic usafrTxoa da maRal-efeqturi nikotinze damokidebulebis samkurnalod da maTi gamoyeneba kanonmdeblobiT aris daSvebuli (wamlis registracia). pirveli rigis medikamentebis gamoyeneba rekomendebulia yovelTvis, garda im SemTxevevebisa, rodesac isini ukunaCvenebia an pacienti gansakuTrebul jgufs ganekuTvneba (mag.: orsulebi, msubuqi mwevelebi, mozardebi, agreTve, pirebi, romlebic Tambaqos sxva formiT iyeneben – ara mowevis saxiT), romlebisTvisac ar aris sakmarisi mtkicebulebebi am medikamentebis gamoyenebis efeqturobis Sesaxeb.

bupropioni

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

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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: 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).

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.

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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).

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.

dozireba: pirveli sami dRis 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).

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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.

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.

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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).

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.

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ra ar aris rekomendebuli Tambaqos moxmarebis SewyvetisaTvis

Tambaqos wevis mitovebisTvis ar aris rekomendebuli Semdegi wamlebis da midgomebis gamoyeneba5:

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.

nikotindamokidebulebis samkurnalo intervenciebis xarjTefeqturoba

nikotindamokidebulebis mkurnalobis zemoTaRniSnuli efeqturi meTodebi (rogorc konsultireba, aseve medikamenturi) Zalzed xarjTefeqturi aRmoCnda mkurnalobis sxva meTodebTan SedarebiT da mizanSewonilia miewodos yvela mwevels (mtkicebulebis xarisxi A).

nikotindamokidebulebis mkurnaloba rogorc sadazRvevo programebis nawili

sadazRvevo programebis mier nikotindamokidebulebis mkurnalobis miwodeba (rogorc konsultirebis, aseve medikamentebis) da am mkurnalobis xarjebis dafarva zrdis im pacientebis procents, vinc cdilobs Tavi daanebos Tambaqos, itarebs mkurnalobas da vinc warmatebiT Sewyvita moweva. amitom, rekomendebulia am mkurnalobis Seyvana rogorc saxelmwifo, aseve kerZo sadazRvevo programebSi (mtkicebulebis xarisxi A).

gansakuTrebuli populaciebi

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

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

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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).

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,

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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).

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7. 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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8. 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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9. praqtikaSi adaptaciis da protokolis SemuSavebis rekomendaciebi

momzadebulia gaidlainis Sesabamisi protokoli `Tambaqos wevis mitoveba da prevencia~.

rekomendaciebi gaidlainis implementaciis Sesaxeb

gaidlainis klinikur praqtikaSi implementaciisTvis saWiroa Semdegi RonisZiebebi:

gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa:

o gaidlainis nabeWdi da kompiuteruli versiebis gavrceleba saqarTvelos pirveladi jandacvis qselSi;

o saojaxo medicinis profesionalTa kavSiris da Sromis, janmrTelobisa da socialuri dacvis saministros veb-gverdebze gaidlainis eleqtronuli versiis ganTavseba;

Tambaqos momxmareblebis identifikaciis programis danergva pirveladi jandacvis yvela centrSi;

adekvaturi treningis, resursebis da ukukavSiris (feedback) uzrunvelyofa efeqturi marTvis ganxorcielebisTvis;

samedicino personalis motivacia nikotindamokidebulebis mkurnalobis CatarebisTvis;

nikotindamokidebulebis gamovlenisa da marTvis (konsultireba da medikamenturi mkurnaloba) xarisxis monitoringi auditis saSualebiT;

meoreuli donis dawesebulebebTan referaluri kavSiris uzrunvelyofa.

klinikuri praqtikis auditis kriteriumebi:

pirvelad jandacvaSi nikotinuri damokidebulebis marTvis auditisaTvis rekomendebulia Semdegi kriteriumebi:

procesi:

ramden pacients Cautarda skriningi Tambaqos momxmareblobis gamosavlenad;

ramden pacients daudginda mwevelis statusi; ramden mwevel pacients Cautarda konsultireba; ramdenma pacientma gamoTqva survili, Tavi daenebeina TambaqosTvis

konsultirebis Semdeg; ramden mwevel pacients Cautarda xanmokle intervencia; ramden pacients Cautarda Tambaqos mowevis Sewyvetis medikamenturi

Terapia; ramdeni pacenti gaigzavna referalze specialistTan;

Sedegi

ramdenma pacientma Sewyvita moweva; xanmokle abstinenciis sixSire; xangrZlivi abstinenciis sixSire.

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10. gaidlainis miRebis xerxi/wyaro

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

11. alternatiuli gaidlaini ar arsebobs

12. mtkicebulebis done, rekomendaciebis xarisxi

mtkicebulebis done da rekomendaciebis xarisxi

done mtkicebulebis done xaris-

xi rekomendaciis xarisxi

I

Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas

A

eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II Zlieri mtkicebuleba, eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas

B

eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia

III klinikuri kvleva randomizaciis gareSe, kohortuli da SemTxveva-kontrolis kvlevebi

C eyrdnoba III donis mtkicebulebas, SeiZleba CaiTvalos Sesabamisad

IV araeqsperimentuli multicentruli kvlevebi D

eyrdnoba IV da V donis mtkicebulebas, saWiroebs konsesuss

Vა avtoritetul profesionalTa mosazreba

Vბ klinikuri gamocdileba, aRwerilobiTi kvlevebi an eqspertTa angariSi

13. gamoyenebuli literatura

1. gulis iSemiuri daavadebis prevencia pirvelad jandacvaSi. saswavlo programa pirveladi jandacvis eqimebisaTvis www.gfma.ge/documents/Gulis%20ishemiuri%20daavadeba.doc

2. saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministro. erovnuli moxseneba saqarTvelos mosaxleobis janmrTelobis mdgomareobis Sesaxeb -2003 weli; Tbilisi, 2004. 113 gverdi Chapter 23 Nicotine. Joy M. Schmitz and Katherine A. Delaune.pp387-403 http://www.moh.gov.ge/ge_pdf/mohseneba/erovnuli_moxseneba_2003.pdf

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3. American Lung Association. Secondhand Smoke Fact Sheet http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35422

4. American Lung Association. International Tobacco Use Fact Sheet http://www.lungusa.org/site/c.dvLUK9O0E/b.39860/k.3FE0/International_Tobacco_Use_Fact_Sheet.htm

5. Bala Malgorzata M., Lesniak Wiktoria. Efficacy of non-pharmacological methods used for treating tobacco dependence: meta-analysis. POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2007; 117(11-12) pp. 504-511

6. Bała Małgorzata M, Leśniak Wiktoria, Strzeszyński Łukasz. Efficacy of pharmacological methods used for treating tobacco dependence: meta-analysis ORIGINAL ARTICLES. POLSKIE ARCHIWU MMEDYCYNY WEWNĘTRZNE J 2008; 118 (1-2) pp 20-28

7. Cahill K, Stead LF, Lancaster T.Nicotine receptor partial agonists for smoking cessation.Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006103. Review. PMID: 18646137 [PubMed - indexed for MEDLINE]

8. Chapter 33 Diagnosis and Classification: DSM-IV-TR and ICD-10. John Cacciola and George E. Woody pp559-564. http://books.google.ge/booksNs_HmvedaeGTviW0xLbKD9wEE&hl=ka&ei=QkOqSracGYXgnAO1h5WpBQ&sa=X&oi=book_result&ct=result&resnum=10#v=onepage&q=&f=false

9. California Environmental Protection Agency. Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant. Executive Summary. June 2005.

10. Centers for Disease Control and Prevention. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, 2006. 6 Major Conclusions of the Surgeon General Report. Available at the Surgeon General's website. Accessed on January 8, 2009.

11. Core Health Indicators. The latest data from multiple WHO sources. http://apps.who.int/whosis/database/core/core_select_process.cfm# The WHO Core Health Indicators database is updated at May 2008.

12. Eisenberg MJ, Filion KB, Yavin D, Bélisle P, Mottillo S, Joseph L, Gervais A, O'Loughlin J, Paradis G, Rinfret S, Pilote L.. Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials. CMAJ. 2008 Jul 15;179(2):135-44. Review. Erratum in: CMAJ. 2008 Oct 7; 179(8):802. PMID: 18625984 [PubMed - indexed for MEDLINE]

13. Encyclopedia of Mental Disorders . Mental Disorders » Kau-Nu » Nicotine and related disorders. Read more: http://www.minddisorders.com/Kau-Nu/Nicotine-and-related-disorders.html#ixzz0QoRSTlPP

14. Etter JF.Cytisine for smoking cessation: a literature review and a meta-analysis. Arch Intern Med. 2006 Aug 14-28;166(15):1553-9.

15. Guideline title: Treating tobacco use and dependence: 2008 update. http://www.guideline.gov/summary/summary.aspx?doc_id=12520 Status: current release.

16. Guideline title: Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May. 257 p.

17. Guideline title: Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Status: current release. http://www.guideline.gov/summary/summary.aspx?doc_id=12286

18. Guideline title: Brief interventions and referral for smoking cessation in primary care and other settings. Status: current release. http://www.guideline.gov/summary/summary.aspx?doc_id=9740

19. Guideline title: Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Status: current release. http://www.guideline.gov/summary/summary.aspx?doc_id=14339

20. Guideline title: Tobacco control. Status: current release. http://www.guideline.gov/summary/summary.aspx?doc_id=11552

21. Guideline title: Smoking cessation. Status: current release. http://www.guideline.gov/summary/summary.aspx?doc_id=9800

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22. Goldstein A;Gwyther R; Ripley-Moffitt C. Essentials of Family Medicine. Fifth Edition. 2007- Psychiatric Problems and Substance Abuse. Chapter 46. Addictions.http://sutlib2.sut.ac.th/sut_contents/H114878.pdf

23. 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.

24. Kaplan& Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Tenth Edition, 12.9 Nicotine-Related Disorders. 2007 by Lippincott Williams &Wilkins http://books.google.ge/books?id=u-ohbTtxCeYC&pg=PA440&lpg=PA440&dq=nikotine+abuse+and+dependence+DSM-IV&source=bl&ots=9fxztjc4tS&sig=w-

25. Lowinson . Joyce H., Ruiz Pedro, Millman Robert B., Langrod John G. Substance Abuse: A Comprehensive Textbook. Fourth Edition. 2005 by Lippincott Williams &Wilkins

26. National Institute for Health and Clinical Excellence (NICE). Brief interventions and referral for smoking cessation in primary care and other settings. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 36 p. (Public health intervention; no. 1).

27. Nicotine Dependence. By Mayo Clinic staff http://www.mayoclinic.com/health/nicotine-dependence/DS00307

28. Rustin Terry A. Assessing Nicotine Dependence. Copyright © 2000 by the American Academy of Family Physicians http://www.aafp.org/afp/20000801/579.html

29. Shiffman S, Ferguson SG.Nicotine patch therapy prior to quitting smoking: a meta-analysis.Addiction. 2008 Apr;103(4):557-63. Review.PMID: 18339101 [PubMed

30. Stead LF, Bergson G, Lancaster T.Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD000165. Review. PMID: 18425860 [PubMed - indexed for MEDLINE]

31. TIP 45: Detoxification and substance abuse treatment: SAMSHA; 2006 Jan 18, p 41-111; http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.85492#toptop AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee

SAMHSA/CSAT Treatment Improvement Protocols 45. TIP 45. Detoxification and Substance Abuse Treatment

32. TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians. Center of Substance Abuse Treatment (CSAT); SAMSHA 1997;

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.45293 AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols A Guide to Substance Abuse Services for Primary Care Clinicians; Treatment Improvement Protocol (TIP) Series24

33. WHO-Europe-Georgia.WHO Report on the Global Tobacco Epidemic, 2008 - The MPOWER package http://www.euro.who.int/countryinformation/CtryInfoRes?COUNTRY=GEO&CtryInputSubmit=

34. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. 2008. Available here. Accessed on July 30, 2008 http://www.who.int/tobacco/mpower/en/

35. WHO- Europe- Highlights on health in Georgia 2005 http://www.euro.who.int/document/E88548.pdf

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14. avtorTa jgufi

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

avtorebi:

gvanca firaliSvili, ekaterine gemazaSvili, givi javaSvili, zura sixaruliZe, Tamar zuraSvili; guram kiknaZe (redaqtori).

eqspertebi:

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;

Documents

Tambaqos wevis mitoveba da prevencia