ca dls4_rối loạn lipid máu
DESCRIPTION
Ca DLS4_Rối loạn lipid máuTRANSCRIPT
4 TINH HUONG 4. ROI LO~N LIPID MAU
B~nh nhan nam 50 tu6i. cao I m70, n~ng 90 kg bi r6i lo~n lipid mc.'w . Theo leri khuyen cC1a lxk sl b~llh nhan da c6 gang thay OOi 161 s6ng nhu· an it Ch~t beO, thti'C an it cholesterol va t?p th~ d~IC. Nhung cac thong s6 lipid huy~t v~n tang, nen b~nh nhan eta phai ct~n khnm t[fi b~nh vi¢n.
Ti~n sfr b~nh: ca. nhan:
- Ong ta c6 gia alnh va 2 con, Ia m9t chCI doanh nghi~p. - Dai thao aucmg type 2 tLr 5 nam tnr6'c day. - Tang huy~t ap (I 0 nam). - HC1t thu6c Ia I g6i/ngay trong 30 nam . - Thlnh thoang u6ng nrQli xa giao, u6ng 2 tach cafe/ngay. - 6ng ta v~n ctang theo ch~ c19 an kieng cho ngucl'i ti~u aucrng.
Gia c1inh: - Cha ch~t ILIC 67 tu6i vl nh6i mau w tim -Me;; ch~t luc 74 tu6i bj ti~u ducmg type 2. - Ong ta c6 m9t em trai 47 tu6i bj cao huy~t ap.
'fham kham: Beo phl. Vong eo: I 07 em. Kh6ng c6 tri~u chu·ng tim m~ch va tri~u ch(rng CLia tang au·o·ng huy~t hay h~ aucmg huy~t. Kh6ng phC1. Ph6i: trong. Ti~ng tim : ct~ll , k.hong c.6 am b~nh ly. Chua c6 d~u hi~u bi~n cht:rng tren th~n do ti~u aucmg.
Sinh hi~u: Huy~t ap: 138/76 Nhjp tim: 76 lfrn I phC1t
Ton ttA: Na K
I 45 m Eq/L, 4 mEq/L
Sinh boa mau: BUN I 0 mg/dL Creatinin (Sr) 0,8 mg/dL
TSH 1,6
Ch§n doan chinh: " Dai thao auo·ng type 2 (J R6i lo;;tn lipid mau
I
Thuoc dang sfr d1,.mg:
Cholesterol TP 230 mg/dL HDL-C 29 mg/dL LDL-C 140 mg/dL Triglyceride 305 mg/dL
Lisinopril 40 mg u6ng I ngay I lfrn Aspirin 325 mg u6ng m6i ngay.
Clorid C02
Nhjp tho·: 151frn I pht:It Than nhi~t: 37°C
I 10 mEq/L. 26 mEq/L.
ALT 16 mg/dL Glucose 96 mg/dL HbAic 5,8% Uric acid 9 mg/clL
PQN _ 1/51
-* ... t.hd~ .... ao~ .... .R .~.h. r. .. ¥ ........ ; ....... ttt .. l?. ........ c. ... i\Jutt- ~r.R.a.t~.at ... .ro.ad. .. ) ................................... .. ................................ .
0 0 .. . .... . . ..... ...... . . .. ... . ......... .. A:lf. ... :ro:.. ........ 00 0 0 0 00 0 00 •••••••••••• 00 • • • • • •• • • • •••••••• • • • •• 0 0 0 •••••• ••• 0 0 00 • • 000 00 0 00 ••••• 00 ••• • •• • • • • •• ••• • • ••• •• 0 •• 00 •••• ttrr. .... .K., ....... 0 0 .... . ... . .. . . .. .. . ..... . . .. 0
fi\ v r ·, l i ~ J.l fl, .-.J I / P ~·····~~K .... ~t?-\ .... C.l\\ .. ~o. ... K.lf.!.C.I .. <1\ll'f~····CtlrA .... Jb.l\\ ............ . @ ...... gciri~ .... t\TP..:TIL ..................................................... .......... ........... .
......................... ...... :1.C ........ ...... IG: .............. 6D..L ............. ±!D.L ...
.. 1¢1/.M~ ........... <.J.Q.o ...... .... <.Am ....... .. <. .. A9.0 ................ (4.9 .. : .... .. _ l I I I I. { . A <:-' I A * .. LIU,\ .. ~ ... : .. ... ~~ ... ~ ..... oq,.w.sz.~ .... ma ... .tnQ...U ..... M<r.l .............. .
6rl;.:Mi..uu .............. :7 ....................... :: ........... A.o.o.:: . .A.~3 ....... ?. .. ~.0 .... . . ...... ab.l'dt .. .rthu~ .. .hu.\ ... ~au ... .)d. ... ~ ... o6.h .. a1 ... ............ . I # ° C
Ca..Q.qcl(kG:(\ .. ~O.Q::: .~:4l.O. A5.P. ::-.A.j.g. JM .. ~ .. .A.53 ..... .. 1h~ .. 1 .. .
.. .. ... Co..a ................. '7a.J.:1.0 .. i?ZQ.0.::.::1.3.9 .. .A~D .. ::)85 ........ <.-:1.0 .... ..
.R&(c.a9 ..... ... .. ... :::-.......... ... .. ... ~.5.0.0 .......... ~.~t~o ........................... .
~) .... xqf.. .. c:b.~h ... ~~ .. ~l~o. ... d!1.o. .... C±lD. .. )J.o.0(. .. -IM}jn.1-. @ .... Gid.(}~5 ···fflP. .. JTI: ........................................................................ ... .
... ~ .. Mdo.~ .... C±\D. .. Jri.o ... Qdm . .1.Qf).!1·'····· ····· ·· ·· ······························
0.." L ..' , 7 t 1 ~ ~o, ? .+. I L _ .u£.nX'I ..... C1l.'D. .. l .. f.::&.au .. fuat.no.ur ... 9.n .. dlrJh ..... ~.Q.n .. Q.lf.t¥1 ...... . , 0 · I ·
................................ ± ... Jii~ .. 'b..u~ ... l'\.11:1.~ .............................................. .
............................... ±.dl6..2cim ... lhti .1h.uA~ .. ct6na .. m.ach .. ~anb .. . . ' · - -~ \
_ ~.uh .. -hfcill.qj .. ~n~ .. L+.\D .. \ ................................................................ .
+ .. Cad. .. J.ht .. .Qs. .... Q~,~ ... ~lo.h .... xd .. ~ ... J:&na .. ma.d\ ... ............ . • I ~ (
o. ... ~h .. ~iAflY.t .. m.a~h .. . ~Quh ... :: ....................................................... . • i """\l .
••••••• • Q ••• JtA.:D.ti~ .. Jg~ .q~ ................. .. ................. ......................... ........ .
{ ·- ] ....,.... o IL ~ ' I _\:" JJ f ..... :.. ... ... ~~.~t1. .. ~n. ... m.t~ ... ~ ... nUJJ .. ::mrotJ.1 ... qu.lt.\.. ............. . . .................. ................................................................ .. .. ............................ ....... .
........ ~ .... +l~r·· ·cl{o.~ .. d.\a~~ .... Cfl.o'\ .... >.. . .lo.Z ................. ................... . . .............................................. .. .. ...... ........ .. ...................... .... .............. ... .. .......... .
~ ...... ~t.ob ... dAro ... Q:\a~h .... naQ.a{ .. bit.o .. ( .WI-.D.) .... ~ ... ~ .... ... . • ( ~ - ~ I
. ................................................................................................................. ...... .. .
... l~ ... 4.~~tn4 ... caLk .. A&., ................ ................... .. ... .. .......... ... . ··························································· ·· ········································· ·· ···················
.9 .... . P.hiab ... ~q ... !n~c.~ .. ~w .. w9'8···.CA:f.t&..2 ................... .. . . ........................................................................................ ................................ ..
·-+ ... ~~ .. ~cl~ .. a:u~q .... ...................................................................... . ····························································· ··· ····················· ·· ····································
@ ... xa.( .. ~.Jil .. c.al. ... ~.:M.~ ... n~.r.rY. ... ~\:u.o~ ............... . @ ... Xa.l .. ~~h ... .b.~~ ... ~h0n ... ~r/. ..... bD.L.::.c. .. a .A.:iO .. rocg/c/L
.... C.OfdoO:I ....... L.D.L:: .. c ... ) .. ~c%···· · ·C.±tD ..................... ................ . . .... A~ .... M..h~ ... ~ ........................... ............ ............ ................. .. ......... .
4J Nom >~cf....~~o: I !A.u matLktl'l~
1au..c::::u.:-Cl.!l-C-c/ btob ~Dac.b \Cruh >..or-£
~oro dti"\-lnldc. < 55bJuL (c.k,_ciuL__Isa.{)
~ a& -\(!,(J. < c;£-\u6L C tN2: - c& --· )_
PQN _ 2/51
!/. oo:±loD.oLoo<. o-:4~ om~/.£00oooooooooo oo oooooooooooo oo o o ooooooooooooooo o OOooooooooooooooooooooooooooo
4/oo :::±-.luJooo ::.thuod.oli..OOOOOooooooooooooo ooooo oooooooooooooooooooooooooooooooo oo ooooooooooooooooooooooo
TJ/ooo:Jan~ooo±IA .. .COO :?:OA.1DO JO~W..Il\m oH~)o~~ooo..=.ton~oo d.\iDI}oooo
oooooodhou.atoo .J'0- ooq.o,oooooooooooooooooooooooooooooo ooooooo ooo oooo ooo oooo oooooooooooooooooo oooooooooo
ooo :±l.P.ol. oob.oo oGooo o .mff/.d.R.. oooo-:?:oodni:dr. oi.. o~oo o o~!. o()~o ocO.o oo
@o o o o o OXa{o~~hoooog~.~ ocfi. oodrooo~o o oA.Oooooamooo J:na{.p.hcl ooo oo
000 OOOOOC:t.t.Do.Co .. ldo.s} OOOOOF.in roJ. nqb.mo). 00000 00 00 00000 000 00 oo ooooooo 00 00 00 000000 00
O o .J>rooooog«:il~ oo~rih ooooooooo ooooooooooooooooooooooooooooooooooooo o oOOooo O OOOOOOOooooooooooooooo o oooooooooooo
o,;. .. ooooo:J'OuoLooooood a .. 7:ooo::r:Etoooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo
.3o}'ooooo:::HoDob o::oC .. oooooomcg/.d.e. oooooooooooooooooo oooooooooooooooooooooooo ooooooooooooooooooooooooo
o.f.I.Y. oooooo oo'Roooooo tn<Jo.t.di..oooooooooooooooooooo oo ooo oooo ooo oo oooooooooooooooooooooooooooooooooooooooooooooo
5-"o,ooo oo oooS!)f. .. oooomm.Ho~ooooooooooooooooooooooooooooooooooooooo o o o ooooooo o oooo o o o o o ooooooooooooooooooo
o~ o .... ooo o o:fll&ooo.Jt-o{oooo 1:::;lo o~ oooHkoooo oo oooooo o oo o ooooooooo o oooooo o oooo o oooooooooooooooo o oooooooo
o'f?.o ooo oo::H0oo o:ibou.o:'~oooooooooooooooooooo o oo o oo ooooooo o ooo ooooooo o ooooooooooooooooooooooooooooooooooooo
@ooo.xo/..ood~booooc oh.l. oA~o~.QJ.p.rdoo~{o .lru.t;. oo~tuo ooo o ooooo
Jaql.. .. .. o tl'i!u.~ OW: .. ~o~ ........ oLDLL.olo J:rt.ticL .. o .tM/ .. 0 0Nfln7::HQL
"';!"::L~ .. . rofl.{jl .. <li .. ~ ..... ln~' ·4··bllk~T~llh :.c. ..... ulldt,.
.................................................................... \ino~ .. k\t ...... ~o .... fir.<al.rl.U
................................................. ................... . . kG),, :4 .b Cii .................. .
oooooo ooool .. ooo OOo oooo ooooo ooo oooooooooooooooooo J. ooooooooo oooooo ooo ov.~o~ooo ooth ounL OO ooooooooo oooo oooooo
ooooooooo l oooooooooooooooo oooooooooo oooooooooooo l ooooooooooo~ooo o oo oooo ~(), oo .. o.l. oooooooooooooooo ooooooooooooooooo oo
Ca.•··l·C.itl?...J.M.~h. .. l! ........ <Ano ...... blD.~ .. ..?..dU.O .. ... <A~.Q ............ ~±mo .l..fmoro~~:J .. o.L<fQO) .... o ........ ..J .. (~AOO~) .. o .......... o .... o
........ 1?.e~cQ% ........................................................ ! ................................ . Ca.o .. ::: o 11.. ~.ot o:·orK . ./.. ............ :< 0~8..9 .... ).JD.ao .. o~J3.0. ...... .<-JhQ ..
~" ~inbo , .. frnro:lDo 0 m .. AoQ o;lo~ o~~Jgp..) .............................. 0 .................. 0
/7'\ I o l b. /' L L ). 1 I L I .1.. . A7 l .\.2)oooX(1c o ood~hooo o&~o(l oooC\t:lC\(\ oooh o9.ooo::1r.Oo(J o~ o •nJJ.Qffi oo :ollJ.Oo L. ooo:Thfoo
OOOOAoo:-o o::f.f5.0 0 0 0 11Lui-. ooo~gooLr/oo od!.R)oookh~Cj·· ? oo····· o ···· ooooo o oooooooooo
@oooo&cuihooo~oooncg~ooc.c!.o :::bm~o o o o d.Oooooo(\Qmooooomd.oooo oo
ooooopo ho.~oooooc.-::M.OD. OO C OOOO~.Q..ooooo.!.\)o~v.OD.o o o :::oooo.o.koo)oooooooooooooo
~I l /1. ooooo o.!.7ooooooqroloooo :nor.t ooooooooooooo ooooooooo oo oooo oooooooooooooooooooooooooooooooooo ooooooooooooooooooooo
oooo cfl"' oooo oo~~~~o ::l:nto oooooo :oooooooooooooooo ooo oooo o oooooooooooooo o ooooooooooo oooooooooooooo oo oooooooo
oooo oa?.: ooo oJ.uo"too:4oo .... ;OJ.5.oooooooooooooooooo oooooo ooo ooooo ooooooooooooo oo ooooooo oo ooooooooooooo oooo ·
0000:1.:-000 00 oo ::±u:?olo ::.c.o oooo ~ncai.dLO OOO O O 00 00 00 0000 0000 000 000 000 000 00 00 00 0 00 00 00 00 000000 00 00 00 00000 000
oooo~ o 7.ooooooo~oooooooomo~loJ.i..oooooooooooooooooo oooooo o oo oo oooooooooooooooooooooooooooooooooooooo oooo ooooo
oooo~ oTooo o ooooS.bof .o rom oHo~o o : ooo o o o o o o o oo·ooo o ooo o ooooo o ooo o o o ooooooooooo o O O o o o· o oo· ooo o o o o oooooooooo ooo
oo J.o?. o oooooo~~oo ·ok~o o .1oclfi o<a o o ot.L1:::·o o o o o ooo ooo o o·ooOO o o o o oo · o o ooo oooo o o o ooo o ooooo o ooooooo· o oo
c. I 1)T..0 ? oo oo"t..7. oooooooo Qooooooo oooo ]o).•oo:o•o•oo•O•o•ooO•oooooo ooooo oooo oooooooooooooooooooooooooooooooo oooo oooo ooooo o• ooo o
/. ;. 1 oooo~o 7. oooooo ::+k~ ooo;,l\r.uoQGooooooooooooooooooooooo o oooooooooooooo o oooooooooooooooooooo o oooooooooooooo ooo oo
@OOOOM~lM:.;,.h-oll-al)oqoooo~o?p.oooo~oob.t'~~o.oo o . oooooo o oo oooooooo o oo ooooo ooooooo
clo~ooo n.~.co.OOO C.~f.?. ooo .A.O onamoooo .<. o :::flo~l9. o oo k:'"?.:'o o o o o oo oooooooooooo ·-
"· ~,h I n I "~D •o: "" ( ,~~_, ... .. 11 .. ::1ZOU .. ~ .... ~ .... nCiJ~ .. cd. .. .,; .o 110 norn o.-~ .L:":t .... laoo:;;:im
~oooo ){g,~n ooxilo ootn~~0-~0~~0011/ o r:P.:. o~J.t ookkl odJ.~o oo~lk~o~
oo.oooooooooooo~ ooooohoD.lo :: oc oo oo .Ao~O.ro.8.1Jlooo o ooooooooooooo··o· o oooo oo oooooooooooooooooooooooooooo
o oo ooo ooo oo o RooJciOO~OOOO JlvO~! oo .mo~ooo.dH~o ~ooooo ···· ooo . o o ooo o o oooooooo o ooooo ooo
oooooo oooooo !\ oJJ.(.!)ooo '?o"ll oca~ooc. o .~ho o oc.rf.oo oc+.\P.ooo~. o o ooo o o o ooo o ooooo o o oo oo oo ooooo oo o
Ooooooo o o o o9. o o o ::-Ho~ o-:: o oc.RPOOOOJ..rr)..3l£. oo oooooo oo ooo ooooo ooo oooo ooo·oooooo oo o o o oooooooooooooooooooo o oo o
o ooooooooo9. o o .Jh£i oo~l. oAcdooo .ma.c.h o o~!?.l-;o h .. o .. ooooooooooooooooooooooooooooooooooooo oooooo (
ooooooooo fl oo oAo~IOOC.c.~tr..$ 0~ 07Ht';o .c.$.~o~h0~oo :.: ooocg~o\o .~O)O<. OO+ o3.
--"-~~-llij..CLC±ii21~~""-"<Jd~o:,._l .>.Zta;,....o...___ ___ _
@_kt~ -lrq dn.__c~fd£
..
, PQN _ 3/51
no M6N nuqc LAM sANG KHOA Du'Q'C- DH Y Du'Q'C TP
HCM
PHANTICH
" ' CALAMSANG4 THEOSOAP
P4>1.:\MT4>1! 4>1..\AG JljA- DLT BQP
S- THONG TIN CHU QUAN
• B~nh nhan nam, 50 tubi.
• Chi€u cao: I m70
• Cdnnijng:90kg} BMI=(1.~~)'=31.14 -?Beophid(\2
• Ly do khtim b~nh : da thay dbi lbi sbng nhung cac chi sb lipid v§n tang
• Tidn su gia dinh: - Cha da qua diri nlim 67 tudi do nhili mau ccr tim
-Me; da qua diri nlim 74 tud~ bj ti€u duirng type 2
- Em trai, 4 7 tud~ bj cao huy€t ap
021061201 5
S- THONG TIN CHU QUAN
• Ti€n sli' b~nh: - Tlinghuyetap 10 nlim
- DT£> type 2 dli 5 nlim.
02J0612015
n_ _ l .J 1 ~ 1 -"';;a ~--4 ., , ~ - L A . L . / A * ::KAn~ qtn-CJ\UZ a~'T""""""":"-~u=n ,
• ._ldn ~nq ~~ ) 6/2/2015
a Cc:~ !\~n~LO~ . Ib~l .
nw- 1jO ±d!V X (cb.ti«~ Ca.oCoch )-G6)
- 5D * .. 2, 3 x ()to I oJ, 52! - Go) - GG,&~ _
• \J! Abw ? ,30'Z IB\(J C ?C::% 2 :z du-1¥}
Co~ oGf, £r&4 dof)b A) !?IX/
,Aj bW - Ih w + a, ? C1p.;\Xt - XbW >
- c: c ±0 , ~ (gq- c,c;) =i:?, olk~ .
__ AM drcwh =;lhQ, C.(ocvknJo ( i cc
d'cv- = - - --=-------=:::.... ::(-J_ X ~c.("
_ 1&1 el-I\_ ,kc c:O'i~ :;ibd n GfR. ,
C-£Rx- AKG x ( s~T A,J5Lf x Cdu&; ) 01olo~
)&(, '6 ( 01 8 fAiAIJ4 X ( !V)Of-lO~
- 7 Jn/h 9171~ · c1u•/ pO~ dbo~ C.H;
h~ abaQ b 1ob :-;/b1i&q
~ -r&~~ ~-Qg ~~~~ ~ua-e.&_~=:kao-~_Lplu/il-o.---
,.M ?~boob --ih-:1: c r~ adkuq ea ;zl!,t +lh '
)u,~}\. ~ rotqpron~ eJi l cMk c:~lft Qwl bo 1o5o too bd :fu~o -:-Iron~ 1 $fu 0 ~ <f<Jn C din©;~ Pa 1. p~{t)
1
..
· ' 4 PQN _ 4/51
("'l t1 • "
- - ~ J\~(_'---___ _ 6/2/2015
--------------------~~~&m r~as~~ ________ l1u..& J\ J\
...------------------, C~rnx:J siimuOa !s-o~ :=r)rH 1 / 0-BANG CHUNG KHACH QUAN J\Ormoru..) ...,-- . .A
1 ~
Lam sang: beo phi, vimg eo: 107cm I \.\~LQ qrnp / - Khong co tri~u chimg tim m~ch va tri~u chirng cua tang cluimg
huy~t hay h~ duimg huy~t
- Khong phu
- Ph6i: trong
- Ti~ng tim: deu, khOng co am benh ly
- Th~: chua co d§u hi~u bi~n chimg tren th~ do ti~u duimg
- Sinh hi?u:
Chi s6 Gia trj do duQ'C Gia tri binh thuimg K~t lu~n
!':lhipti'." ...... .J.~l~.l1f.P.~.~t .... .. . ... ~0:~~1 ~11fP.h,~t.. . . .... . . ~ ... . Than nhi~t 37°C .. ............. .. ...... 1.?:: J.?,?.'<:.... .1 ~~~~~:~p: ... 138/76mmHg 120/SOmmHg NIJiP..tha ····· ··· i5.ii;;;ph~; · · 16::. 2iiii;;;phu; ·· · ·· ··· · .1
~~~e biahWrq_:
:::t~(~,~~~~-
0- BANG CHUNG KRACH QUAN qn lam sang:
Sinh hoa mau Chis6 Gfa trj do dLJV'c Gfa trj binh thU"O'ng K~t lu~n Ghi chU
Glucose 96 70 .-tJOmgfdL .L
HbAIC 5.8% <6.5% .L
Crcatinin 0.8 0.6-1.2 mgldL .L
_ J'O::,t\ &.A -Jh,£6 j , ~if( cyo( -bra~ 'i>?( JSnnnon--
~ ~=~4b~ronob }~;:·~LDL (da~q J,=<l- ~"3 ) do :\oo~ -th~ ' b,'J'A Q; prz:l , JunJ sh~, d~
c .bo~ shrnt cl' 1cac<J O )
Nh,r& qnp , ~ , L1 9mro -> ~~ clw~e~
~.loc! ~id -> :Lb12L~.1 T(i: __ _
~--~A~r~,d~. ~u~w:~----------------------BUN 10 7-22 mg/dL .L
ALT 16 <35 UIL .L
0.35-6.2 .L TSH 1.6 KhOng ~nh
1=--+,-----+--:-::-::----=----+---,---+!t~~~~.~-i~?. .
1 a cl d UvfL 1/ n1fdc. ~ t:. Co24l\ ) m~lo~o }f(\0~ < 200 mg/dL
> 40 mg/dL TC 230
HDL-c 29
Cao giOi h~;m 1-:':"-,--E=-----+-.::::.::.::~---+---'---+~~~P.:::::::::
< 100 mg/dL LDL·c 140
TG 305 i-==-'-+-'-'-----+-.:.;..;..c=---+----'---+~~?-~~~-~~.l-'-"--+-'-=-----+-<.:.:.150'-'m""g/d:.::.L __ -+----'---+C•o Uric acid 9 3. 7- 7.4 ms/dL
I ....\....~ 02.W20ts tt .;,ti/cl:..U.SJL'--------------------'
;}-;!,., \ "* bvN /~0_!.1. -~ ~~-~~ ch~n~~ 1 ~~ w CQ •:tOna nh~o~ rHrd r htw~ 1'\aC\
doke\-o;c. "' ..J . .J_~ LT,-,,, j ~~ Mil 6",9T.<£..,r!-d..---11 ~ . ~~~ 0- BANG CHUNG KRACH QUAN ~ li.u;a ?f!-t'~- v qn lam sang: ~ ~ r ~~--~--------lo-n~d6~-------------,
~ t\(tt + ~.J.:r.t Chi sci Gia trj do dU'q'C Gia trj binh thtrlrng K~t lu~n Ghichi• --
O ()II ~al Nn 145 135- 145 mEqiL .L Anion gnp= [Nn'} + [K' ] _/J\! ..) K 4 3.5-5 mEqiL .1 -[HCO,-]-[Ci j
1-"---t-----t-,---,-.,:,-,.--+---i = 14S+4- 24,t:..,)Ao ~C:;:.Iori::..d ~1:,::.10 __ ..£95_-::;:105'-";m:='Eq/L'-=---+--'-1--! c 14 1_; lll&f/Q.. CO, 26 22-28mEqiL .L 7.1
Ch~n do an: - E>TE> type 2
-RLLPH
- Tang huy~t ap
ThuBc dang sfr dyng: Lisinopril 40mg u6ng I ngay I IAn
Aspirin 325 mg u6ng mdi ngay 0210612015
~-han phd~ du!/ 55%±1 co!l- t 5'4 C.~.~hY4$_rt,
~ __cq;f~c; =z =H c.~- JA,-1- rnEq}J,..,_. --
-7 ANillN Cff - M t 3 m X:~/-"-'----(
6+: < 1!0 rn~LJ . ( - ~lt_nfu_! d_~)
• long : obi~ actd chmi~ e. ~Jl~Qh ~---
• ~~WW~~AA/ ~-----------------
[gu-cJ noi J /ro o.J ' meg f olfc
xei D'J ~i4n c:.h: ,&,( Qorl YrfV CCJcJ ( >~6)
ah1~ d ura ~uhb ,J,,g.? -ltd: ' clu16~ .~
. .uhl~~ ih~o _\~ -ih~t\ , ~~ -l-or~ -+hi kh~ ca.-.; ~baj dimqj JbJ,ct/ eM cd;)
ll _ I ... ? f),../ \ A I 2!Do~ <7JT!l ,Ko1 ,Dooq .
'Jctidfl9 h_ar 001 f a ud !A(t,1/ruo.M'
-tcrnrj cci -zl-b( do n~ua ;!) obdn )ay '
+ Pw; phr ---- t- sx w h:3i :hq; a cs-d u,rt. dih-d'J
-t ;-Ph ~ JG ->- t s.x ,,.-[T-f) !??
+ n, 0 M -7 Jt h& 11 9~ a cTd II Cl? 0 7 :than
C.hJ ~~ Aspi, .-a P; R·~~ ..Jk::1~ f()ol'Gi du -Ji • t \) J
.ba. 'b{b c:wrl ur«.. Ca\-+r:S bn ~_frt6)
+ c.h/ d1: an cfOJt__p.roJ-~J:>.ll.Dl/~ : J. # -t.i~~c.hn_ohtr'nCj-a~~
.lh0n~ ~(j . C fudui,_pfw5 fha±: ,_SIJ.JA-t-
~prOkn
2
A\.t:>.tt-Gql-::_l_ -t -+ [J(~-1_= __ (LJico;_J t_ La,-J) ...
PQN _ 5/51
I _• A ,., , A<.'tloo~ Cell\
I I
A- DANH GIA TINH TR~NG B~NH NHAN
0210612015
Cac vftn d~ ciia b~nh nhan:
I. R6i lol.ln lipid huyet
f 2. Dai thao du<m.g type 2
~ 3. Tang huyet ap
4. HQi chtmg chuy€n h6a
A-DANH GIA TINHTR~NG B~NHNHAN 1. Rbi lo~n lipid huy~t: • Y~u t6 nguy CO": - £lai thao duimg - strll. SS
- Tubi cao - Beo phi d9 2 - Hut thubc Ia
C~n lam sang: TC: cao gi&i h@n HDL : th~p LDL: cao gi&i h@n TG: cao Danh gia SIJ din thi~t cua vi~c di~u trj: - B~nh nhan da bi £lT£l 5 nlim
G Nguy co 10 nlim theo Framingham: > 25% va c64 y~u tb nguy ca dfin d~n CHD - B~nh tim ml_lch vimh
-?nen cAn thi~t phai dieu tri d~ nglin ngira nguy ca nhbi mlm ca tim dfin d~n d<?t quy
- B~nh nhiin da thay dbi lbi sbng nhung cac chi sb lipid vfin tang 0210&'2015 •
• Di€u tri khuy€n cao: - B~nh nhan bi £lT£l - LDL: 140mg/dL - Nguy co I 0 nil.m theo ASCVD: 36.3% -7 Sli d\111g li~u phap Stalin cuimg d9 cao: Atorvasttin 40
- 80mg, Rosuvastatin 20-40 mg (theo ATP IV)
Di€u tri hi~n thoi: Chua c6
D€xuftt: Rosuvastatin20mg x I l~n/ ngay
0210612015
• 'i>I?P ABX mm ±!a ,J ch2~~ 6
@ l} tJil: to' bq{'~ cd do~ ,:M·~ C-+ID
• Nom > !15 <lurrt C '50 <\w!? )
o !]:l n ,k/ qp q~fi~ I cia ff\&( v. N14cl:{<ss-Tilo'U
p dbog .At~ -b1 k;nq 2\n~,o{ .£9 cap
~ ;.{_Q_ociin~
~Qgx: M~
Arae 5X
J2p co o:ltu= 0 TCt ' n2 ;a m~ /Jt
:HD\.. a9g m~ lciQ
\~>.in£,r WsrGd pr.o<) urg_, A.;?K m~n±l~
0 lrod..row C ¥c --t\~~s-mo "(Q t
0 SIT\() s
-> ~!L_
()i, -11Ql A'- enG;, cb,<% \ -;¥ I CC\0
- >- )ld''?~ Nmw·n , d"~ nk&Q bo d-onJ fa.c.'idurrc
-~ }run du9~ &' bm 1-:1 <hh~ rla!ta brrckn~ 1i cW,n~
h<hn_ sta.~b ~~ _ ~QJ"'--------
_kh&~
Ao-dolu_ 3
PQN _ 6/51
2. Dai thao dtrlmg: DTD type 2 da 5 nam YSu tA nguy cO': TiSn sti gia dinh: m~ mAt nam 74 tuBi vi DTD Type 2 Tu6i >4 0 tu6i Beo phi Hut thu6c Ia Tri~u chling: khong c6 trieu chling h~ duiJng huy~t vii tang duiJng huy~t qn lam sang: HbA 1c: 5.8%
Glucose: 96 mg/dl = 5.47 mmoi/L D:lnh gia Slf dn thi~t ciia vi~c diSu tri:
DuiJng huySt ciia benh nhan dang duc;rc ki~m soat t6t bAng 16i s6ng ( ch~ d(i an ) , khong sti d~ng tlm6c di~u tri -7 tiSp tuc duy tri I6i s6ng vii kiclm tra duiJng huyclt thuiJng xuyen.
0210612015
A- DANH GIA TINH TR~NG B~NH NHAN 3. Tang huy~t ap:
Y~u tA nguy cO': - Ti~n sti gd: cha mAt nam 67 tu6i vi NMCT, em trai 47 tuBi bj THA
Tu6i 50 tu6i Beo phi do 2 Hut thu6c Ia
- DTD Urn sang: HA: 138/72 mmHg Danh gia Slf dn thiSt ciia vi~c di~u trj :
Theo JNC 8 vii ESHIESC, ADA2014 buyS! ap cua benh nhan dang duc;rc ki~m soat t6t
Danh gia di~u tri hi~n thiri: Lisinopril 40mglloin/ ngay ~ hw ly ~· }:an Aspirin 325 mglloin/ ngay ~ khiing h<;1p ly 7' 1 ~ ~
D~ xuiit: - Lisinopril 40mg/lfrn/ ngay / tlopftiOCJ(~ JV -Aspirin 81 mg/lfrn/ ngay ( chu y [acid uric]) "
0210612015
...)<1&~h1£h -=:h'U(1CJi-ct1n v-dn rna~ -> _1' ~ca~ . . . ---1uib_-\K . .qm~L/' ::h ·d _ ~IE.. __.;;._
1 6/2/2015 _tiE_~- o ~-;:.-5.-MLc.d'n_~e.q 6&-~ -'?-t +1A
I
T'lE qan ~ PA--::>- -"'-co bor_cok '7 "'-"~~r~M _..,.1'
c.ua~ £~1a~-t-±l,.~-\...o. ___ _
ol,. CO' c~' ;lhf chs'-' I Kh.) -t.l-A- dl!.t )<lJd~1 ?
.1< 1/b ;fu/n jb 6\? -h&(. l\a ~ w tq -z PQ a1o
c hu~R'o Ao~adoa s>Y! a~g a -;:= Aa'fPttos:!o I
-> &~a'h" s!Q lf -? -to/. c:L,?'i £~ t
i' l11,~A -;lh~~do~ ih-~o - "> 1' tgl a&Jnd ·Mon<
-;:. Ju1 1 gAtY mqi)( /at !Cfc --::>- qJ\!p kh~1 fflJ ~ f1A
-t dmoq +Om obi~ e uq as:-- .fut: - ? khcft I J( I ) I -o.\fo(, -7 1Aan9 nu'd't- -;:. 1dp_;fut1 vao
Aron - -z lcb~c Jh ~7 ti'h (l'\~ - ·--
-+ m C!c b rm1~ :z c o ma~ =z 1';>-.&1 cnh o~~~
b'o~ -7 t MA
* J_u1q chon ;1-b-m~{ -B- ll1 A J<k co' b&ib Jwn ~boo.
• i>Jft --'7 nt:E:r I AR.6 ~ J.8, -bg~~ -7 J? b'bdw / CC.b
~--~~~~------------------------
.LW cDe~ cho bodlFfr d!lqm£ lll~ dBp}
.fu:I'1LQp-nt_.l_:~tatn~/l.&J1l~a.~ 1 C ilL.altl:JL) _ ~Cl~ Ji w ~ r r1~ ?M0 ·~., ~~ phno ~-£_~ _j_ <)I\"' 1() ~ /M -j' ().. "' - l " 2 / l I ~ ., {) "' '"d -' ------F ()( v!!l3 BllL ul'(laJj Lt~lllU.~I!U. _ Iilli!.\--~ \1' ap Al!' Ao~ C.au fTf ,C\ -"'-~ CULD£}L(Q
A- DANH GIA TINH TR~NG B~NH NHAN 1 1oo dvta ~~~ 1hdp . 4. H9i chung chuySn boa:
Y~u tA nguy CO': r \ ,..r ' I "' 1 + "T Ti~nstigd:M~daquadiJinam74tu6i,biti~uduimgtype2 cer-a ! ;lc k\& mRO C h!l~gO tm~cgo s;o d- -;> Tu6i 50 tu6i, tang huy€t ap
Beo phi de) 2 Anwn h.osio J[ ( !YWl IKE :: A Acyf7'()-eN,)o DTD il d
• Lam sang: ( ) Vimg eo: 107 cm 0(b£Q(<h'o% R.n~!O
- TG: 305 mg/dL
- HDL- c : 29 mg/dL .-.-I I h +J h- I -1\ )Ct Dang di~u trj bang thu6c h~ huy~t ap <a r A~ 1 O I P u 1f)Oc"3 1
Danh gia Slf din thi~t ciia vi~c di~u trj: 1 1 p _, !l
HCCH him tang tinh tr~ng d~ khang insulin -7 kh6 ki~m soat DH L\h. eM>, 1 (J 1\,C\' Acl~U Cholesterol mau cao, tang h~y~t ap + HCCH -7 gop phfrn t~o nen d ) u«~ ) man!! xcr viia trong thanh dc)ng m~ch -7 nguy ccr dc)t quY.... , A 1 .
9 1 021D612oT5 " ? \A!.-...(....-"W..Ll._.I.~L\<l'Ul.L_J;;.~C\-'(ll[.lu.A:l..ll1~~:lWL.I. -7 m C:W U
• AC Ei -/" c:hl; &on"A Altb !b~, p~ud I
, 1 I I 1-l c' I,; 0 CCb , phcu /n~lf >(CjJ l -JhJ.J.ac._CJat-LII.LL!•1"-"b'------
, I fA..,'f J. I I\ \.tOt 1 - ..J"" ffillOi.-
~-~/~n~du~~L~-------------- proh.tiJ Cc&burnt" ) _;> 4
-} o/ JJ}c }o_o --:> <\iO cl )?~ "-' /
---"'~- o_r,q I
Q.C}-1- ctskt- ---PQN _ 7/51
(. : ..
)
~£1 -lr/bc&~ l: .lr.1 {35-
J~~ 2p bQli ~ Q~(Lrh £b phclt ch o ho <1mr
~_L~cochm~
Cct~~~ 1l\1ru... QC
• Di@u trj khuy~n cao: - La m\lc tieu thlr 2 ngoai LDL- c
Di6u tri nguyen nhan ( thira can I beo phi va it ho~;~t dong thB h,rc) + KiBm soat can n~ng tich cuc ( chS do an u6ng lanh m~;~nh, h~;~n ch6 cliilt beo bao hOa, tang cuerng rau hoa qua, ca va cac lo~;~ih~;~t...)
+Tang cuirng ho~;~t dong thB luc ( d6u d(ln 30- 60 phutl ngay vai cuerng do vira phai nhu di bo)
- Di6u tri cac ySu t6 nguy ccr lien quan/ khong lien quan lipid + Di6u tri THA + Sfr d\lngAspirin a b~nh nhan bi CHD + Di6u tri tang TG val HDL thdp
• Danh gia di@u tri hi~n thOi: Ch6 do an, tap th€ d\lC -7 hqp ly 0210612015
p - KE HO~CH DIEU TRl Myc tieu di~u trj:
MI,IC Tiing huy~t lip Dai thao a~rimg RAi ~OUJ,l;~!ipid tieu
Ng6n - Duy tri HA hi~n - Duy tri f>H hien t(li - TG: < 150mg/dl hon tili - HbiAC < 6.5% -HDL-c:>40mg/dl
( <140/90 mmHg) - DH d6i: 70 - 130mg/dl - LDL-c: < 100 mgldl - f>H sou tin:< 180 mg/dl
Doli - T!ng cuimg - Tting cuOng kiam soat - Ngiin nglra etic biSn h(ln ki€m soilt HA
- Ng!n nglra v;i hlmcMmtiSn triSnCHD
02/0612015
d<ii thlio duCmg chlmg do xa viia - Ng3n nglra va him ch{im cDc bien chimg d6i thdo duOng (cln djnh duCmg huy6t) - Giii c5n n~g I)• tuCmg
p - KE HO~CH DIEU TRl
Phllc da di~u trj : Rosuvastatin 20mg x I IAn! ngay Lisinopril 40 mg x I IW ngay Aspirin 81 mg x I IAn! ngay
Theo diii di~u trj: Theo d5i cac xn: CK, HbAIC, Creatinin, K+, (acid uric] Ki.\m Ira duimg huy~t, huy~t ap thuimg xuyen t~i nha
HCCH
- KiSm sodtcfin n(ing
- KiSm tra cac chi s& lipid huy~t sau 6 tuk va diSu chinh IiSu n~u khong d~t duc;rc m\IC tieu, va sau 12 tuAn khong d~t duc;rc m\lc tieu LDL nen diSu tri tich C\rc bAng each tilng IiSu, ket hc;rp thu&c khac, sau khi d~t m\lc tieu nen theo d5i mili 4-6 thang. Bao cho bac si ngay khi g~p cac tri~u chimg nhu dau khong do nguyen nhiln viln d(\ng, vang da ...
-\-::A, fun ' • n- ~..fn 0.1 'n, I. A fL A '
-/-~--9~-.12\\0 YGI~~~
. .QLV_ono--.iJldba 0..~(...;? cs~':l Qtti ~liln12iij . " d' , ~4: """"'j 6/272015
-'* l:t91 C.kl~fl \. ]it_~ [a cJ cl l.tY!.'lJ
----------~~"-'--'""'oplclo~r.eL. -15m~ f hc;Jd[.
-HOJ No.m < .LJ D m~ /df..
n · . ~ Jt ~ I I .ll~ .-=Inn ~ C\Uo~ ltfbtac -& +W! tMp
-±llr > A 30 I g 'i mm±l ~ J,~ cfuo}
d un-1_;lbuci-1 :B :hm9 HA .
GOurose Jpj ' ~AAO ms !dP .AroJ- ctan}
okmc-a dbnc!c1 --fi cao +coS£ .
-lr .A ~~--------------------
5
PQN _ 8/51
p- KE HOA.CH DIEU TRJ
• Hu6ng d~n b~nh nhan: - Cach do huy~t ap, du<mg huy~t t11i nhil - Tuan thil ch~ d(l dieu tri - Tuan thil ch~ d(l an ( di;\c bi~t nhieu rau xanh) - Van d(\ng the h,rc vira sue, thu<mg xuyen, lien t\IC - 86 thudc h\, ruQU bia - Kiem soat can ni;\ng
02.ot'1612015
TAl LI~U THAM KHAO
I. AHFS Drug 2. Duqc thu qudc gia 3. Slide Su d11ng thudc trong dieu tri RLLP mau cua Co
Huang Thao (Bm DLS). 4. Slide Thudc trj RLLP mau cila Th~y Tr~n Hung (Bm
DLy). 5. Google 6. Tai li~u hQC tap ciJa cac "tien nhan" 7. (ATP IV)ACC/AHA Cholesterol Guidelines
CIIDC CAC BAN THI TOT! 0210612015
6/2/2015
----------:---------;·· ..
6
PQN _ 9/51
LIPOPROTEIN
Tinh chfrt chung cua cac lipid la khong tan trong nu6c, do d6 dS c6 thS iuu thong trong huyst tuang cua mau, lipid phai a d~ng phuc hgp vai protein g9i la lipoprotein, tan dugc trong nu6c. Protein trong lipoprotein dugc gQi la apoprotein hay apolipoprotein. C6 khoang 9 lo~i apoprotein chu ySu dugc tim thfry trong lipoprotein.
1. Cftu true: - Lipoprotein c6 d~ng nhu hinh cfiu, duang kinh khoang 1 OOA 0
- 800A 0 g6m c6 cac phfin tu lipid (triglyceride, phospholipid, sterid, cholesterol) va protid lien kSt v6i nhau chu ySu bai cac lien kSt Van der Waals.
- Theo mo hinh cua Shen (1977) phan tu lipoprotein g6m c6: + Phfin vo ben ngoai day khoang 20A 0 g6m apoprotein va phospholipid c6 tinh
-_ ) phan ClJC, dam bao tinh hoa tan cua phan tU lipoprotein trong huySt tuang
+ Phfin loi a trung tam g6m triglyceride va cholesterol ester h6a khong phan
ClJC + Gifra 2 phfin nay la cholesterol t\I do (khong ester h6a)
2. Phan loai: Lipoprotein g6m nhiSu lo~i khac nhau, m6i lo~i dong m9t vai tro xac dinh trong
S\I v~n chuySn cua lipid Lipoprotein c6 thS dugc phan lo~i theo m9t s6 d~c tinh ly h6a, thuang la dlJa VaO cy tr<;>ng hay dlJa VaO S\I phan tich b&ng di~n di vai cac gia khac nhau: Phlin lo{li d¥a vao tf trpng: xac dinh b&ng phuang phap sieu ly tam, lipoprotein dugc phan thanh 5 lo~i:
( ) + VLDL (Very low density lipoprotein): lipoprotein ty tr<;>ng rfi.t thfrp
+ LDL (Low density lipoprotein): lipoprotein ty tr<;>ng thfrp + IDL (Intermediate density lipoprotein) lipoprotein ty tr<;>ng trung binh + HLD (High density lipoprotein): lipoprotein ty tr<;>ng cao
- Phlin lo{li d¥a vao phuung phap ili?n di tren gia polyacrylamide: Lipoprotein dugc phan thanh 4 lo~i, b~t dfiu tu thanh phfin di chuySn xa nhfrt dSn thanh phfin
di chuySn ch~m nhfrt: +a -lipoprotein, di chuysn cung t6c dQ voi c1.1 r;lobulin
+ ~ -lipoprotein di chuySn cung t6c d9 vai ~ - globulin
+ TiSn ~ - lipoprotein + Chylomicron, di chuySn rfi.t it va thlJc tS dirng l~i a diSm xufi.t phat tuc diSm
d~t cua mfiu huyst thanh ds lam di~n di.
PQN _ 10/51
3. Vai tro: Chylomicron hllipoprotein c6 kich thu6c 16n nh&t (750 - 1000 nm) chua ham luqng triglyceride cao (85% ), ham luqng protein thdp · ( <2% ). Duqc t?o thanh
a ru<?t, c6 vai tro v~n chuySn triglyceride, cholesterol cua thuc an tu ru<?t theo
h~ b?ch huySt vao h~ d?i tufi.n hoan. Trong mau, chylomicron tuong tac v6i lipoprotein lipase, thuy phan triglyceride thanh acid beo duqc oxy h6a, cung
c&p nang luqng hay tbng hqp l?i triglyceride cts d\f tru.
- VLDL: Duqc tbng hqp a gan va ru9t, chua khm1ng 8% protein va 92% lipid,
chu ySu la triglyceride va m<?t ph~n cholesterol. Vai tro: v~n chuySn triglyceride n<?i sinh tu gan ctsn cac mo ngo?i bien va tuong tac vai lipoprotein lipase cts thuy phan triglyceride giai ph6ng acid bfu t\I do.
- LDL: duqc coila m<?t d?ng thoai h6a cua VLDL sau khi bi m&t triglyceride. C6 15% protein ( chu ySu ApoB 100) va 83% lipid ( chu ySu la cholesterol n<?i sinh).
LDL v~n chuySn cholesterol dSn mo va tuong tac v6i receptor LDL tren mang tS bao, nha d6 tS bao thau tom duqc cac h?t LDL, cholesterol duqc dung lam nguyen li~u dS tbng hqp steroid tham gia thanh ph~n c&u t?o mang tS bao. Cholesterol trong LDL ( LDL- c) duqc coi la cholesterol "xau" vi n6 tham gia
vao S\f phat triSn cua cac mang XO' vfra a thanh d9ng m?ch. - IDL : VLDL sau khi giai ph6ng triglyceride, nh~n them cholesterol ester va m&t
Apo C se chuySn thanh IDL. Ch&t nay nhanh chong bi chuySn h6a. HDL: duqc tbng hqp a gan va ruQt, chua kho<!mg 50% protein, 50% lipid, trong d6 cholesterol chi chiSm khoang 18%. Cholesterol cua HDL duqc gQi la
cholesterol " tfH" vi trong xa vua d9ng m?ch, HDL c6 vai tro bao v~ nghia la
luqng HDL cang cao thi nguy CO' bi XO' vua d9ng m?ch cang th&p. DLD v~n chuySn cholesterol du thira til cac tS bao ngo?i vi v@ gan dS thai ra ngoai b~ng duang m~t.
Chyl01nicron ChylomicrN\ Remnant
D CE 0.95
TG
Gul~
I 0 1.006
1.06 0 :o :0. :A
Li~w ~ -----7 -----7 1 I I ·· I
. B-100 : 13-100 : B-HlO:
~;
~ 1.02
I I I VLDL I
VLDL : Remnant : LDL : f-IDL 1.10
1.20
Siz<~ (!\) 5,000 800
Density (g/mJ-1)
300 255 80 1.006 1.019 1.()63
858:1, IDL
eo.,. .·· ~ · I.(J06- I.li i'J
SO"/,. · 15 1
Vo
".~ 1.019- 1.063 0. _1) % I
50 o,_;l .06.1·1.21
20 40 60 P;trtide diameter, nm
•;., total lipid % total protein
80
j- ;
PQN _ 11/51
C~p nh~t di~u tri rBi lo~n lipid mau
1.D~ICUONG
B~nh tim m~ch xa vfra (atherosclerotic cardiovascular disease-BTMXV) la nguyen nhan hang d~u gay tu vong va tan t~t tren th~ gi6i Trong nam 2012, BTMXV gay ru vong cho khofmg 17,3 tri~u nguai tren toan th~ gi6i [ 1]. Nhieu nguyen nhan dfru d~n BTMXV.
ThS.BS Ph~m To Quynh BS CK II N guy~n Thanh Hi~n
Trong d6, c6 nhfmg y~u t6 nguy ca (YTNC) khong dieu chinh dugc nhu tu6i, gi6i nam nhung cling c6 nhieu y~u t6 c6 the di€u chinh dugc lien quan d~n 16i s6ng nhu hut thu6c hi, it ho~t d()ng the h,rc, th6i quen an u6ng hay lien quan d~n cac r6i lo~n khac nhu tang huy~t ap (THA), dai thao duang (DTD), r6i lo~n lipid mau (RLLM). Vi~c di€u tri s6m va tich qrc cac YTNC d6ng vai tro quan tr9ng trong h~n ch~ ti~n trien BTMXV. Nhi€u nghien Clru Va thfr nghi~m cho thfiy vai tro ngay cang quan trQng cua statin- m{)t lo~i thu6c dieu tri RLLM- trong dv phong tien phat va thu phat BTMXV. G~n day da c6 nhfrng thay d6i trong each ti~p c~n va di€u tri RLLM. Bai vi~t nay trinh bay each ti~p c~n m6i hi~n nay. 1.1. Djnh nghia RLLM c6 the dugc dinh nghia nhu sv tang bfrt thuang cholesterol va/ho~c triglycerid trong mau, va/ho~c Sl,f giam HDL- cholesterol.
1.2. Nguyen nhan RLLM c6 the do di truy€n (nguyen phat) ho~c do h~u qua cua nhfmg b~nh khac ho~c do thu6c (thu phat)
1.2.1~ RLLM nguyen phat R6i lo~n di truy€n c6 the gay ra qua nhi€u hay thi~u h1,1t lipoprotein Lipoprotein bi r6i lo~n c6 the la LDL, lipoprotein (a), lipoprotein t6n luu (ph~n du l~i cua lipoproein sau khi bi lfiy di triglyceride- lipoprotein remnants), lipoprotein giau triglyceride (g6m chylomicron, chylomicron t6n luu va VLDL), hay HDL.
Bang 1. Nhting r6i lo~n lipoprotein nguyen phat[2]
R6i lo~n Gen
Bit thrrimg LDL
Tang cholesterol mau gia dinh LDL-R
Khi~m khuy€t apo B 100 gia dinh ApoB
Tang cholesterol mau gen tr9i nhi~m site th€ thuang PCSK9
Tang cholesterol mau gen l~n nhi~m site the thuang ARB
·:.
PQN _ 12/51
R6i lo~n Gen
Khong c6 betalipoprotein MTP
Giam betalipoprotein ApoB
Sitosterolemia gia dinh ABCG5/ ABCG8
Tang lipoprotein lipoprotein(a) mau gia dinh Apo (a)
Lipoprotein tAn IU'u
R6i lo~;m betalipoprotein type III ApoE
Thi~u lipase gan HL
Lipoprotein giim triglyceride
Thi~u lipase lipoprotein LPL
Thi~u apo C-II Apo C-II
Thi~u apo A-V ApoA-V
Tang triglycerid mau gia dinh Dagen
Tang lipid mau h6n hqp gia dinh Dagen
Bit thll'irng HDL
Thi~u apo A-I ApoA-I
B~nh Tangier, thi~u HDL gia dinh ABCAl
H{)i chUn.g thi~u LCA T gia dinh LCAT
Thi~u CETP CETP
B~nh Niemann-Pick type A va B SMPDl
B~nh Niemann-Pick type C NPCl
1.2.2. RLLM thll' phat[3]
PQN _ 13/51
()
Bang 2. Nguyen nhan thll' phat RLLM
Nguyen nhan thll' TangLDL-C Tang triglyceride ph at
ChS d9 an Ma bao hoa hay rna Tang can, chS d9 an rAt low-fat, an chuy~n h6a, tang can, nhi~u carbohydrates tinh chS, qua chan an nhiSu ruQU
Thu6c Lqi ti~u, cyclosporine, Estrogen ducmg u6ng, glucocorticoid, glucocorticoids, tach acid m~t, uc chS protease, acid amiodarone retioic, steroid d6ng h6a, sirolimus,
raloxifene, tamoxifen, uc chS beta (tru carvedilo ), thiazide
B~nhly T~c m~t, h<)i chirng th~ h<)i chirng th~n hu, suy th~n man, lo~ hu duang ma
R6i lo~m hay thay Nhuqc giap, beo phi, thai DTD (ki~m soat kern), nhuqc giap, d6i chuy~n h6a ky* beo phi, thai ky*
*cholesterol va triglyceride tang dAn trong su6t thai ky
2. TRq:U CHiJ'NG LAM SANG
HAu hSt b~nh nhan khong c6 tri~u chirng ca nang va tri~u chirng thvc th~ d~c hi~u. Hi~m han, b~nh nhan bi RLLM gia dinh c6 th~ c6 u vang a da va u vang a gan nhu gan banh che, gan g6t va gan du6i ban tay.
RLLM thuemg duqc chcln doan bai tAm soat xet nghi~m thucmg quy a b~nh nhan khong ~.;u lli~u du1ug llay 1J~ul111llaH eo eae b~nh 1:9 ll~n quan d~i1 RLLM 3.CIIANDOAN Cac bu6c tiSn hanh chcln do an RLLM[3]
~ ) &mh Phan tich lipoprotein mau nen duqc thvc hi~n sau 12 gia nhin d6i bao g6m: cholesterol toan phAn, triglycerid, HDL-cholesterol(HDL-C) va LDL-cholesterol (LDL-C).
Nhfrng chu y trong xet nghi~m LDL-C[4] LDL-C thuemg duqc u6c luqng tlr cong thuc Friedewald:
. LDL-C = cholesterol toan phAn - VLDL-C - HDL-C
VLDL-C duqc u6c luqng bAng 1/5 n6ng d9 triglyceride nen c6 th~ c6 m<)t s6 sai s6 lien quan dSn tinh LDL-C:
. Cong thuc chi c6 gia tri khi n6ng d9 triglyceride du6i 400mg/dL. NSu triglyceride tren mire nay, LDL-C ck duqc do trvc ti~p bAng phan tich sieu ly tam hay ky thu~t kSt rna mi~n dich . . U6c luqng LDL-C bi anh huang bai cac-sai s6 trong xet nghi~m cholesterol toan phAn, triglyceride va HDL-C. Vi cholesterol toan phAn, triglyceride bi anh huang
....
PQN _ 14/51
dang k€ theo chs d9 an nen theo quy u&c chung hi~n nay, cac xet nghi~m lipid mau nen lam hie d6i (> 12 gia khong an) .
. l16'c tinh VLDL-C b~ng n6ng d9 triglyceride da danh gia th~p hon thvc tS luQ'Ilg cholesterol cling c6 kha nang sinh xa vfra trong VLDL t6n luu (VLDL remnants) hay con gQi la IDL (intermediate density lipoprotein) .
. LDL-C u6'c tinh bao g6m ca cac choleserol cua cac lipoprotein khac nhu lipoprotein( a) va lipoprotein-X. Lipoprotein( a) c6 th€ lien quan dSn nguy CO' BMV d<)c l~p v6'i LDL. Nhung, lipoprotein-X Ia ph~n ti'r chua cholesterol duqc t<;~.o ra trong b~nh gan u m~t, l;;ti khong lien quan dSn BTM.
S6 luqng ph~n ti'r LDL lien quan m;;tnh v6'i BTM. Tuy nhien, b~ng ky thu~t phan tich dinh luqng cholesterol trong LDL thi khong th€ xac dinh chinh xac s6 cac ph~n tu LDL. Cac LDL kich thu6'c nho mang it cholesterol hon cac LDL kich thu6'c 16'n. Cimg m9t luqng LDL-C, b~nh nhan c6 LDL nho c6 nhi~u hon 70% s6 ph~n ill LDL so v&i nguai c6 kich thu6'c LDL 16'n.
6 nguai c6 tinh tr<;~.ng d~ khang insulin (h9i ch(rng chuy€n h6a, DTD type 2) c6 sv khong d6ng b9 gifra LDL-C v6'i n6ng d9 cac ph~n ill LDL va apolipoprotein B. D6 Ia do d~ khang insulin gay ra tai c~u true LDL, cac ph~n ill LDL hi tach b6't cholesterol va kich thu&c tra nen nho hon, dfin dSn tang s6 luqng cac ph~n tu LDL. Vi v~y, tang d~ khang insulin hay tang s6 luQ'Ilg cac YTNC chuy€n h6a khong lam tang muc LDL-C dang k€, nhung lam tang nhi~u n6ng d9 ph~n ill LDL nho va tang t6ng luQ'Ilg ph~n tu LDL.
G~n 2/3 b~nh nhan DTD type 2 du dang di~u tri statin va c6 LDL-C du6'i 100 mg/dL, vfin con c6 qua nhi~u ph~n ti'r LDL. Tuong tl,l', 41% b~nh nhan DTD type 2 du dang di~u tri statin va c6 LDL-C du6'i 70 mg/dL ciing con c6 qua nhi~u ph~n ill LDL. Do d6, nhfrng truang hqp d~ khang insulin rna da d;;tt muc LDL-C dich nen do luang n6ng d9 cac ph~n ill LDL hay thay thS b~ng xet nghi~m apo B. non HDL-C: non HDL-C duqc tinh b~ng cholesterol toan ph~n trir HDL-C. non HDL-C duqc dung d€ danh gia toan b9 cac ph~n ill sinh xa vfra trong mau (VLDL, IDL, LDL) va lien quan t6t v6'i muc apoB. HDL-C: M~c du tang HDL-C tien doan giam mang xa vfra va h;;t HDL-C c6 lien quan dSn gia tang biSn c6 va ti'r vong o· b~nh nhan b~nh d<)ng m;;tch vanh. Tuy nhien, do con thiSu cac b~ng chl:rng thuySt phvc v~ hi~u qua can thi~p lo;;ti RLLM nay tren nguy CO'
BTMXV, nen h;;t HDL-C chua duqc xem Ia ml}c tieu di~u tri chinh BTMXV Triglyceride:Tang triglyceride mau thuang lien quan dSn h;;t HDL-C va tang LDL nho d~m d~c. Vi v~y, anh huang cua tang triglyceride, mau tr~n BTMXV c6 t?€ do tinh tr<;~.ng h;;t HDL-C va tang LDL nho d~m d~c. Do con thieu cac bang chl:rng thuyet ph\lc nen hi~n nay, triglyceride chua duqc xem la YTNC BTMXV.
Bmrc 2 : Xac djnh b~nh nhan co BTMXV lam sang
Xac dinh b~nh nhan c6 cac d;;tng lam sang cua BTMXV
. H9i chl:rng vanh c&p, dau th~t ngvc 6n dinh
. Ti~n can nh6i mau CO' tim cil, dau th~t ngl,l'c khong 6n dinh
. Tai tu6'i mau m;;tch vanh hay d<)ng m;;tch khac
. D9t quY.
. Con thiSu mau nao thoang qua
. B~nh d<)ng m;;tch ngo;;ti bien do xa vfra
)
PQN _ 15/51
(· .
( )
NSu c6 cac d~ng lam sang cua BTMXV Ab~t d~u di~u tri statin (xem 4.2.1)
NSu khong cac d~ng lam sang cua BTMXV, tiSp buac 3
Bu6'c 3: Xac djnh b~nh nhan co LDL-C 3 190 mg/dL?
NSu c6 LDL-C 3 190 mg/dL Ab~t d~u di~u tri statin m~nh (xem 4.2.1) NSu khong LDL-C 3 190 mg/dL, tiSp buac 4
Bu6'c 4: Xac djnh b~nh nhan co trong nhom tuBi tir 40-75 va co DTD khong? Xac dinh b~nh nhan tu6i tu 40-75 va c6 DTD
NSu c6 tu6i ill 40-75 va c6 DTD Ab~t d~u di~u tri statin (xem 4.2.1)
NSu khong tu6i tu 40-75 va c6 DTD, tiSp buac 5
Bu6'c S:danh gia nguy cO' BTMXV trong 10 nam
Danh gia nguy ca BTMXV trong 10 nam b~ng Pooled Cohort Equations (http:/ /my .americanheart.org/ cvriskcalculator hay http://www. cardiosource.org/ scienceand-quality/practice-guidelines-and-quality-standards/2013-prevention-guidelinetools.aspx).
It] .•. .. l'licW't«.•ti.M ~"~~~··rot• ~:w~ .... ~>( ... ~~=~~--~lM'!IOH 'ltflh~1ktu-i~~ it~ 'IM6r. . .iCI' '-V4.J.IU 1M! t:K;s,.li f!!OJ'*"" .lUMttl riMI W~v~· 'tl !i:t; lNC: :'Ui *'*~t;M.f~ !f.O.f~<((ri 'l' l tf, ·U\&I~tJi
-ft:i'Ct1 tiihtw ['(l • ..,.._ t<.i ... \1~~
NSu nguy ca BTMXV 10 nam 37 ,5%®statin trung binh-m~nh (xem 4.2.1)
NSu nguy ca BTMXV 10 nam < 7,5%®tiSp buac 6
Btr6'c 6:Mqt sB truirng hQll d~c bi~t NSu nguy ca BTMXV 10 nam < 7,5%
. Danh gia l~i nguy ca BTMXV 10 nam m6i 4-6 nam
. Xem xet m9t s6 ySu t6 c6 lgi khi dung statin
- LDL-C 3 160 mg/dL
- Tang lipid mau di truy~n - Ti~n can gia dinh c6 BTMXV lam sang sam: nam <55 tu6i, nfr <65 tu6i
- CRP sieu nh~y 32 mg/L - Di@m voi h6a m~ch vanh 3300 don vi Agatston hay 375% theo tu6i, gi6'i, chting t9c
I
..
.. PQN _ 16/51
- ABI (chi s6 huySt ap c6 chan- canh tay) < 0,9
- N guy ccr BTMXV lau dai cao
So· dfi 1. Ti~p c'n b~nh nhan RLLM[3]
TuBi ~ 75, .statin tru,U1h (hung r:::-=-=::;-:-:;..----.~-=--· -~c:o:_ _______ .... ...,.. binh neu khong thich hqp)
I BTMXV lam sang? ~------------........ r:;::---;r:--:--::::-::--.--~:----:7"':~~-,
1 - Tuoi > 75 hay khong tbich bqp
khong statin m~-+statin trung b:inh
c6 LDL-C~
mg/dL?
I khong•
kh6ng
190 , _________ .., ..
Nguy ca BTivlXV 10 nam~ 7.5° ?
khong
f>anh gia l@i nguy co BTiviXV 10 nam m&i 4-6 nam
statin m~ (trung binh neu khong thich hqp)
Nguy ca BT1v1XV 10 nam ~ 7 ~5%-+ statin m~
I statin trung binh- m~nh
BU'(YC 7: Ki~m tra b~nh nhan c6 tang triglyceride 3500 mg/dL?
. NSu c6 tang triglyceride 3500 mg/dL, di~u tri fibrat d~ giam nguy ccr viem tl,ly c~p(xem 4.2.2)
4. DIEU TRl Xu tri RLLM bao g6m thay d6i lGi sGng va di~u tri thu6c
Thay d6i lGi s6ng la ccr ban trong di~u tri RLLM
Trong sfi cac thufic RLLM, statin c6 vai tro VU'Qi tri)i. Statin Ia thuBc c6 chi djnh b~t bui)c trong mi)t sa trll'img hQl> (xem cac bll'6'c chAn doan)
. B~nh nhan c6 BTMXV lam sang
. B~nh nhan c6 LDL-C 3 190 mg/dL
. B~nh nhan c6 trong nh6m tuAi tir 40-75 va co DTD
. Nguy cO' BTMXV 10 nam 37,5%
I
(
PQN _ 17/51
)
4.1. Tbay d6i lfii s6ng[3,5]
Can ni_ing va bo~t d(}ng tb~ l\fC
Qua din khi BMI ~25 kg/rn2 va <30 kg/rn2; beo phi khi BMI ~30kg/rn2 . Beo bl,l11g v6i
nguai cha.u A khi vong eo a narn ~ 90 ern, a nu ~ so ern.
Qua can, beo phi, beo bl,l11g g6p ph~n gay RLLM. Do d6, giarn can lam cai thi~n lipid rnau, hon nfra con tac d()ng c6 lqi len cac YTNC BTMXV khac thuang di kern tren cac b~nh nhan nay.
C~n khuyen b~nh nhan giarn thuc an giau nang luqng cling nhu tang tieu th\l nang luqng b~ng tang v~n d()ng thS h,rc dS t6ng nang luqng rn6i ngay am 300-500 kcal.
Nen ho~t d()ng thS h,rc 3-4 l~n/tu~n. rn6i l~n trung binh 40 phut v6i cuang d9 thS h,rc trung binh, n~ng
RU'(}'U
Luqng ruqu t6i da rn6i ngay rna khong lam tang triglyceride Ia 20-30g v6i narn, va 10-20g a nfr. D6i v6i nguai tang triglyceride, khuy~n cao b6 ruqu.
Tbu6c hi
Ngung hut thu6c Ia c6 lqi ro rang tren nguy ca tu vong toan b9 BTMXV
Cb~ d(} an
LrrQ11g va lo~i lipid trong tbfrc an
T6ng luqng lipid trong thuc an nen khoang 25-35% calo thu nh~p. Khi luqng lipid >35% calo thu nh~p thuang lien quan d~n tang acid beo bao hoa va tang calo thu nh~p. Nguqc l~i , n~u luqng lipid qua thfrp c6 nguy ca lam giarn hfrp thu vitamin E va cac acid beo thi~t y~u, g6p ph~n lam thay d6i bfrt lqi tren BDL.
Lo~i lipid trong thuc an
. Ca thS nguai hfrp thu lipid chu y~u du6i d~ng cac acid beo tv do, va rn()t ph~n nh6 hon Ia cholesterol
. Luqng acid beo bao hoa nen < 6 % calo thu nh~p
. Luqng acid beo chuySn h6a <1% calo thu nh~p
. Luqng cholesterol trong chS ctQ auly luLmg nen <..: 150mg/tigay
. Nen an lo~i chua nhi~u acid beo khong bao hoa don va acid beo khong bao hoa da n-3, n-6 (ornega-3, ornega-6)
. Luqng acid beo khong bao hoa da n-6 nen < 10% calo thu nh~p
Bang 3. Lo~i lipid va anb bU'(Yng len cbuy~n boa, tim m~cb[6]
Lo~i lipid Anb buO'Ilg len cbuy~n boa Anb buO'Ilg len tim m~cb
Acid beo bao hoa (SF A: -Tang HDL-C va LDL-C -Tang cy 1~ b~nh DMV saturated fatty acids) -C6 thS thuc d~y t~o huy~t -C6 thS tang nguy ca ung thu
kh6i ti~n li~t tuy~n, d~i trang
Acid beo khong bao hoa -Giarn LDL-C nhv -C6 thS giarn thfrp b~nh don(MUFA: -TangHDL-C DMV monounsaturated fatty -C6 thS can tra qua trinh oxy acids)
PQN _ 18/51
Lo~i lipid Anh huO'ng len chuy~n h6a Anh huO'ng len tim m~ch
h6a
Acid beo khong bao hoa da -C6 th€ giam t<;to huy~t kh6i -Tang tY I~ n-3/n-6 c6 th~ n-3 (PUFA: -Quan trQng trong phat tri~n giam tY I~ b~nh DMV polyunsaturated fatty vong ID<;!C Va nao -n-3 c6 th~ tang trQng luQTig acids) sinh
-C6 th~ ngua d9t ti'r tim
Acid beo khong bao hoa da -Acid arachidonic, chfrt quan -C6 th~ giam b~nh DMV n-6 (PUFA: trQng trong viem -LuQTig nhi~u c6 th~ sinh ung polyunsaturated fatty thu acids)
Acid beo chuy€n h6a -Tang LDL-C -Tang tY I~ b~nh DMV (trans fatty acids), chu y~u -GiamHDL-C rn hydrogen h6a PUF A -Tang Lp(a) trong cong nghi~p thgc -Can tra chuy~n h6a PUF A phftm
Carbonhydrate trong ch~ dq an LtrQng carbonhydrate nen chi~m khofmg 45-55% calo thu nh~p. Khuy~n khich an nhi~u rau, tn:li cay, h<;tt, va ngu c6c nguyen h<;tt.
LuQTig du<'mg d.n giam < 10%. H<;tn ch~ cac lo<;ti nu6c ngQt. cAn ti~t ch~ ch~t che h011 v6i b~nh nhan c6 tang can hay tang triglyceride mau.
Protein Nen an cac lo<;ti thit tr~ng, thit n<;tc,gia d.m, ca
H<;tn che thit do
Ch~txO' Nhli'ng thgc phftm nhi~u chfrt xa hoa tan thu<'mg duqc dung n<;tp t6t, c6 hi~u qua giam LDL-C. Li~u khuy~n cao 5-15 g chfrt xa hoa tan m6i ngay.D~ di~u tri t6t rna mau, che d9 an d.n 25-40g chfrt xa, t6i thi~u 7-13 g chfrt xa hoa tan.
Nen an theo ch~ do DASH (Dietary Approaches to Stop Hypertension)
Bang 4. Ch~ dq an DASH cho nguiri co nhu du 2100 calo/ngay
TAng lU'Qllg mO' 27% calo Natri 2300 mg
MO' bao hoa 6% calo Kali 4700 mg
Protein 18% calo Calcium 1250 mg
)
-'
PQN _ 19/51
. )
)
Bang 4. Ch~ dq an DASH cho nguiYi co nhu du 2100 calo/ngay
Carbonhydrate 55% calo Magne 500mg
Cholesterol 150mg
4.2. ThuBc h~ lipid mau[2,3,5,7] 4.2.1. Statin Tac dvng tren lipid mau
. Giam LDL-C: 20-60%
. Giam triglyceride: 10-33%
. Tang HDL-C: 5 - 10%
Nhfrng tac dqng khac ciia statin
Chftt XO'
. Cai thi~n muc d9 r6i lo<;m dan ill(;lCh do n9i mo
. Ch6ng huy~t kh6i
. Giam viem ill(;lCh mau
. Giam tang sinh ca tran m(;lch mau
. Lam 6n dinh mang xa vua
Chi djnh statin Statin c6 chi dinh b~t bu9c trong 4 nh6m (xem cac bu&c ch~n doan)
. B~nh nhan c6 BTMXV lam sang
. B~nh nhan c6 LDL-C 3 190 mg/dL
. B~nh nhan c6 trong nh6m tu6i tir 40-75 va c6 DTD
. Nguy ca BTMXV 10 nam 37,5%
Statin c6 thS duqc si'r dvng khi . LDL-C 3 160 mg/dL
. Tang lipid mau di truy~n
30 g
. Ti~n can gia dinh c6 BTMXV lam sang sam: nam <55 tu6i, nu <65 tu6i
. CRP sieu nh<;ly 32 mg/L
. DiSm voi h6a m(;lch vanh 3300 dan vi Agatston hay 375% theo tu6i, gi&i, chling t9c . ABI (chi s6 huy~t ap c6 chan- canh tay) < 0,9
. Nguy ca BTMXV lau dai cao
Cac thuBc statin (bang 5)
Bang 5. Cac thuBc statin
D~c di~m Atorvas
! LDL theo 38-54% li~ll (10- 80)
Flu vas Lovas Pravas
17-33% 29-48% 19-40%
(20- 80) (20- 80) (10- 40)
Rosuvas Simvas
52-63% 28-48%
(10- 40) (10- 80) .· --
• •...
PQN _ 20/51
D~c di~m Atorvas Flu vas Lovas Pravas Rosuvas Simvas
Thai gian ban 15-30 0.2-2.3 2.9 1.3-2.8 19 2-3 huy
Anhhu6ng Khong C6 j hfrp thu ! hfrp thu Khong Khong cua thuc an
Thai gian T6i Dingu Vao bua an Ngu Bfrt ky T6i dtmgthu6c
Chi~n luge dung statin (bang 6)
Chi~n luqc dung statin dva tren muc d() lam giam LDL-C mau
. Statin m~: liSu u6ng hang ngay lam giam trung binh LDL-C 350%
. Statin trung binh: liSu u6ng hang ngay lam giam trung binh LDL-C 30% -50%
. Statin y~u: liSu u6ng hang ngay lam giam trung binh LDL-C < 30%
Bang 6. Chi~n luge dung statin[3]
Statin m~nh Statin trung binh Statin y~u
Atorvastatin (40)-80mg Atorvastatin 10(20)mg Simvastatin 10 mg
Rosuvastatin 20(40)mg Rosuvastatin(5) 10 mg Pravastatin 10-20mg
Simvastatin 20-40mg Lovastatin 20 mg Pravastatin 40 (80)mg Fluvastatin 20-40mg
Lovastatin 40 mg Pitavastatin 1 mg
Fluvastatin XL 80mg
Fluvastatin 40mg bid Pitavastatin 2-4 mg
Thu6c, liJu dung in nghieng la auf)'c Cl,lC quan ly thu6c va duf)'C phdm Hoa kj; cho phep nhung chua aUf)'C kdm ch{mg frong CQC nghien CUu thif nghi?m kdm ch{mg ngJu nhien
Chi~n luge sfr dl)ng statin theo tirng truimg hQ'P Cl) th~ . B~nh nhan c6 BTMXV lam sang
- Truang hqp tu6i £75, statin mC;tnh (trung binh n~u khong thich hqp)
- Truang hqp tu6i > 75 hay khong thich hqp statin mC;tnh®statin trung binh
. B~nh nhan c6 LDL-C 3 190 mg/dL
- Statin mC;tnh (trung binh n~u khong thich hqp)
. B~nh nhan c6 trong nh6m tu6i tu 40-75 va c6 DTD
- Statin trung binh - Nguy ca BTMXV 10 nam 37,5% ®statin mC;tnh
. Nguy ca BTMXV 10 nam 37,5%
- Statin trung binh- mC;tnh
PQN _ 21/51
( )
)
Truemg hgp b~nh nhan c6 chi dinh dling statin m~nh, nhung c6 m9t trong s6 cac y€u t6 sau d.n xem xet chQn statin trung binh
. Tu6i > 75
. Tinh tr~ng hay tuong tac thu6c lam giam d9 an toan ella statin
. Ti€n dl.n khong dung n~p statin
Tac d\lng ph \I . Dau ca, c6 th6 chuy6n thanh b~nh ca (tang creatine kinase), n€u khong di~u tri d~n d€n viem ca/ly giai cavan. Nguy ca bi tac d1,mg phv nay tang khi ph6i hgp v6i gemfibrozil, niacin, erythromycin, khang n~m azoles (uc ch€ CYP3A4)
. Nhuc dfiu, chuang bl,lllg, dau bl,lllg, bu6n non, tao b6n/tieu chay, n6i mAn do (thuemg g~p nh~t) . Tang cac chi s6 chuc nang gan (AST, ALT, CK, phosphatase ki€m, bilirubine toan phfin)
KhO'i trj statin
Tru6c khi kh&i tri statin
. Ki6m tra bilan lipid mau
. Ki6m tra cac nguyen nhan thu phat gay tang lipid mau
. ALT. Khi AL T > 3 lfin ngu5ng: khong di€u tri statin, ki6m tra b~nh gan m~t, ki6m tra l~i AL T
. CK (khi b~nh nhan c6 ti€n can khong dung n~p statin hay c6 b~nh ca). Khi CK >5 lfin ngu5ng: khong di€u tri statin, ki6m tra b~nh ca, ki6m tra l~i CK
. Cac nguy ca t6n thuang ca Bang 7. Cac y~u t6 nguy cO' tAn thll'O'Dg c0'[8]
Y~u t6 n()i sinh y" t" .. h eu o ngo:~u sm
-Tu6i > 80 -Li€u cao statin
-Phv nfr -L~m dl,lllg rnQU
-Chung t9c chau A -Dung thu6c gay nghi~n -BMI th~p -Dling thu6c huang tam thfin
-Ti€n can dau gan, ca -Ph~u thu~t d.n nhu d.u trao d6i ch~t 16n
-Ti€n can tang CK -T~p th6 dvc n~ng va/ho~c khong thuemg
-DTD xuyen(thuemg bi€t y€u t6 kh&i kich)
-Ti€n sir gia dinh dau ca -Di€u tri: amiodaron, thu6c khang n~m nh6m
-B~nh ca do chuy6n h6a azole, cyclosporin, fibrates, khang sinh nh6m macrolide, nefazodone, acid nicotinic, uc ch€
-B~nh th~n n~ng (eGFR £30ml/phut) protease, tacrolimus, verapamil, wafarin -B~nh gan m~t bu c~p -An nhi€u bu&i -Suy giap
-Men CYP c6 da ki6u gen
Theo doi khi di~u trj statin ~~.--
PQN _ 22/51
. 4-12 tuftn sau khi kh6i tri vai statin hay khi di~u chinh li~u thu6c: ki~m tra bilan lipid mau . 12 tuftn sau khi kh6i tri vai statin hay khi tang li~u statin: ki~m tra ALT
. Hangnam - Ki~m tra lipid mau sau khi da d~;tt muc LDL-C dich hay t6i uu - Ki~m tra AL T, neu AL T < 3 lftn ngu5ng
. Ki~m tra CK khi dang di~u tri statin rna b~nh nhan c6 b~nh CO', dau CO'
. Ki~m tra bilan lipid mau bfrt kY khi b~nh nhan khong dung thu6c lien tl)c hay c6 nhfing b~nh ly kern theo c6 th~ lam RLLM thu phat
. Ki~m tra AL T bfrt ky khi b~nh nhan c6 cac b~nh ly gan m~t c6 th~ lam tang AL T
Theo doi dap ung di~u trj v6i statio Danh gia dap t'rng di~u tri va tuan thu di~u tri. Dap t'rng vai thu6c khi
.LDL-C giam 350% so v(ri truac di~u tri 6 b~nh nhan dang dilng statin m~;tnh . Neu khong c6 LDL-C truac d6, chQn mvc tieu dich Ia LDL-C < 100 mg/dL a b~nh nhan dang dung statin m<;tnh . LDL-C giam tir 30% den< 50% so vai truac di~u tri 6 b~nh nhan dang dung statin trung binh .N6ng d9 LDL-C va phftn tram giam LDL-C khong phai la tieu chu~n di~u tri, chi dung d~ danh gia dap t'rng va tuan thu di~u tri.
*Truemg hqp b~nh nhan dap t'rng vai di~u tri . Tiep tl)c di~u tri cung lo~;ti va li~u luqng statin da cho trong 3-12 thang
. Xem xet giam li~u statin khi LDL-C hai lftn thu lien tiep < 40 mg/dL
. Ngung statin khi LDL-C < 20 mg/dL
*Truemg hqp b~nh nhan khong dap t'rng vai di~u tri . Ki~m tra tinh tr~;tng khong dung n~;tp vai li~u statin theo khuyen cao
- B~nh nhan c6 cilng l(tc nhi~u b~nh n~ng, ph6i hgp
- R6i lo<;tn chuc nang gan, th~ - B~nh su khong dung n~;tp vai statin, hay c6 b~nh CO'
- AL T tang tren 3 lfrn nguang - Su dvng d6ng thai thu6c gay tuang tac hay anh huang den chuy~n h6a statin
- > 75 tu6i Acfrn giam thanh statin lo~;ti trung binh. ChQn li~u statin t6i uu rna khong gay tac dvng phv. Nen chQn statin c6 tac dvng h~;t LDL-D m~;tnh rna khong cftn li~u di~u tri cao
§Neu khong c6 tinh tr~;tng khong dung n~;tp - Ki~m tra tuan thu di~u tri: thu6c, tich cvc thay d6i I6i s6ng
- Lo~;ti trir nguyen nhan RLLM thu phat
- Theo doi lipid mau sau 4-12 tuftn, neu khong d~;tt dap t'rng di~u tri Tang li~u statin Hay xem xet them thu6c h~;tlipid nh6m khac
··· )
PQN _ 23/51
Xfr tri tang men gan lr b~nh nhan dang dung statin F < 3 IAn nguong
§Ti~p tl,lc di€u tri
§Ki€m tra l~i trong 6 tuAn
F~3 IAn nguang
§Ngung statin, ki€m tra l~i trong 6 tuAn
§N~u ALT tra v€ binh thuemg, cho I~i statin, chu y h~n ch~ tac d1,mg ph1,1[? ,8]
- Statin m~nh v6i li€u th~p - D6i thu6c sang lo~i statin it tac d<)ng len CYP3A4 (rosuvastatin)
- u6ng each ngay (rosuvastatn) hay tuAn 2 IAn (atorvastatin)
SO' d6 2. Theo doi men gan khi di~u tr! statin[7]
Ngu:ng statit1 ngan h?n- Blillh gi.a l?i mengan
I Men gan ban ak .l
Tang
< 3 Hht ngt.Wng
Tiep ~c statin. Kiem tra men g:an trong 6 tufut
Binh thu:ang
-....._
~ I
Nghi. ngo ton thuong gan do statin.. I "T:;:::iec;;-"p-· -.t!,ic-· -ng-.u:n-g-s7ta-:::.tin-.' . . Tim, B nguyen nhan lr.lllic
'<it Thu 1¥ statin cu lieu thap hay doi statinkhac
X if tri tang CK lr b~nh nhan dang dung statin . Truong hQ'P CK >5 IAn nguong
Binhthuemg ---.. Tiep tvc statin. Kifun tra moi nam hay khi tang li~u hay Hlm san~ b~t tf!.lJ'Dn"
- Ngling di€u tri, ki€m tra chuc nang th~n va theo doi CK m6i 2 tuk
- Danh gia CK c6 tang do nguyen nhan khac nhu g~ng sue ca - Xem xet b~nh CO' n~u CK vfin con tang
. Truemg hQ'P CK :::;5 IAn nguang
- N~u khong c6 tri~u chtrng t6n thuang ca, ti~p t1,1c dung statin (huang dfin b~nh nhan theo doi biSu hi~n b~nh ca, ki€m tra CK sau d6)
- N~u c6 tri~u chtrng b~nh CO', theo doi tri~u chtrng va CK d€u d~n. 4.2.2. Cac thuBc di~u tr! RLLM khac Cac thu6c di€u tri RLLM khac (trir statin) chi nen sir dl,lllg trong cac truemg hqp sau:
. Khong d~t dich di€u tri h~ LDL-C khi da dung li€u statin t6i uu dung n~p duqc. Sir d1,1ng cac thu6c lipid nay cAn ph6i hqp cling v6i statin
. Khong dung n~p v6i statin
1.
I·
PQN _ 24/51
. Tang triglyceride 3500 mg/dL
Trrrimg hQP statin li~u tfii rru khong d~t dich di~u trj
. K~t hqp statin v6'i thu6c (rc ch~ hfrp thu cholesterol
. K~t hqp statin v6'i tach acid m~t
. K~t hqp statin v6'i acid nicotinic
Trrrirng hQP khong dung n~p statin
. Tach acid m~t
. Acid nicotinic
. Thu6c uc ch~ hfrp thu cholesterol, don d<)c hay ph6i hqp v6'i tach acid m~t. Trrrimg hQP tang triglyceride 3500 mg/dL
Tang triglyceride la nguyen nhan gay 10% vi em tl)y cfrp
Ti~t ch~ calo va luqng m5' (khuy~n cao 10%-15% ), b6 ruqu va di€u tri thu6c tich eve.
H~ triglyceride b~ng cac thu6c
§Fibrate don d9c khi khong c6 chi dinh b~t bu<)c cua statin
§Statin kern fibrate khi c6 chi dinh b~t bu9c cua statin
4.2.2.1. Fibrate
C6 2 nh6m chinh: fenofibrate va gemfibrozil
FFenofibrate
Tac d\mg
. Lam giam triglyceride: 41 -53% .
. Utm tang HDL: 5 - 20%
. Utm giam LDL-C: 6 - 20%
Chi djnh
C6 th~ dung d6ng thai v6'i statin lo~i trung binh- thfrp khi khong dap trng v6'i statin don d9c
. cAn th~n tr9ng khi dilng statin va fibrate cling hie vai cac thu6c chuy~n hoa qua cytochrome P450
. Nen cho fibrate bu6i sang va statin bu6i t6i d~ giam thi~u n6ng d9 dinh
Khi triglyceride> 500 mg/dL
Li~u dung: 200mg/ ngay
Tac dl)ng phl):Kh6 tieu, dau bl,lllg, mAn do, soi m~t, tieu chay.
Trrong tac thufic: tang d<)c tinh cua cyclosporine; tuong tac warfarin, c6 th~ lam tang ho~t tinh khang dong
KhOi trj fibrate
. Theo doi chuc nang th~n khi khai tri
. Khong nen cho fenofibrate n~u GFR < 30 ml/phut/1,73m2
Theo doi khi di~u trj fibate
. Theo d5i chuc nang th~n trong vong 3 thang sau khai tri, m6i 6 thang sau d6
. Truang hqp 30 <GFR< 59 ml/phut/1,73m2, li€u fenofibrate t6i da <54 mg/ngay
. Ngung fenofibrate khi GFR < 30 ml/phut/1,73m2
!.
I~
PQN _ 25/51
. )
FGemfibrozil
Tac dl}ng
. Uun giam triglyceride: 35 - 50% .
. Lam giam nh~ LDL-C: 10-15% .
. Tang HDL: 5 - 20%.
Li~u dung: 600 mg x 2 lftn khi tang triglycerid n~ng Tac dl}ng phl}:Kh6 tieu, dau bl)llg, tieu chay.
Trrong tac thufic: tang ho~t tinh cua warfarin
Khong nen dung d6ng thai vai statin do tang nguy C(J huy ca van
4.2.2.2 Tach acid m~t
Tac d{lng
. Lam giam LDL-C: 15-30%
. Tang triglyceride
. Khong hay tang nh~ HDL-C
Chi djnh
. Khong d~t dich di€u tri h~ LDL-C khi da ditng li€u statin t6i uu dung n~p duqc. Sir dvng thu6c lipid nay dn ph6i hqp cung vai statin
. B~nh nhan c6 chi dinh dung statin nhung khong dung n~p vai statin
. Khong cho tach acid m~t khi triglyceride 3300mg/dL
Li~u dung . Cholestyramine: 4 g x 2-6 lfinl ngay, u6ng khi an
. Colestipol: 5g X 2-6 lfinl ngay, u6ng khi an
Tac dl}ng phtptao b6n, chuang bvng, d§.y hai, bu6n non, dau thuqng vi.
Trrong tacquan trQng vai amiodarone, digoxin, warfarin, statin, thiazides, uc ch~ beta, thyroxine, phenobarbital. C6 th~ lam kern h~p thu cac vitamin tan trong dfiu (A, D, E, K). C6 th~ tang khuynh huffile r.My mau. Co th~ lam giam h&p thu nhi~u thu6c khuc, ncn dung thu6c khac 1 gia truac hay 4 gia sau
Theo doi khi di~u trj tach acid m~t . Theo doi bilan lipid mau 3 thang sau khcri tri, m6i 6-12 thang sau d6
. Truong hqp 250< triglyceride< 299 mg/dL
- Cfin trQng khi cho tach acid m~t - Theo doi sat bilan lipid mau trong 4-6 tufin sau
- Ngung tach acid m~t khi triglyceride> 400 mg/dL
4.2.2.3 Acid nicotinic Tac dl}ng
. Lim tang HDL (tac dvng ro nh~t cua nh6m nay): 15- 35%
. Lam giam LDL-C: 10-25%
. Giam triglyceride: 25 - 30%.
Chi djnh
"'
PQN _ 26/51
. Khong d~t dich di~u tri h~ LDL-C khi da dung li~u statin t6i uu dung n~p duqc. Su d1,mg thu6c lipid nay c§n ph6i hqp cling v6i statin
. B~nh nhan c6 chi dinh dung statin nhung khong dung n~p v6i statin
. Acid nicotinic khong nen cho khi
- AL T > 2 l§n ngu5ng
- Tri~u chling da n~ng, tang duemg huy€t dai d~ng, gout dp, dau b1,mg khong giai thich duqc
- Rung nhi m6i khoi phat hay S\lt can g§n day
Li~u dung . 2000- 3000 mg/ngay chia lam 3 l§n, u6ng trong bua an
. Lo~i ph6ng thich nhanh c6 nhi€u tac d\lng ph\1 han lo~i ph6ng thich ch~m, nhung hi~u qua h~ LDL-C han va it d(>c gan han
Tac d\lng ph\1 . Do bting da: ~m, ngua ph§n tren ca thS va nhuc d§u c6 thS xay ra v6i 1i€u khoi d§u .
. C6 thS cai thi~n tac d\lflg do bting da bimg each cho aspirin. Aspirin 325mg duqc cho nua gia tru6c khi dung acid nicotinic, khoi d§u li€u th~p va dinh chuAn li€u tang len .
. R6i lo~n tieu h6a .
. D9c gan, tang du<'rng huy€t, tang acid uric huy€t.
TU'ong tacwarfarin ( c6 thS lam tang khang dong).
KhOi tri acid nicotinic . KiSm tra AST,ALT, du<'rng huy€t d6i, HbA1c, acid uric
Theo doi khi di~u trj acid nicotinic . KiSm tra AST,ALT, du<'rng huy€t d6i, HbA1c, acid uric khi tang li~u thu6c, m6i 6 thang sau d6
4.2.2.4. Thu8c ll'c ch~ S\f h~p thu cholesterol
Ezetimibe
Tac d\lng . Giam LDL-C: 17% .
. Khong d6i triglyceride va HDL-C.
Chi djnh . Khong d~t dich di~u tri h~ LDL-C khi da dung 1i€u statin t6i uu dung n~p duqc. Su d\lng thu6c lipid nay dn ph6i hqp cling v6i statin
. B~nh nhan c6 chi dinh dung statin nhung khong dung n~p v6i statin
Li~u dung: 1 Omg/ngay
Thu AL T tru6c khOi tri Khi cling dting v6i statin, ngung ezetimibe khi AL T > 3 l§n ngu5ng
4.2.6. Acid beo khong bao hoa da n-3 (acid beo omega 3) Nhfrng acid beo n-3 [eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] la thanh ph§n chinh cua d§u ca
... PQN _ 27/51
Tac dt,mg . Lam tang LDL: 4 - 49%
. Lam tang HDL: 5 - 9%
. Giam triglyceride: 29 - 45%.
Chi djnh: tang triglycerid mau nen ph6i hqp cung v6i fibrate
Li~u dung: 2-10 g/ngay, u6ng trong hay ngay sau an TU'ong tacaspirin, clopidogrel
Tai li~u tham khao 1. Peter WF Wilson," Overview of the risk equivalents and established risk factors for cardiovascular disease", Uptodate Nov 2013
2. JacquesGenest & PeterLibby: Lipoprotein Disorders and Cardiovascular Disease. In Braunwald's heart disease: a textbook of cardiovascular medicine 9th W.B Saunders Company, 2012
3. ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. http://circ.ahajournals.org. Circulation. 2013;00:000-000.
4. Robert S Rosenson," Measurement of serum lipids and lipoproteins", Uptodate Nov 2013
5. ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal.2011; 32, pp. 1769-1818
6. Matthew W Gillman,"Dietary fat" , Uptodate Nov 2013
7. Neil J.Stone: drugs for elevated low-density lipoprotein cholesterol. In Antman. EM & Sabatine.MS: Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease 4th. W.B Saunders Company, 2013: 975-984
8. www.RxFiles.ca. June 2013
PQN _ 28/51
H(>I CHUNG CHUYEN HOA 1. Hanh chinh:
1.1. Ten b:li gi<!mg: H(>I CHUNG CHUYEN HOA (HCCH)
1.2. D6i tuQTig: Chuyen khoa 1 N()i khoa.
1.3. s6 luQTig:
1.4. Thai gian: 2 ti~t 1.5. Dia di~m: 1.6. Giang vien: Bs CKII. Doan Thi Kim Chau.
1.7. B9 mon: N()i
2. Ml}.c tieu: 2.1. Trinh bay duqc djch t~ h9c, d~c di~m lam sang va c~n Him sang, bi~n
chln1gHCCH.
2.2. Nh6 duqc y nghia cac thanh t6 HCCH.
2.3. N~m vilng cac tieu chuAn chAn doan, ml)c tieu di~u tri HCCH.
2.4. Di~u tri duqc b~nh nhan c6 HCCH.
3. Nqi dung:
3.1. D~i cuong H9i chln1g chuy~n h6a (HCCH) la m()t trong nhilng v~n d~ sue khoe c()ng
d6ng dang duqc quan tam nh~t hi~n nay. Theo hi~p h()i dai thao dub'ng qu6c t~ (IDF), HCCH la m()t t~p hqp nhilng y~u t6 nguy co cua b~nh tim mc;tch va n()i ti~t (nhu dai thao du<'Yng type 2), n6 anh huang d~n ch~t luQTig cu()c s6ng cua b~nh nhan va t6n kern ngan sach y t~ toan dan cua nhi~u nu6c tren th~ gi6i.
Nhi~u thu~t ngfr d6ng nghia HCCH (Metabolic syndrome) bao g6m, h()i chtrng X chuy~n h6a (Metabolic X syndrome), H9i chtrng da chuy~n h6a (Plurimetabolic syndrome), h9i chtrng r6i loc;tn chuy~n h6a (Dysmetabolic syndrome), HC · khang insulin (Insulin Resistant syndrome), HC Raven (Raven syndrome) ...
HCCH bao g6m cac y~u t6 nguy co (YTNC) nhu tang huy~t ap (THA), b~t thub'ng dung nc;tp glucose, tang Triglycerides (TG), giam HDL-cholesterol, d~ khang insulin. Sau nay cac b~t thub'ng chuy~n h6a khac duqc qui cho la HCCH nhu beo phi, albumin ni~u vi th~ (Microalbuminuria), b~t thuemg v~ tieu sqi huy~t va r6i loc;tn v~ dong mau. N goai ra con nhi~u y~u khac nhu tang acid uric mau, tang y~u t6 uc ch~ hoc;tt h6a plasminogen 1 (Plasminogen activator inhibitor- 1: P AI - 1) ...
3.2. Djch t~ hQc: T~n su~t va ti 1~ HCCH ngay cang tang va c6 khuynh huang tang d~n theo
tu6i. Tc;ti My theo nghien ctru ENHANCE III, ti 1~ HCCH ad() tu6i tren 20 la
25%, gia tang tren 45% ad() tu6i tren 50. HCCH g~p a 10% a ph\1 nfr va 15% a nam gi6i c6 dung nc;tp glucose binh thub'ng. H~u h~t a b~nh nhan dai thao dub'ng c6 HCCH ( g~p a 78% ph\1 nfr va 84% a nam gi6i).
Ti 1~ m~c b~nh theo tu6i tuong duong nhau a nam (24%) va nfr (23,4%)
Ti 1~ m~c b~nh theo chung t()c: Da tr~ng: 23,4% a nam, 22,9% a nfr. Da den: 13,9% a nam, 20% a nu.
1
PQN _ 29/51
Vi~! nam: Chua c6 thdng ke v&i s6 luqng Ian, nhung cac nghien cliu t~i 1 s6 nai cho thay HCCH a vi~t Nam khong ngirng gia tang trong th~p nien gfrn day. 3.3. M{)t s6 d~c di~m lam sang va c~n lam sang cua HCCH.
M9t s6 di;ic di€m lam sang va c~n lam sang cua HCCH duqc ghi nh~: - Beo phi hoi;ic beo phi d~ng nam
- f>ai thao duemg hoi;ic giam dung n~p glucose - Tang huy€t ap
- Rdi lo~n lipid mau
- Albumin ni~u vi th€ (Microalbuminuria: MAU)
- T6n t~i va gia tang cac chfit chi di€m cua viem man tinh - Bfit thuemg trong tieu sqi huy€t va dong mau
- Tang acid uric mau va b~nh gut
- Gia tang ho~t d9ng h~ thfrn kinh giao cam
- Hi~n di~n cua b~nh ly gan nhiSm rna hoi;ic h9i ch(mg bu6n tn'mg da nang 3.4. Chin doan h{)i chll'ng chuy~n boa.
C6 nhiSu tieu chuftn chftn doan H9i ch(mg chuy€n h6a khac nhau. Hi~n nay tieu chuftn cua IDF vacua WHO duqc qu6c t€ chfip nh~n nhu la tieu chuftn vang d€ chftn doan xac dinh m9t nguai c6 h9i chtmg chuy€n h6a.
3.4.1. Tieu chulin ciia TJ chuc v tl thi giui (TCYTTG hav WHO) niim1999: M9t ngum GU(JC chdn aocm xac atnh c6 H9i ch(mg chuyin h6a khi:
• f>uemg huy€t:
-Tang glucose mau luc d6i: GO: 2: 6,1 mmol/1 (110mg/l),
- Hoi;ic rdi lo~n dung n~p glucose G2: 2: 7,8 mmol/1 (140mg/l), - Hoi;ic f>Tf>: khi f>H d6i 2: 126mg%, Hoi;ic sau an G2 2: 11 mmol/1 (200mg/l) - Hoi;ic dS khang insulin.
Va kem v6i ft nhdt 2 trong 4 thimh phdn sau.
• Beo phi: Vong bt,mg/vong mong > 0,85 (Nil'), > 0,90 (Nam) va/hoi;ic BMI :2: 30 kg/m2
.
• RL lipid mau: TG;;::: 150mg/dL va/hoi;ic HDL-C < 40mg/dL.
• Tang huy€t ap: ;;::: 140/90 mmHg hoi;ic dang dung thudc diSu tri THA.
• Albumin ni~u vi th€: d9 thanh lQc albumin AER > 20J..tg/phut, hoi;ic albumin /Creatinin :2: 30 mg/g
3.4.2. Tieu chulin hOi chung chuvin h6a ciia NCEP - ATP III (National Cholesterol Education Program- Adult Treatment Panel Ill) (2001): f>uqc chftn doan xac dinh c6 H9i chtmg chuy€n h6a khi c6 it nhfit 3 trong 5 thanh phfrn sau:
• Beo phi d~ng nam: Vong ht,mg > 102cm (Nam), > 88cm (Nfr)
• Tang triglyceride mau: :2: 150mg/dL (1,69mmol/L).
• Giam HDL-C: < 40mg/dL (1,04mmol/L) (Nam), < 50mg/dL (1.29mmol/L) (Nil')
• Tang huy€t ap:;;::: 130 I 85 mmHg hoi;ic dang dting thudc diSu tri THA
• Tang glucose mau:Glucose huy€t tuang finh m~ch luc d6i :2: 6, 1mmol/L
2
PQN _ 30/51
3.4.3. Tieu chulin chlin ilotin cua Hiep hOi ctic nha NOi tiit Lam sang MY - AA CE (American Association of Clinical Endocrinologists) 2003: + Tieu chudn chinh:
• DS khang insulin bi€u hi~n b~ng tang n6ng d() insulin trong mau tuong d6i so v6i duemg mau.
• BMI 2: 25kg/m2.
• RL lipid mau TG2: 150mg/dL vaHDL-C <40mg/dL &nam va < 50mg/dL &nil'.
• Tang huySt ap 2: 130/85mmHg.
• R6i lo~n du<'mg huySt d6i hay DTD type 2.
• Tang acid uric mau.
+ Tieu chudn ph~:
• Tang dong mau.
• Albumin ni~u vi th€.
• H()i chU11g bu6ng trfrng da nang.
• B~nh d()ng m~ch vanh.
• R6i lo~n chuc nang 16p n()i m~c m~ch mau.
3.4.4. Tieu chulin chlin ilotin cua Lien iloan iltii thtio ilu'img quae ti - IDF (International Diabetes Federation) 2005.
• S\1' gia tang vong b1,mg la chinh c()ng v6i 2 trong cac tieu chuAn sau:
• TG 2: 150mg/dL hay dang diSu tri tang TG
• HDL-C < 40mg/dL 6 nam va < 50mg/dL 6 nil' hay dang diSu tri.
• THA 2:130/85mmHg hay dang diSu tri thu6c h~ huySt ap.
• D ' 100 /dL h ~ DTD d h ;~. d ' ' d' uongmau> mg, o~c UQ"C C an oan truac 0.
Dan toe Gi6i Vongbung
ChauAu Nam 2: 94cm
Nu > 80cm
NamA (Vi~t Nam) Nam 2: 90cm
Nil' > 80cm
Trung Qu6c Nam 2: 94cm
Nfr 2: 80cm
Nh~t Nam 2: 85cm
Nu >90cm
Bang 1: Tri s6 danh gi~ vong bl,lllg theo chling t()c.
3.5. Y nghia cac thimh t6 HCCH: 3.5.1. Beo phi dang nam:
Beo phi ki€u bl,lllg (BPKB) d~c trung b&i tinh tr~ng m6 rna du thira trong CO'
th€ t~p trung chu ySu quanh eo lung, vung bl,lllg, lam gia tang nguy ca phat tri€n HCCH do S\1' gia tang n6ng d() cac acid beo W do trong tinh m~ch ctra d~n dSn sv tang tiSt VLDL-cholesterol va giam S\1' thoai biSn insuline cua gan.
3
,.
PQN _ 31/51
Cach danh gia BPKB la do vong b1,111g (VB) ho~c danh gia cy 1~ vong b1,111g tren vong mong (VBNM).
Tieu chi danh gia beo phi d~ng nam: Chi s6 vong ht,mg duqc danh gia theo tieu chufin WHO danh cho dan t9c Chau A khi VB nam 2: 90cm, nfi' 2: 80cm. M6c CCJ th~ hQC do VOng b1,1ng t~i vi tri ngang qua trung di~m xuang SUOn cu6i clm.g va mao ch~u, cu6i ky tha ra binh thuemg.
Beo phi, d~c bi~t la beo phi ki~u b1,111g lien quan d.t ro v6i cac b~nh man tinh khac nhu DTD Type 2, b~nh tim do d<)ng m~ch vanh, r6i lo~n lipid mau.
Beo phi d~ng nam la tieu chi quy~t dinh cua HCCH theo IDF do c6 sg tuang quan gifi'a beo phi d~ng nam Vffi Sl,f phan b6 rna trong phu t~ng va hi~n nay t6 chuc rna duqc xem nhu la ca quan c6 cht'rc nang n9i ti~t.
* Cac cytokin cua t6 chuc rna: - Mo rna ti~t ra cac cytokin (hay Adipocytokin: Leptin, Adiponectin ... ), cac
hormon nay c6 tac d1,111g giam d~ khang insulin, uc ch~ qua trinh viem. d nguai beo phi, cac hormon nay bi giam ti~t va n6ng d9 adiponectin tuang quan nghich v6i n6ng d9 inslin huy~t tuang va glucose mau h1c d6i, dfrn d~n tinh tr~ng xa vfi'a m~ch va DTD type 2.
- TNF a, interleukin-6 c6 vai tro trong b~nh sinh beo phi va d~ khang insulin. - PAl - 1 (plasminogen activator inhibitor - 1): ch~t uc ch~ ho~t h6a
plasminogen duqc ti~t ra tir nhi~u lo~i t~ bao trong mo rna nh~t la rna n9i t~ng. Trong beo phi c6 Sl,f gia tang san xu~t va ho~t h6a p AI - 1 tac d<)ng trong nhi~u ti~n trinh sinh hQC khac nhau nhu tan sinh m~ch mau va gay X(J vfi'a
-Protein cua h~ th6ng Renin angiotensin (RAS): cac angiotensin duqc ti~t ra chu y~u a ma t:;mg va tuang quan ch~t che v6i muc d9 beo phi. RAS nay c6 tac d1,111g co m~ch va c6 kha nang gay tang huy~t ap.
Tom l~i HCCH n6i chung va beo phi d~ng nam duqc xem la 1 thgc t~ Him sang d~ nh~n ra nguy ca cao b~nh tim m~ch. 3.5.2. R6i loan lipid mau t:rong HCCH.
R6i lo~n lipid mau la m9t y~u t6 khong th~ tach rai cua H9i cht'rng chuy~n h6a. Trong d6 c6 hai thanh phfin quan tr9ng la Triglyceride va HDL- C duqc chu y trong HCCH han la Cholesterol va LDL.Tieu chi Triglyceride la 150mg%, HDL-C < 40mg% d6i v6i nam va < 50mg% d6i v6i nfi'.
R6i lo~n lipid mau duqc xem la nguyen nhan quan trQng cua cac b~nh ly m~ch mau xa vfra nhu: b~nh d<)ng m~ch vanh, d9t quy, b~nh m~ch mau ngo~i vi, xa vfi'a cac m~ch mau t~ng. D~c bi~t Sl,f gia tang triglycerid va giam HDL c6 lien quan kha ch~t che v6i d~ khang insulin, cu<'mg insulin va r6i lo~n dung n~p glucose.
3.5.3. Tang huy~t ap trong HCCH: THA trong HCCH lien quan beo phi va d~ khang insulin. Tang n6ng d9
inslin huy~t tuang c6 th~ lam THA thong qua cac ca ch~ sau: - Tang Insulin mau lam gia tang ho~t tinh h~ th6ng thfin kinh giao cam lam
gia tang cam t'rng giao cam trong huy~t ap h~ th6ng. - Tang insulin va gia tang ho~t tinh giao cam kich thich Sl,f h~p thu mu6i t~i
th~n dfrn d~n sg gia tang th~ tich. Ngoai ra d~ khang insulin c6 th~ gay m~t can d6i su dvng glucos~ va sg s~
su~t nitric oxide (NO) la ch~t quan trQng gay dan m~ch va insulin c6 the tang dieu
4
. .. ·
. .
PQN _ 32/51
hoa angiotensin II type 1 do keo dai thai gian tac dl,1Ilg va gia trmg thai gian ban huy cua angiotensin II. Ben c~nh d6 S\]' gia tang n6ng d9 cac cytokin cua t6 chile m5' a b~nh nhan beo phi ciing tac d()ng tren h~ th6ng huy~t ap. 3.5.4. R6i loan glucose trong HCCH.
Trong dS khang insulin, t~ bao ccr, m5' va t~ bao gan khong Slr d\lllg insulin m9t each thich hQ'P. Do tang duang mau, nhu d.u insulin tang, t1,1y san xu~t insulin nhiSu han, cu6i cling khi tl,ly khong san xu~t du nhu du inslin cua C(J th~ va glucose tang trong mau. Nguai bidS khang insulin c6 n6ng d9 glucose mau cao va insulin cao luu thong trong mau cling 1 h1c.
Nhfrng nguai c6 n6ng d9 glucose mau cao han binh thuang nhung du6i mile DTD thi duqc gQi la tiSn DTD, tinh tr~g nay duqc gQi la r6i lo~n duang mau d6i hay r6i lo~ dung n~p glucose. Phin 16n nhfrng nguai bi tiSn DTD se phat tri~n thanh DTE> trong vong 10 nam va nhfrng nguai tiSn DTD cling c6 nguy C(J b~nh tim m~ch cao han. 3.5.5. HCCH va mot s6 y~u t6 nguy ca khac.
L6i s6ng:
- Ch~ d9 dinh du5'ng
-it v~n d()ng
- Nhi6m khufin
' H(}i chtlng chuy~n hoa: Vi em Thay d6i n9i moi
- Beo phi trung tam I++
Stress oxy h6a nu6c tiSu
- Ti~uduang
' - Tang huy~t ap Giam s6 luqng
- R6i lo~n lipid mau cAu th~n
- Khang Insulin
' ~ Suy giam chile
nangth~n
R6i lo~n chile nang TB n9i m~c ' Albumin nieu vi
~ th~ va d~i th~
~ Tang bi~n c6 m~c Suyth~nm~n b~nh va tu vong
dotimm~ch giai do~n cu6i
SO' <1fi 1: SO' d6 m6i lien h~ gifra albumin ni~u vi th~ va HCCH
5
PQN _ 33/51
3.5.1.1. Albumin ni~u vi th~ (MAU).
Duqc gQi la albumin ni~u vi th~ khi luqng albumin tuong duong 30- 300 mg/ ngay (tuong duong d9 thanh thai albumin ni~u tir 20- 200 11g/phut), ho~c ti 1~ albumin! creatinin nu6c ti~u tir 30- 300mg/g.
Trong HCCH t~p hqp cac yeu t6 nguy ca rna ban than cac yeu t6 nay lien h~ ch~c che v6i MAU ngo~i trir beo phi, diSu nay giai thich MAU duqc xem la yeu t6 nguy ca d()c l~p va yeu t6 nguy ca tir vong tim m~ch 16n nhfit. MAU duqc coi la yeu t6 dv doan cac bien chtmg b~nh th~n va tim m~ch a b~nh nhan DTD.
MAU la bfug chtmg xufit hi~n b~nh th~n v6i tAn sufit gfip 20 IAn a b~nh nhan DTD type 2 hay khong c6 DTD.
3.5.1.2. DS khang insulin.
DS khang insulin la tinh tr~ng trong d6 cac t6 chuc nh~y cam insulin nhu rna, CCY va gan dap tmg kern V6i tac d\illg sinh hQC CUa insulin, anh huang den SlJ 6n dinh n9i moi cua glucose theo chiSu huang gia tang lam n6ng d9 insulin mau cao hon binh thubng d~ duy tri glucose mau binh thubng. H~u qua cua gia tang insulin mau se gay ra nhiSu r6i lo~n chuy~n h6a va bi6n ch(rng nhiSu ca quan.
Danh gia sv dS khang insulin nguai ta thubng do insulin luc d6i, do gian ti6p b~ng chi s6 HOMA- IR.
DS khang insulin c6 th~ lien quan d6n sv gia tang nhiSu YTNC tim m~ch. DS khang insulin trong HCCH c6 cache phuc t~p, tac d()ng qua l~i gifra beo phi trung tam va dS khang insulin. Nhfrng d~c di~m quan trQng cua CCY ch€ sinh b~nh la:
- DS khang insulin c6 th~ lien ket v6i b~nh m~ch vanh.
· - R6i lo~n lipid mau gay xa vfra d()ng m~ch, bi~u hi~n chinh y6u tam ch(rng d6 la lam giam HDL-C ph6i hqp v6i tang TG va pharr tu LDL nh6, d~m d~c.
- THA thubng xay ra 6 ngum dS khang insulin. - Tinh tr~ng tiSn viem v6i chfit chi di~m CRP va tiSn huyet kh6i v6i tang
n6ng d() plasminogen activator inhibitor (PAI-l) va fibrinogen huy€t tuong.
3.5.1.3. Pharr tmg viem va r6i lo~n dong mau. Sv gia tang m()t s6 cac chfit chi di~m tiSn viem dv bao cho sv hinh thanh
HCCH va pharr (rng viem la du n6i gifra HCCH va xa vfra m~ch. Ca 2 tinh tr~ng tiSn viem va tiSn huyet kh6i do beo phi lam gia tang nguy ca b~nh m~ch vanh.
- Protein C pharr (rng ( CRP) la 1 chfit pharr (rng pha cfip chinh duqc xem la chi s6 viem va ph6i hqp v6i h()i ch(rng vanh cfip-thong qua kha nang lam mfit 6n dinh va gay va mang XCY vfra.
- P AI -1 duqc ph6ng thich v6i s6 luqng gia tang tir mo rna b\illg c6 khuynh huang lam gia tang huyet kh6i do va mang XCY vfra.
- Cac yeu t6 khac nhu pharr tir ket dinh t€ bao thanh m~ch (VCAM-1) lien k€t cac b~ch cAu gay xa vfra nhu nhu te bao don ~an, cac lympho T gia tang ho~t d()ng lipid va bi€n d6~ lipoprotein. Cac cytokin tien viem nhu IL-lb, TNF-a lam trinh bay VCAM-1 ate bao n()i m~c m~ch mau.
- Angiotensin II la 1 trong nhtmg p?an tu tiSn viem quan trQng trong ti€n trinh xa vfra a te bao n()i m~c m~ch va va te bao ca tron, gay ra tinh tr~ng oxy h6a, di trU va tang sinh te bao catron va tai t~o m~ch.
CRP kich thich tang sinh va di tru te bao ca tron gay ra bai angiotensin II.
6
.,
PQN _ 34/51
3.6. Bi~n chling ciia HCCH. 3.6.1. Benh tim mach:
HCCH lam gia tang nguy ca ill vong do b~nh m~ch vanh k~ ca c6 DTD va khong DTD va c6 cang nhi~u y~u t6 cua HCCH thi nguy ca ill vong tim m~ch cang cao.
3.6.2. Ti~n DTD va DTD:
0 Hoa ky hau h~t b~nh nhan DTD type 2 xay ra a nguai c6 chi s6 BMI > 22kg/m2
. Nhi~u nghien c(ru da ghi nh~n a nh6m ngu<'Yi tren 45 tu6i c6 BMI > 25 dn phai sang loc ti~n DTD type 2, tuy nhien < 45 tu6i nhung BMI > 25 c6 nhi~u y~u t6 nguy C(J d1ng can sang lQC ti~n DTD type 2.
3.6.3. Ccic bi~n ch(mg beo phi:
R6i lo~ chuc nang ho hfip, r6i lo~n h~ th6ng ca xuang kh6p, ung thu, b~nh tieu h6a, h~ th6ng da, h~ th6ng cac tuy~n n9i ti~t, tam than kinh. . . la cac bi~n chtmg c6 th~ g~p a ngu<'Yi beo phi va gia tang ti 1~ tir vong tru6c h~t la do cac y~u t6 nguy ca tim m~ch.
3.7. Di~u trj HCCH:
3.7.l.Muc tieu di~u tri: Thay d6i 16i s6ng v6i cac bi~n phap khong dling thu6c va dung thu6c ml,lC dich la lam giam nguy C(J cua cac y~u t6 HCCH cfing nhu bi~n h' f h c th" nh c ung 1mm~c . \1 e usau:
Tieu chiHCCH Nguy cO' cao Nguy CO' rftt cao
Huy~t ap (mmHg) < 135/85 < 120/80
Glucose mau d6i (mmol/1) < 6,1 < 5,6
Glucose 2 gia sau an (mmol/1) < 10 <8
Triglycerides (mmol/1) < 1,7 < 1,5
HDL-C (mmol/1)
Nam > 0,9 > 1,0
Nfr > 1,0 > 1,1.
3.7.2. Muc tieu di~u tri beo phi: Theo tac gia George A Bay, m1,1c tieu di~u tri thanh cong beo phi nhu sau:
. - Ly tucrng la tra v~ tr9ng luqng ly tucrng ho~c ban dau va giam cac YTNC.
- S1,1t can tren 2kg/thang trong thang dau di~u tri. - Giam tren 5% tr9ng luqng ru 3 - 6 thang di~u tri. - Giam can ru 10 - 15% tr9ng luqng la k~t qua t6t, tren 15% la tuy~t v<'Yi.
- Sir dl,lllg t6i da lo~i Sibutramin la 2 nam, lo~i Orlistat la 4 nam.
3.7.3. Phuang phap khong dling thu6c: Theo hi~p h9i DTD qu6c t~ (IDF), can thi~p dau tien HCCH la thay d6i I6i s6ng v6i 1 s6 bi~n phap khong dung thu6c bao gbm :
- Giam can n~ng.
- H~n ch~ ruqu bia
- Gia tang ho~t d9ng th~ h.rc b~ng each luy~n t~p th~ dl,lC.
- Giam sir dl,lllg mu6i an. - Duy tri ch~ d9 an kieng nhung day du ca2+, K+ va Mg2+.
7
PQN _ 35/51
- Ngung thu6c lava giam luqng rna bao hoa va cholesterol.
3. 7.3 .I. Can thi~p thay d6i 16i s6ng vao S\I tang din va beo phi. Ch~ d9 an kieng thich hqp k~t hqp v&i luy~n t~p th6 d1,1c d6 giam din va giam
kh6i luqng rna la bi~n phap duqc khuy~n cao. M~c du thay d6i v~ beo phi m<)t each hoan toan va duy tri lau dai kh6 d~t duqc tuy nhien khi ap dl,lllg cilng mang l~i lqi ich khac nhu :
- Giam r6i lo~n lipid, giam nguy ccr tim m~ch. - Cai thi~n cam giac thoai mai va tang chfit luqng CUQC s6ng.
- Giam nguy ccr phat tri6n DTD.
3.7.3.2. Can thi~p thay d6i 16i s6ng vao sv phat tri6n ti~n DTD va DTD type 2.(Xem phfin ch~ d9 an trong bai di~u tri DTD).
3. 7 .1.3. Can thi~p thay d6i 16i s6ng vao r6i lo~n lipid mau (xem bai di~u tri r6i lo~n lipid mau).
3.7.3.4. Can thi~p thay d6i 16i s6ng vao THA. 3.7.3.5. Thay d6i 16i s6ng can thi~p vao tang dong va phan (mg viem.
3.7.4. Di~u tri HCCH b~ng thu6c.
3.7.4.1. Huang d~n thvc hanh: (1) - Dling thu6c cho nguOi beo phi BMI > 30kg/m2 dang dling ch~ d9 an
kieng, thay d6i 16i s6ng va c6 m1,1c tieu giam can. (2)- Su dl,lllg thu6c cho ngucri thfit b~i trong ch~ d9 an kieng va v~n d<)ng. (3)- Cac thu6c bao g6m Sibutramine, Orlistat, phentermine, diethipropion.
( 4) - Ph~u thu~t cdn xet d~n trucrng hqp BMI > 40 kg/m2, thfit b~i trong cac
bi~n phap tren va cdn thvc hi~n t~i cac trung tam chuyen khoa v&i ph~u thu~t vien kinh nghi~m. 3.7.4.2. Di~u tri cac y~u t6 cua HCCH.
- Di~u tri DTD type 2. - Di~u tri THA. - Di~u tri r6i lo~n lipid mau.
Tai li~u tham khao: 1. PGS. TS. Trfin Hilu Dang - PGS. TS. Nguy~n Hai Thuy, (2008), "Giao trinh
sau agi h9C chuyen ngcmh n9i tih va chuyin h6a "' Trucrng D~i HQC y - Duqc Hu~, Nha xufit ban D~i H9c Hu~.
2 . . GS. Mai Th~ Tr~ch- GS. Nguy~n Thy Khue, (2008), "N9i tdt h9c agi cuong", Nha xufit ban Y hQc.
3. Larsen, Kronenberg at al, (2009), "William text book of Endocrinology", Elevent edition, Nha xufit ban Saunders.
8
-1-
. ...
PQN _ 36/51
,.
TINH AN TOAN CUA DAU cAVA ACID BEO OMEGA-3
Nguyin Mai Hoa djch
Ngu6n: Medicines Safety Update 2010, 33(2):48-51
Dau ca chua acid beo omega-3, acid eicosapentaenoic (EPA) va acid docosahexaenoic (DHA). C6 bang chung cho thay di;ing DHA va EPA trong che pham dau ca c6 lc;fi tren tim mi;ich. Mqt so dO' li~u cho thay nhO'ng tac d~ng c6 lc;ti khac cua dau ca, bao gom tang cu'ang 51,( phat trien mat/nao a tre nh6, co the sU' d~ng trong tinh tri;lng viem nhi@m, cung cap chat dinh du'Ong (trong roi loi;in tieu hoa), roi loi;in sue khoe tam than, b~nh Alzheimer va viem kh6'p di;ing thap.
Tuy nhien, nguy cd chay mau, cl~c bi~t Ia chay mau h~u ph~u khi sU' d~ng dau ca Ia mqt van de can du'c;fc quan tam. Theo kinh nghi~m, mqt so bac si se tri hoan vi~c ph~u thu~t va gay me li;ii neu b~nh nhan clang sU' d~ng dau ca. !<hong co hu'6'ng d~n lam sang nao cClng nhu' chi co m9t vai gc;ti y trong y van noi ve van de nay. Nam 2008, Thomas va cqng sl,( bao cao ve tinh tri;ing chay mau cam va d@ bam tim khi sU' d~ng dau ca. Cac tac gia cho rang dau ca co the co tac d~ng tu'dng tl,l' warfarin va gay ra nguy cd chay mau.
Cd che pho bien nhat giai thich cho d~c tinh chong dong cua dau ca du'c;tc biet den Ia lien quan den sl,l' thay doi tY I~ phospholipid tren mang tieu cau. Tren in vitro, dau ca Ci;inh tranh Ltc che cycle-oxygenase (COX), do do, uc che acid arachidonic (ARA) trong tieu cau chuyen thanh thromboxan A2. Dau ca co the lam giam ket t~p tieu cau do giam nang dq ARA trong tieu cau va giam COX - dong vai tro trung gian ti;IO ra thromboxan A2 tLt EPA. DHA co the cCing imh hu'ang den sl,l' ket t~p tieu cau do Ci;inh tranh v6'i ARA trong cau thanh mang tieu cau, do do, no lam giam lu'c;tng ARA co kha nang ti;io thanh thromboxan A2. M9t so cd che khac nhu' giam sl,l' phat trien cua tieu cau va cac yeu to dong mau cCing gop phan gay ra nguy cd.
Tom hiqc y van
y van chi ghi nh~n 3 tru'ang hc;fp co bien co chay mau ho~c thay cloi chi so xet nghi~m a b~nh nhan dung dong thai dau ca va cac thuoc chong dong. Du'6'i clay Ia nhO'ng bang chung thu du'c;fc tlt' cac bai tong quan va thU' ngh i~m lam sang co cloi chung v6'i placebo:
Nam 1994, Leaf va cqng sl,l' eta tien hanh thU' nghi~m lam sang ng~u nhien co cloi chung tren 551 b~nh nhan ti;IO hinh mi;!Ch mau bang thu thu~t ti;IO hinh dqng mi;!Ch vanh qua da (Percutaneous Intraluminal Coronary Angioplasty), v6'i m~c clich nghien cuu tac d~ng phong nglt'a h~p van tim tai phat cua acid beo omega-3. Cac cloi tu'c;tng nghien cU'u clu'c;tc dung lieu cao EPA va DHA ho~c placebo 14 ngay tru'6'c va 6 thang sau khi thl,l'c hi~n thu thu~t. Tat ca b~nh nhan cung clu'c;tc sU' d~ng aspirin lieu 325mg trong 6 thang sau khi ph~u thu~t ti;io hinh m9ch vanh. Ket qua Ia, vi~c can thi~p thu thu~t tren khong giup phong nglt'a h~p van tim tai phat, dong thai, khong co 51,1' khac nhau co y nghia thong ke ve thai gian chay mau giO'a hai nhom.
Nam 2002, Heller va cqng sl,( da danh gia tinh an toan cua dau ca a giai doi;in h~u ph§u trong mqt thU' nghi~m lam sang ng§u nhien, mu doi, cloi chung v6'i placebo. 44 b9nh nhan trong nghien cuu du'c;tc chi clinh djch truyen dinh du'ong chua lieu cao acid beo omega-3 sau ph§u thu~t 5 b~ng. Khong nh~n thay sl,( khac bi~t r5 r~t giO'a nhom thu va nhom chung ve cac bien co chay mau.
Nam 2007, Haris cla ra soat li;ii 19 thU' nghi~m lam sang trong do b~nh nhan ph§u thu~t tim mi;ich ho~c chQc do dqng mi;ich clui du'c;tc chi cljnh acid beo omega-3 dung dong thai v6'i cac thuoc chong dong khac. Trong 14 thU' nghi~m, acid beo omega-3 du'c;tc chi djnh tru'6'c khi ph§u thu~t 1 den 42 ngay, a 5 thU' nghi~m con li;ii, b~nh nhan au'c;tc chi clinh omega-3 sau ph§u thu~t, v6'i lieu 1,4 - 21g/ngay. Ket lu~n du'c;tc clu'a ra Ia bien co chay mau co y nghia tren lam sang "hau nhu' khong phat hi~n du'c;fc".
Anh hu'ang cua acid omega-3 can ke ddn (prescription omega-3 acid - POM) va aspirin len chuc nang cua tieu cau khi dung ddn le ho~c dung phoi hc;fp da du'c;fc nghien cuu bai Larson va cqng sl,( nam 2008. Bay Ia mqt thU' nghi~m lam sang rna thl,l'c hi~n tren 10 ngu'ai khoe m9nh, v6'i li~u trinh 4 tuan lien tiep nhau, trong do, m6i cloi tu'c;fng Ia doi chung cua chinh hQ. Nghien cuu cho thay POM dung ddn le khong co tac d~ng len sl,( ket t~P . tieu cau, tac d~ng nay chi co khi dung rieng aspirin ho~c phoi hc;fp POM va aspirin.
-·
PQN _ 37/51
Nam 2009, Watson va c(?ng slf da tiE~n hanh xem xet dO' li~u cua m(?t nghien cuu hoi cuu, trong d6 182 doi tu'c;tng trong nh6m b~nh du'c;tc dfeu trj bang aspirin, clopidogrel va d'au ca IH~u cao; con 182 doi tu'c;tng cua nh6m chung chi su dt,mg asprin va clopidogrel trong khoimg thai gian trung blnh Ia 33 thang. Khong c6 b~nh nhan nao a nh6m chung va m9t b~nh nhan a nh6m b~nh g~p bien co chay mau (b~nh nhan ung thu' trlfc trang can truyen mau). Tuy nhien, slf khac nhau nay khong c6 y nghia thong ke. Cac nha nghien cuu ket lu~n rang ket hc;fp lieu cao dau Ca VOi aspirin va clopidogrel to ra an toan va Slf phoi hc;fp nay khong lam tang nguy cd chay mau so v6'i khi chi su dyng aspirin va clopidogrel.
Quan diem cua cd quan quim ly du'(jc pham va hi~p hQi tim m~ch cua mc?t so quoc gia
a Uc, dau ca c6 trong thanh phan thlfc pham chuc nang va m9t so thuoc OTC, du'oi ten "dau ca bien omega-3". Trong cd so dO' li~u phim ung c6 h9i cua Cd quan Quim ly Du'c;tc pham Uc (Therapeutic Goods Administration - TGA), W nam 1987 den thang 2/2010, c6 tong so 92 bao cao v6'i 11 tru'ong hc;tp mo ta bien co chay mau lien quan den vi~c su dyng acid beo omega-3 va dau ca. Trang d6, chi c6 3 tru'ong hc;tp (chiem 3,2%) nghi ngo phan ung c6 h9i xay ra do dau ca dung ddn le (3,2%). TY I~ nay tu'dng tlf cac dO' li~u da du'c;tc bao cao tren the gi6'i. M~c du tlt bao cao tlf nguy~n phan ung c6 h9i, khong thong ke du'c;tc day au cac tru'ong hc;tp xay ra, nhu'ng nhG'ng dO' li~u tren ding cla cho thay nguy cd xay ra slf co chay mau lien quan den vi~c su dyng cac che pham dau ca tu'dng doi thap va chi co m9t tY I~ nho nghi ngo do dau ca trlfc tiep gay ra.
Cd quan quim ly Y te Canada (Health Canada) cho phep cac che pham dau ca du'c;tc cong bo nhieu tac dyng nhu' duy trl sue khoe tot, bao v~ tim, h6 trc;t giam triglycerid huyet thanh va tang cu'ong can bang tinh than c6 lc;ti cho sue khoe. Khong co bat ry Slf cimh bao, th~n trqng, chong chi djnh hay phan ung c6 h9i nao clu'c;tc de c~p den trong chuyen lu~n cua san pham nay vao thang 6/2009.
Nam 2004, Cd quan quan ly Thlfc pham va Du'c;tc pham Hoa Ky (Food and Drug Administration) phe duy~t nhung tac dyng cua dau ca nhu' sau: "NhG'ng nghien cuu cung cap nhieu thong tin hG'u fch nhu'ng chu'a di den du'c;tc ket lu~n cuoi cung rang slt dt,mg EPA va acid beo omega-3 DHA co the lam giam nguy cd mik b~nh m9ch vanh". Dong thai, ding khuyen cao, "Thlfc pham chuc nang khong nen khuyen cao ho~c chi d~n tren nhan ve lieu dung EPA va DHA hang ngay vu'c;tt qua 2g".
Nam 2008, H9i Tim m9ch Quae gia Uc (National Heart Foundation of Australia) du'a ra tong quan khuyen cao ve vi~c su dyng ket hc;tp EPA va DHA thong qua acid beo omega-3 ho~c dau ca nhu' sau: su dyng EPA va DHA a ngu'oi 16'n giup giam nguy cd mik cac b~nh m9ch vanh, phy nO' dlf djnh mang thai, dang mang thai ho~c cho con bu, tre em, ngu'oi 16'n da du'c;tc chan doan mac cac b~nh m9ch vanh, ngu'oi 16'n co chi so lipid
· mau bat thu'ong. Bai tong quan khong de c~p den kha nang c6 anh hu'ong ro r~t len qua trlnh dong mau cua
rl~tt r~ v~ nhltng ht11 y th~n trong khi sU' d1,1ng ~;~c;; s~n pharn nay. Hi~p h(?i tim m9ch Hoa Ky (American Heart Association) ding du'a ra khuyen cao tu'dng tlf. Thea do, b~nh
nhan Slt dyng lieu cao acid beo omega-3 can CO Slf thea doi cua can b(? y te va dung lieu cao CO the gay ra
chay mau 0 m9t so ngu'oi.
Trang to rdi thong tin ve dau va chat beo, H(?i Tim m9ch Anh (British Heart Foundation) cho rang slt dyng acid beo omega-3 giup bao v~ tim m9ch. Tuy nhien, to chuc nay ding lu'u y b~nh nhan nen tham khao y kien bac si khi Slt dyng dong thai warfarin va che pham dau ca do nguy Cd chay mau CO the xay ra.
Ket lu~n \ Cac dO' li~u lien quan den nguy cd chay mau khi Slt dyng dau ca cho thay Slf tang nguy Cd chay mau tren ly thuyet khong du'c;tc the hi~n ro rang trong cac ket qua nghien cuu tien hanh tren ngu'oi. M~c du :hua c6 clay du dO' lieu he thong ve tfnh an toan cua cac che pham nay nhu'ng cac cd quan quan ly du'c;tc pham ding nen can nha~ ve tfnh an toan cua cac san pham chua dau ca va acid beo omega-3 trong thong tin san pham.
M~t khac, can b9 y te nen lu'u tam ve nguy cd chay mau a b~nh nhan dang dieu trj bang thuoc chong dong
va dau ca. Nam 2007, trong bai baa mang nhan de "Xem xet tfnh an toan cua li~u phap acid beo omega-3", tac gia
Bays c6 clu'a ra m9t so gc;ti y sau: Ngltng su dyng dau ca lieu cao khi co b~nh chay mau cap tfnh, vf dy tru'ong hc;tp trong va ngay sau d(?t quv.
xuat huyet ho~c 0 b~nh nhan dang mac ho~c c6 nguy cd cao b! d9t quv. xuat huyet.
,.
!·
...
., PQN _ 38/51
• )
()
Ngung su dyng dau ca 4-7 ngay tru'oc khi su dyng thuoc/ph~u thu~t cap thiet co nguy cd cao g~p bien chltng chay mau, nhu' slt dyng aspirin, warfarin va clopidogrel. M~c du v~y, truyen djch dinh du'ong dau ca sau ph§u thu~t o byng du'ong nhu' khong lam tang ro r~t bien co chay mau tren lam sang va thu'ong du'c;1c coi Ia an toan, the hi~n tren chuc nang dong mau va chuc nang cua tieu cau.
Can nh~k kha nang ngan ngua huyet khoi va lc;1i fch tren tim mc;~ch khi bat dau sll dyng dau ca trong giai doc;~n h~u ph~u.
• PQN _ 39/51
ACID BEO OMEGA-3 (Omega-3 fatty acids) Hoang Tich HuyJn dtch
Tom t~t
Trong thuc an, lipid a du&i 2 d~ng: triglycerid va cac phospholipid. Acid beo la phan tu hfru ca g6m m9t chu6i carbon, m9t d~u la g6c metyl (- CH3), con d&u kia cua chu6i la chua acid carboxylic (- COOH). Acid beo omega-3 la cac acid beo khong no nhiSu n6i doi, trong chu6i carbon c6 nhiSu ducmg n6i doi. Chu6i c6 khi dai t&i 18 - 22 nguyen tu carbon. Omega-3 (w- 3 ho~c n- 3) chi ra r~ng n6i doi d&u tien a C thu 3, tinh tir g6c metyl.
NQi dung bai
Nhii'ng acid beo nhi~u nfli doi "thi~t y~u" Nhfmg omega-3 chinh trong thuc an va a ma ngueri tala: acid alphalinoleic (ALA), acid eicosapentaenoic (EPA) va acid docoxahexaenoic (DHA). - ALA la acid beo "thi€t y€u", vi khong t~o thanh duqc trong ca th~, dn phai nh?p tir thilc an. - Trai l~i, EPA va DHA khong thgc S\f "thi€t y6u", vi c6 th~ t~o duqc trong CO' th~ tir ALA. Tuy nhien, S\f t~o thanh EPA va DHA khong du, vi t~o rfit ch?m va c6 gi&i h~n. Cac h~ enzym dung d~ xuc tac chuy~n sang omega-3 cling d6ng thai giup chuy~n sang omega-6 va omega-9, nen se c6 tuang tac gifra cac con duang chuy~n h6a. Han nfra, mot s6 y€u t6 khac c6 th~ lam ch?m l~i qua trinh chuy~n h6a sang omega-3 (nhu nghi~n mQ'U, an nhiSu duang varna bao hoa, dai thao duang, stress, tang huyst ap, r6i lo~ tv mi€n). Nhu v?y sv t~o thanh EPA va DHA rfit khong d§.y du, dn phai nh?p tir ngu6n thuc an (ho~c thvc phfrm chile nang) m9t luqng phong phu, khong nhfmg ALA, rna ca d~n xufit chu6i dai la EPA va DHA. Chuy~n boa cua acid beo omega-3 ALA la ti~n chfit cua hQ cac acid beo omega-3. Trong ca th~ nguai, ALA chuy~n thanh EPA (C20: 5) va DHA (C22: 6) qua cac phan ilng mfit bao hoa (them cac n6i doi a d~u carboxyl) va keo dai (them cac nguyen ill C). Acid linoleic (LA) la ti~n chfit cua hQ cac acid beo omega-6. Trong CO' th~, LA se chuy~n thanh acid arachidonic (AA). AA va EPA se c~nh tranh l~n nhau a cling cac enzym chuy~n h6a: - Du&i tac dvng cua cyclo - oxygenase va lipo - oxygenase, thi AA se t~o nen cac prostaglandin va thromboxan nh6m 2 (PGE2, PGI2, TXA2) va cac leucotrien nh6m 4 (CTB4, LTC4- LTE4), cac eicosanoid giup cho k€t t?p ti~u du va phan ilng gay viem. - Nhung du&i Sl,l' xuc tac cua cling cac enzym tren, thu EPA se t~o cac prostaglandin va thromboxan nh6m 3 (PGE3, PGI3, TXA3) va cac leucotrien nh6m 5 (CTB5, LTC5 -CTE5) c6 tac dvng ch6ng viem va ilc ch€ sv k€t t?p ti~u du. Cac eicosanoid d~n xufit cua omega-3 c6 th~ d6i khang v&i tac dvng gay viem cua cac eicosanoid omega-6. Omega-3 do c~nh tranh, nen lam giam san xufit cac cytokin d~n xufit cua acid arachidonic (AA). Vai tro sinh ly cua acid beo omega-3 - Tham gia vao cfiu true mang t€ bao, vao lap kep cua phospholipid, anh huang d€n tinh thfim va d9 deo cua mang. EPA c6 vai tro chile nang trong Sl,l' truySn.
,.
PQN _ 40/51
)
- Omega-3 h't thimh ph~n quan tn,mg cua mo th~n kinh. DNA di;ic bi~t quan tn;mg a h~ th~n kinh va a vong m~c, la thanh ph~n d.u true cua mang na-ron. - Omega-3 con tham gia vao CO' ch€ dm mau va vao phfm (mg viem va c6 anh huang t6i cac phan (mg mi€n djch. ALA khong c6 chuc nang di;ic bi~t nao, rna chi la ti@n ch~t cua omega-3. NguBn g6c ALA, EPA, DHA ALA c6 trong rau xanh, trong d~u h~t lanh, d~u d~u nanh, qua 6c ch6, cay cai d~u. EPA va DHA c6 mi;it chu y€u a d~u ca, a ca beo ( ca thu, ca h6i, ca trich, ca ngir, ca tr6ng, ca sardine .. . ) Can b~ng omega-6/omega-3 Sv tieu th\1 acid linoleic ( omega-6) tang len r~t nhanh trong vai th~p ky g~n day. d Chau Au, c6 qua tai omega-6 so v6i omega-3, tY I~ tir 1939- 1985 v@ omega-6/omega-3 la ~ 10! Qua thira acid beo omega-6 se lam giam sv t~o thanh cac acid beo omega-3 (EPA, DHA), rna omega-3 l~i d6ng vai tro quan trQng trong dong mau va trong phan tmg viem, cho nen dn c6 ty 1~ hai hoa omega-6/omega-3, nh~t la a tre con bu illy (tinh ch~t cua t€ bao, S\f sap nh~p IDO V.V .. . ).
Theo khuy€n cao, cy I~ nay nen la 4,7 (3,6- 5,8), trong thvc t€ la 5,0. LQ'i ich ciia acid beo omega-3 * Trong b~nh tim m~ch:
- Ch6ng lo~n nhip tim - Ch6ng huy€t kh6i - Ch6ng vfra xa d9ng m~ch - Ch6ng viem - T~o thu~n lqi cho chuc nang n9i mo m~ch mau - Lam giam huy€t ap ( v6i li€u cao) - Giam ham luqng triglycerid huy€t thanh
Ph~n 16n cac nghien cilu djch t€ hQc cho th~y an ca nhi@u (nh~t la ca beo) c6 him giam t)r 1~ ti'r vong do b~nh tim m~ch. Omega-3 c6 lam giam triglycerid- mau. D~ dv phong thu phat, nhieu cong trinh cho th~y omega-3 dimg sau nh6i mau ca tim c6 lam giam nguy ca tir vong do b~nh tim m~ch. * Trong cac b~nh viem va mi€n djch Trong viem kh6p d~ng th~p, b6 sung d~u ca c6 tac dl)ng c6 ich lo~i trir m9t s6 tri~u chtmg. Trong cac b~nh viem m~n tinh duemg tieu h6a (b~nh Crohn va viem loet d~i trang) va hen ph€ quan, cac b~nh tv mi€n, th~y omega-3 c6 lqi ich vira phai trong dv phong thu phat. * Ung thu: Chua c6 b~ng chln1g la acid beo omega-3 lam giam nguy ca ung thu. * B~nh ngoai da: 1'!9t vai nghien Clru cho th~y omega-3 CO ich trong h6 trq di@u trj viem da, cham va vay nen. * Trong benh doc kh6, loan ph6i hgp dong tac va trong cac r6i loan v€ tu ky, v€ tang dong, th~y omega-3 (chu y€u la EPA) c6 khi c6 ich lqi, nhung chua du b~ng chln1g kh~ng djnh v€ hi~u lvc. Khi mang thai, cho con bu va a tre nh6 tu6i:
· ' --·
:
• -· PQN _ 41/51
Cac acid beo omega-3 la mfiu chat cho Sl,f phat triSn h~ thfrn kinh cua thai va tre bu me. Trong thai ky, n~u m~ khong dling du omega-3, thi thai se thi~u h\lt omega-3 (DHA, EPA), nen c6 thS anh hu<'mg xfiu t6'i Sl,f phat triSn thfrn kinh cua tre. Cung dp dfry du omega-3 n:ong thai ky con ngan ngira de non, ngan ngira tre nhv can luc SO' sinh va bao dam thi Ivc tot cho tre sau nay. Khuy~n cao an ca (nhfit la ca beo) it nhfit 2 lfrn m6i tufrn, cho ca ngm)'i mang thai va thai ky cho con bu. !ac dl}ng khong mong mu6n cua omega-3/ th~n trQng It g~p khi an ca: - Rai loan tieu h6a: q hai mui vi tanh cua ca, bu6n non, kh6 tieu, non, dfry hai, tieu chay ho~c tao b6n. N~u dling Ii€u binh thuang (<= 3 gam/ngay) thi it g~p tac d\lfig ph\1. Nen uang nang dfru ca trong bua cam. - Chay mau: omega-3 ( d~c bi~t khi dung Ii€u cao) gay uc ch~ sv k~t t~p tiSu du, lam tang thai gian chay mau, dn luu y khi dling cho nguai c6 nguy ca xufit huy~t (nhu chfin thuang nghiem trQng, khi phiu thu~t v.v ... ). Cling dn th~n tr<;mg khi c6 rai lo~n dong mau va khi c6 xufit huy~t. - V 6'i gan: v6'i b~nh nhan da c6 tang triglycerid - mau, thfiy c6 tang vira phai enzym gan (AST, ALT) khi dling omega-3. Do d6 dn theo doi d€u d~n enzym gan a b~nh nhan rai lo~n chuc nang gan dling omega-3. - Su d\lllg qua Ii€u vitamin: Cfrn nh6' la dfru gan ca chua c6 khi luqng cao cac vitamin A, D, cho nen chi dung dfru ca (b6 gan) chua omega-3. Cfrn th~n trQng tranh nhfrm lin dung lau dai va v6'i li€u cao dfru gan case gay qua Ii€u vitamin A, D. Cfrn luu y r~ng vitamin A c6 thS gay quai thai n~u trong thai ky, nguai illy dung qua li€u dfru gan ca. - Rai lo~n lipid - mau: Li€u qua cao dfru ca c6 thS gay tang nhv LDL - cholesterol a m9t sa nguai. - Kh6 kiSm soat glucose - mau: - Rai lo~n ngoai da: Phat ban da, cham, trtmg ca, nhung hi~m g~p. Th~n trQng khi dung ol!lega-~: - Roi lo~n dong mau, xuat huyet - Suy gan - TiSu duang typ 1 va 2 (nguy CO' tang glucose mau) - Cfrn th~n khi dling omega-3 cho b~nh nhan hen qua min v6'i aspirin (nguy ca kich phat can hen). - N~u c6 di (mg ho~c qua min cam khi an ca, thi dn tranh uang dfru ca ho~c omega-3 (lfiy tir dfru ca). ' , 0
- v 6'i b~nh nhan da c6 tang thai gian chay mau khi dung dau ca, thi nen can th~n khl dung thuac chang dong mau. Khuy~n cao - Dv phong nguyen phat: an ca 2 lfrn m6i tufrn (trong d6 llfrn an ca beo). Dung nhi€u lo~i ca khac nhau. - Dv phong thu phat khi c6 b~nh tim m~ch: sau nhai mau ca tim 1 g dfru catngay (chua EPA+DHA) K~t luan: , V6'i ng~ai khoe m~nh, an ca 2 lfrn m6i tufrn (c6 m9t Ian, an ca beo). Di€u tri h6 trq sau nh6i mau ca tim, dling cling cac thuoc chuyen khoa.
r.
·-
PQN _ 42/51
)
V6i cac b~nh khac (ung thu, viem kh6p d.;tng thfrp, b~nh tam th~n, ngoai da v.v ... ) lgi fch chua r5 r~t.
Tai li~u tham khao
J. Pharm. Belgique, 2007; 62, S6 4, Tr 102 - 114
- ~ 1
PQN _ 43/51
)
BQYTE Cl}C QUAN LY DlfQC
So: 5074 I QLD-DK V /v c~p nh~t thOng tin d- qc ly . thuoc
nh6m statin
K.inh giri:
C()NG HOA XA HOI cuu NGHIA VI~T NAM D()c I~p - TIJ do - H~nh phuc
Ha N9i, ngay 05 thang 04 nam 2013
- Sa Y tS cac tinh, thanh ph6 trvc thu()c trung uong; - Cac b~nh vi~n, vi~n c6 giu(mg b~nh tqrc thu()c B9 y t~; - Cac cong ty dang Icy, san xu~t thu6c luu hanh t~i Vi~t Nam.
Ngay 04/12/2008, Ct,1c Quan ly Duqc da c6 cong van s6 12048/QLD-BK v~ vi~c c~p nh~t cac thong tin lien quan d6i v&i thu6c nh6m statin vao to huang d~n sir dl,lng va to tom t~t d~c tinh san phAm cua thu6c tren CO" sa t6ng hqp bao cao tir t6 chuc y t~ Th~ gi&i (WHO) va CO" quan quan ly duqc cua cac nu&c.
Tir thang 06/2011 d~n thang 03/2012, Ca quan Quan ly Duqc phAm va Th1,rc phAm Hoa Ky (FDA) da lien ti~p dua ra cac thong bao v~ d() an toan kern theo yeu cAu thay d6i thong tin tren to huang d~n sir d1,1ng cua cac thu6c di~u tri r6i lo~n lipid mau nh6m statin. Cac di€m thay d6i chinh tren to huang d~n sir d1,1ng cac thu6c nay lien quan dSn gi6-i h~n li~u dung, tac d1,1ng khong mong mu6n, tuong tac thu6c, canh bao va th~n tTQng khi sir dl)ng d6i v&i t~t ca cac thu6c nh6m statin, d~c bi~t la vi~c b6 sung ch6ng chi dinh ph6i hqp thu6c va gi&i h~n li~u khi dung d6ng thai v&i cac thu6c CO kha nang tang nguy CO" ffi~C b~nh CO" va/ho~C hQi ChUng tieu CO" van CUa lovastatin va simvastatin.
T~i Vi~t Nam, nh6m thu6c statin hi~n dang luu hanh du&i d~ng ch~ phAm don thanh phAn ( atorvast~tin, puvast~tin, 1ov~stflt~n ) pitava~tatin~ pravaotutin, ro3uvMtc1tlil, simvastatin) va che pham phoi hqp (phoi hQp simvastatin v6-i ezetimib ho~c
atorvastatin v6-i amlodipin).
Can cu kSt lu~n cua H()i d6ng xet duy~t thu6c - B() Y tS d6i v&i thu6c nh6m statin; nh~m dam bao m1,1c tieu sir d1,1ng thu6c hqp ly, an toan va hi~u qua, C1,1c Quan ly Duqc thong bao nhu sau:
1. Sa Y t~ cac tinh, thanh ph6 trvc thu()c trung uong va cac b~nh vi~n, vi~n c6 giu0ng b~nh trvc thu()c B9 Y t~:
1.1. Thong bao cho cac CO" sa kham, chua b~nh, cac don vi kinh doanh duqc phAm tren dia ban biSt thong tin duqc ly c~p nh~t lien quan d~n thu6c nh6m statin neu t~i cong van nay (chi ti~t trong cac Phl,l ll)C dinh kern);
1.2. Tang cu0ng th1,rc hi~n vi~c theo d5i tac d1,1ng khong mong mu6n cua thu6c trong qua trinh su d1,1ng va luu hanh; gui bao cao ADR (n~u c6) v~ Trung tam Qu6c gia v~ thong tin thu6c va theo doi phan U:ng c6 h~i cua thu6c (13-15 Le Thanh Tong, Ha N9i) ho~c Trung-tam khu VlJC v~ thong tin thu6c va theo doi phan U:ng c6 h~i cua thu6c TP. H6 Chi Minh (201B Nguyen Chi Thanh, QwJ_n 5, TP. H6 Chi Minh).
PQN _ 44/51
2. Cac cong ty dang lcy, san xu~t:
2.1. D6i vai thu6c nh6m statin da duqc dp phep luu hanh tren thi truemg:
2.1.1. Trong vong 03 thang k~ tu ngay ky cong van nay, yeu cfiu cong ty dang ky, nha san xu~t tht,rc hi~n vi~c: Ti~p tl,lc c~p nh~t thong tin lien quan d~n tac d\mg khong mong mu6n, tuong tac thu6c, canh bao va th~n tn;mg khi su dvng, giai h~n li~u dung khi ph6i hqp thu6c, ch6ng chi dinh ph6i hqp thu6c theo cac n9i dung huang d~n tuong trng t~i cac Phl}. ll}.C 1, Phl}. ll}.C 2, Phl}. ll}.C 3 va Phl}. ll}.C 4 kern theo cong van nay vao nhan, to huang d~n su dvng thu6c cung cac thong tin da cong b6 trong chuyen lu~n statin- tai 1i~u Duqc thu Qu6c gia Vi~t Nam (Taiban trQn b9 600 chuyen lu~n, NXB Y hQc- 2012, trang 240-243).
2.1.2. Hinh thuc c~p nh~t thong tin: Theo huang d~n cua phvlvc II -Thong tu s6 22/2009/TT-BYT ngay 24/11/2009 cua B9 Y t~· quy dinh vi~c dang ky thu6c.
2.2. D6i vai thu6c nh6m statin dang chcr xet duy~t:
Cvc Quan ly Duqc chi xem xet c~p s6 dang kY luu hanh sau khi cong ty da n9p 0 tai li~u sua d6ilb6 sung cac n9i dung lien quan d~n tac dvng khong mong mu6n, tuong tac thu6c, canh bao va th~n trQng khi su dvng, giai ht;tn li~u dung khi ph6i hqp thu6c, ch6ng chi dinh ph6i hqp thu6c d6i vai ho~t ch~t nh6m statin theo huang d~n tuong trng neu tt;ti cac Phl}. ll}.C 1, Phl}. ll}.C 2, Phl}. ll}.C 3 va Phl}. ll}.C 4 kern theo cong van nay cung cac thong tin da cong b6 trong chuyen lu~n statin - tai li~u Duqc thu Qu6c gia Vi~t Nam (Tcii ban trQn b9 600 chuyen lu~n, NXB Y hQc- 2012, trang 240-243) vao cac phfin lien quan cua h6 SO' va duqc thAm dinh dt;tt yeu cAu.
Cvc Quan ly Duqc thong bao d~ cac don vi bi~t va thvc hi~n ./.
Nui nhtj,n: - Nh- tren; - BT. Nguyea,'fhi Kim Tien (deb/c); - Oic Thu tr-<mg (deb/c); - C~c tr- bng (deb/c); - ~c QLKCB, Thanh tra BYT (de ph6i hqp); - T6ng cong ty D- qc VN; - C1,1c Quful Y- B¢ QP; C1,1c Y te - B¢ CA; C1,1c Y te GTVT-BoGTVT; - :Bao hiem XHVN; - TT DI & ADR Qu6c gia; TT DI & ADR KV (BV Chq Ray); - Th1mh vien HD XDT; Chuyen gia th~m d!nh hO sa PC, DL Him sang; - ~c QLD: PhOng QLKDD; PhOng QL TTQC thu6c; TC D- qc & MP; Van phOng ~c (de dang tai Website); - L- u VT, DKT (2b ).
KT. ClJC TRUONG PHO ClJC TRUONG
(Da ky)
Nguyen Van Thanh -·
• PQN _ 45/51
)
)
Phl}.ll}.C 1
Cac n(}i dung thay dflilbA sung chong dfii v6'i thuAc nhom statio
(Dinh kern thea c6ng van s6 5074/QLD-EJK, ngay 5/4/2013 cua C1;tc Quem ly Du9·c)
Cac n(}i dung thay dflilbA sung
Tac dl}.ng khong mong muAn
Bo sung m()t so tac dt,mg khong mong
muon sau:
• Suy giam nh~n thuc (nhu m~t
tri nh6·, lu Ifin ... )
• Tang duong huySt
• TangHbAlc
TrrO'ng hie thufic
Ngoai cac tuong tac da c6, bo sung va
sua d6i thong tin sau (nsu co cac
thong tin tuong ung) trong phfin
Tuong tac thu6c, Li~u dung, Ch6ng
chi dinh, Canh bao va th~n tn;mg khi
su dt,mg:
Tang nguy ca t6n thuong ca khi su
dt,mg statin d6ng thai v&i cac thu6c
sau:
- Gemfibrozil
- Cac thu6c h~ cholesterol mau nh6m
fibrat khac
- Niacin li~u cao ( > 1 g/ngay)
- Colchicin
ThuAc ap dl}.ng
Tat ca cac statin, ke ca
trong chS ph~m ph6i
hQ'P (xem them ghi chu
v&i pravastatin)
Ghi chu
- Pravastatin: khong phai
b6 sung tac dt,mg khong ' ' mong muon ve tang
duoog huyst va tang
HbAlc.
Tat ca cac statin, ke ca - Pitavastatin: khong phai
trong chS ph~m ph6i b6 sung thong tin tuong
hQ'P (xem them ghi chu tac v&i colchicin.
v&i pitavastatin, - Lovastatin: b6 sung va sua
lovastatin va d6i them thong tin theo
simvastatin) ph\11\lc 3. ..
- Simvastatil,l; b6 sung va
sua d6i them thong tin
theo ph\11\lc 4.
Ngoai cac tuang tac da c6, bo sung Tat ca cac statin trir - xem them ph\11\lc 2 ve cac
thong tin v~ tuong tac thu6c gifra cac
statin v&i cac thu6c uc ch€ protease
cua HIV va viem gan sieu vi C (HCV)
va b6 sung vao cac phfin tuong ung
fluvastatin, kB ca trong
chS ph~m ph6i hqp c6
tuong tac cfin ch6ng chi
d!nh ph6i hQ'P ho~c gi&i
thanh phfin la statin h~n li~u khi ph6i hqp.
(xem them ghi chu v&i - Fluvastatin: khong phai b6
trong ffi\lC Li~u dung, Ch6ng chi d!nh, fluvastatin, lovastatin va sung cac lo~i tuang tac
PQN _ 46/51
Canh bao va th~n trQng khi sir d1,mg:
Vi~c sir d1,mg d6ng thai cac thu6c hc;t
lipid mau nhom statin v&i cac thu6c
diSu tri HIV va viem gan sieu vi C
(HCV) co thS lam tang nguy ca gay
t6n thuong ca, nghiem trQng nhfit la
tieu C(J van, th~n hu d~n dSn suy th~n
va co thS gay tu vong (ph1,1l1,1c 2)
v &i lovastatin va simvastatin, bo sung
thong tin vS ch6ng chi dinh m&i, tranh
su d1,1ng d6ng thai va gi&i hc;tn liSu
dung khi su d1,1ng d6ng thai v&i m()t
s6 thu6c ho~c d6 u6ng c6 kha nang
lam tang nguy C(J m~c cac b~nh C(J
va/ho~c tieu C(J van.
Canh bao va th~n trqng khi sfr dl}.ng
simvastatin)
- Lovastatin: Bo sung
them thong tin theo ph1,1
l1,1c 3
- Simvastatin: B6 sung
them thong tin theo ph1,1
l1,1c 4
- B6 khuyen cao theo doi djnh ky Tat ca cac statin, ke ca chuc nang gan va thay b&ng khuysn trong chs phAm ph6i
cao lam xet nghi~m enzym gan tru&c hqp.
khi b~t dfiu disu tri b&ng statin va
trong tru<mg hqp chi dinh lam sang
yeu du xet nghi~m sau d6.
- Can nh~c theo doi creatin kinase
(CK) trong tru<mg hqp:
+ Tru&c khi diSu tri, xet nghi~m CK
nen duqc tien hanh trong nhiing
tru<mg hqp: Suy giam chuc nang th~n,
nhuqc giap, tiSn sir ban than ho~c tiSn
su gia dinh m~c b~nh ca di truySn,
tiSn su bi b~nh ca do su d1,1ng statin
ho~c fibrat tru&c do, tiSn sir b~nh gan
va/ho~c u6ng nhiSu ruqu, b~nh nhan
nay.
- Lovastatin: B6 sung them
cac thong tin theo ph1,1l1,1c 3.
- Simvastatin: B6 sung them
cac thong tin theo ph1,1l1,1c 4.
r
. . ~
PQN _ 47/51
cao tu6i (> 70 tu6i) co nhfrng yeu t6
nguy CO' bj tieu CO' van, kha nang xay
ra tuang tac thu6c va m()t s6 d6i
tuQng b~nh nhan d~c bi~t. Trong
nhfrng truemg hqp nay nen can nh~c
lqi ich!nguy co· va theo doi b~nh nhan
tren lam sang khi di~u tri b~ng statin.
NBu kSt qua xet nghi~m CK > 5 l~n
gi&i h~n tren cua muc binh thuemg,
khong nen b~t ctAu di~u tri b~ng statin.
+ Trong qua trinh di~u tri b~ng statin,
0 b~nh nhan dn thong bao khi co cac
bieu hi~n V~ CO' nhu dau CO', cung CO',
ysu co· . . . Khi co cac biBu hi~n nay,
b~nh nhan dn lam xet nghi~m CK dB
co cac bi~n phap can thi~p phil hqp.
()
::
PQN _ 48/51
PhQIQC 2
Khuy~n cao v~ tll'O'ng hie thu6c gifra cac statin v6i cac chAt rrc ch~ protease ciia
HIVvaHCV
Statin Cac chAt rrc ch~ protease co Khuy~n cao ke do·n
tll'O'ng tac
Atorvastatin • Tipranavir + Ritonavir
Telaprevir Tranh su dt,mg atorvastatin
•
Su dt,mg th~n trQng va neu can • Lopinavir + Ritonavir thiSt nen dung li~u atorvastatin
thAp nhAt
• Darunavir + Ritonavir
• Fosamprenavir Kh6ng qua 20 mg atorvastatin/
• Fosamprenavir + Ritonavir ngay
• Saquinavir + Ritonavir
Nelfinavir Kh6ng qua 40 mg atorvastatin/
• ngay
Pitavastatin • Atazanavir
• Atazanavir + Ritonavir Kh6ng h1;1n chS v~ li~u dung
Darunavir + Ritonavir •
• Lopinavir + Ritonavir
Pravastatin • Darunavir + Ritonavir Kh6ng h1;1n chS v~ li~u dung
Lopinavir + Ritonavir •
Rosuvastatin • Atazanavir Giai h1;1n li~u rosuvastatin t6i
• Atazanavir + Ritonavir da 10 mg m<?t lfin/ngay
Lopinavir + Ritonavir •
Lovastatin Xem chi tiet & phv lvc 3
Simvastatin Xem chi tiet & phvlvc 4
~
I ·
PQN _ 49/51
Phl}.ll}.C 3 M(}t sA khuy~n cao khac lien quan d~n tu-O'ng tac thu6c cua ho~t chAt lovastatin
1. Ch6ng chi dinh dung lovastatin ph6i hqp v&i ca.c thu6c ire chS CYP 3A4 m~nh nhu:
• ltraconazol
• Ketoconazol
• Posaconazol
• Erythromycin
• Clarithromycin
• Telithromycin
• C.:ic thu6c ire chS protease cua HIV
• Boceprevir
• Telaprevir
• Nefazodon
2. Tninh sir dl,lllg dbng thai lovastatin v&i:
• Cyclosporin
• Gemfibrozil
3. Tninh dung luqng l&n nu&c ep buai (Grapefruit juice) (>llit/ngay)
4. Kh6ng dung qua 20 mg lovastatin/ ngay khi su dvng d6ng thai v&i:
• Danazol
• Diltiazem
• Verapamil
5. Kh6ng dung qua 40 mg lovastatin/ ngay khi su dvng v&i:
• Amiodaron
~·
-PQN _ 50/51
Phvivc 4 M()t s6 khuy~n cao khac lien quan d~n trrong hie thufic ciia ho~t ch§t simvastatin
1. Ch6ng chi dinh dung simvastatin ph6i hqp v&i cac thu6c uc chS CYP 3A4 m~nh nhu: • I traconazo I
• Ketoconazol
• Erythromycin
• Clarithromycin
• Telithromycin
• Thu6c uc chS protease cua HIV
• Boceprevir
• Telaprevir
• Nefazodon
• Posaconazol
• - Gemfibrozil
• Cyclosporin
• Danazol
2. Tranh dung luqng l&n nu&c buai ep (Grapefruit juice) (> 1 lit ngay)
3. Khong dung qua 10 mg simvastatinlngay khi sir dvng ph6i hqp v&i:
• Verapamil
• Diltiazem
• Dronedaron
(Ch6ng chi dinh ph6i hqp cac thu6c nay v&i chS ph~m co ham luqng simvastatin 2: 20 mg)
4. Khong dung qua 20mg simvastatinlngay khi sir dvng ph6i v&i:
• Amiodaron
• Amlodipin
• Ranolazin
-·
PQN _ 51/51