B Y T TRNG I HC DC H NI NG TH THU HUYN KHO ST TNH HNH S DNG THUC TRN BNH NHN LUPUS BAN H THNG C HI CHNG THN H TI TRUNG TM D NG MIN DCH LM SNG BNH VIN BCH MAI KHA LUN TT NGHIP DC S H NI - 2013 B Y T TRNG I HC DC H NI NG TH THU HUYN KHO ST TNH HNH S DNG THUC TRN BNH NHN LUPUS BAN H THNG C HI CHNG THN H TI TRUNG TM D NG MIN DCH LM SNG BNH VIN BCH MAI KHA LUN TT NGHIP DC S Ngi hng dn: 1. ThS. Nguyn Th Hin 2. PGS.TS. Nguyn Vn on Ni thc hin:Trung tm D ng Min dch lm sngBnh vin Bch Mai H NI - 2013 LICM N Trc tin, cho php ti gi li cm n chn thnh nht ti ThS Nguyn Th Hin, trng b mn Y hc c s trc tip dn dt, ch bo tn tnh v cng ti hon thnh cun lun vn trong sut thi gian qua. Ti xin c gi li cm n su sc nht tiPGS. TS. NguynVn on, gim c trung tm D ng - Min dch lm sng Bnh vin Bch Mai lun to iukingipvchbotinhngkinthcqubuthchincunlun vn ny. Xin chn thnh cm n ti cc thy c trong b mn Y hc c s to iu kinvgiptitrongsutqutrnhhonthnhkhalunttnghip,cmn cc thy c trong b mn Dc lm sng v nhng gip v ch dy qu bu. Cmnccbcs,iudngtrungtmDng-Mindchlmsngv cc nhn vin Phng lu tr h s bnh n Bnh vin Bch Mai v to iu kin thun li gip ti hon thnh kha lun tt nghip ny.Cuicng,xincmngianh,bnbluncnhvngvinti nhng lc kh khn. Cun lun vn ny s khng c hon thnh nu khng c s gip ca tt c mi ngi.Xin chn thnh cm n ! Sinh vin thc hin ti ng Th Thu Huyn MC LC t vn ............................................................................................................. 1 Chng 1: Tng quan ........................................................................................... 3 1.1. nh ngha ........................................................................................................ 3 1.2. Dch t hc ....................................................................................................... 3 1.3. Nguyn nhn gy bnh SLE .............................................................................. 3 1.3.1. Bt thng v min dch ................................................................................ 3 1.3.2. Yu t di truyn -gii tnh .............................................................................. 4 1.3.3. Yu t thun li 4 1.3. C ch bnh sinh .............................................................................................. 5 1.3.1. C ch bnh sinh SLE .................................................................................... 5 1.3.2. C ch bnh sinh HCTH trn bnh nhn SLE ................................................ 5 1.4. Triu chng lm sng, cn lm sng ................................................................. 5 1.4.1. Triu chng lm sng, cn lm sng ca SLE ................................................ 5 1.4.2. Triu chng lm sng, cn lm sng ca HCTH ............................................. 6 1.4.3. Bin chng .................................................................................................... 7 1.5. Chn on......................................................................................................... 8 1.5.1. Chn on SLE .............................................................................................. 8 1.5.2. Chn on HCTH .......................................................................................... 9 1.6. Tng quan v iu tr lupus ban h thng c hi chng thn h ................... 9 1.6.1. Nguyn tc iu tr SLE c HCTH ................................................................. 9 1.6.2. iu tr SLE c HCTH .................................................................................. 9 1.6.3. iu tr cc triu chng, bin chng bnh nhn SLE c HCTH ............... 12 1.6.4. SLE c HCTH v thai nghn ....................................................................... 14 1.6.5. Theo di trong qu trnh iu tr .................................................................. 14 1.6.6. Ch n ung, chm sc ........................................................................... 14 Chng 2: i tng v phng php nghin cu.......................................... 16 2.1. i tng ....................................................................................................... 16 2.2. Phng php nghin cu ................................................................................ 16 2.3. Cc ch tiu nghin cu................................................................................... 16 2.4. X l s liu ................................................................................................... 17 2.5. Tra cu tng tc...17 Chng 3: Kt qu v bn lun .......................................................................... 18 3.1. Mt s c im lm sng, cn lm sng bnh nhn SLE c HCTH ...... 18 3.1.1. c im chung.......................................................................................... 18 3.1.2. Biu hin ca SLE ....................................................................................... 20 3.1.3. Biu hin ca HCTH ................................................................................... 19 3.1.4. Cc bnh mc km...................................................................................... 25 3.2. Tnh hnh s dng thuc............................................................................. 26 3.2.1. Cc nhm thuc s dng trn bnh nhn..................................................... 27 3.2.2. S dng thuc theo phc iu tr ............................................................. 28 3.2.3. Nhm thuc chnh iu tr bnh ................................................................... 29 3.2.3.1. Glucocorticoid ............................................................................... 29 3.2.3.2. c ch min dch ........................................................................... 32 3.2.3.3. Khng st rt tng hp ................................................................... 34 3.2.4. Cc nhm thuc khc ................................................................................... 34 3.2.4.1. H p.............................................................................................. 35 3.2.4.2.Li tiu ........................................................................................... 36 3.2.4.3. H m mu..................................................................................... 37 3.2.4.4. Nhm thuc tiu ha ...................................................................... 38 3.2.4.5. Truyn albumin .............................................................................. 39 3.2.4.6. Khng sinh ..................................................................................... 40 3.2.4.7. Thuc kch thch to mu, truyn mu ............................................ 42 3.2.4.8.Thuc tc ng ln qu trnh ng mu v tiu fibrin .................... 43 3.2.4.9.Gim au....................................................................................... 44 3.2.4.10.Ri lon tm thn ........................................................................ 45 3.2.4.11.Dch truyn, vitamin h tr ......................................................... 45 3.2.4.12.Thuc khc .................................................................................. 46 3.2.5. S lng thuc (hot cht) s dng trn mi bnh nhn ............................... 47 3.2.6. Tc dng khng mong mun ........................................................................ 48 3.2.7. Tng tc thuc ........................................................................................... 48 3.2.7.1. Tng qut ....................................................................................... 48 3.2.7.2. Cc cp tng tc nghim trng ..................................................... 49 3.2.7.3. Cc cp tng tc thng gp ........................................................ 49 3.3. V s dng thuc trn bnh nhn mang thai.................................................... 50 Chng 4: Kt lun v xut ........................................................................... 51 Ti liu tham kho Ph lc 1: Mu phiu thu thp bnh n Ph lc 2: Danhschbnhnhn lupusban h thng chi chng thnh iu tr ti TTD- MDLS bnh vin Bch Mai Ph lc 3: Bng cc ch s xt nghim DANG MC T VIT TT ACEIangiotensine coverting enzym inhibitor ADNacid deoxyribo nucleic- phn t mang thng tin di truynANAantinuclear antibody - khng th khng nhn ARBangiotensine receptor blockers - chn th th angiotensine BCbch cu BNbnh nhn CCchng ch nh Ds-DNA antidouble stranded- DNA - khng th khng chui kp DNA GCglucocorticoid HATT huyt p tm thu HATTrhuyt p tm trng HChng cu HCQhydroxycloroquin - thuc khng st rt tng hp HCTHhi chng thn h KSRTHkhng st rt tng hp LNlupus nephritis - vim cu thn lupus PHMDphc hp min dch Pulsephng php s dngliu cao ng tnh mch ngn ngy r-metHuG -CSFrecombinant humangranulocyte colony stimulating factor- yu t kch thch sn sinh bch cu SLEsystemic lupus erythematosus - lupus ban h thng STTs th th THAtng huyt p TTtng tc TTD - MDLSTrung tm D ng - Min dch lm sng VKDTvim khp dng thp DANH MC BNG Bng 2.1Phn loi mc tng huyt p.....................16 Bng 2.2. Phn loi mc suy thn..17 Bng 2.3Phn loi mc thiu mu. 17 Bng 3.1Thi gian iu tr ni tr.. 20 Bng 3.2Biu hin lm sng v cn lm sng ca SLE.20 Bng 3.3Kt qu xt nghim b th 21 Bng 3.4c im v tr ph .. 19 Bng 3.5Protein niu lc nhp vin........................ 23 Bng 3.6T l gp hng cu v bch cu trong nc tiu.23 Bng 3.7Protein mu v albumin mu lc nhp vin ..24 Bng 3.8T l gp ri lon cholesterol v triglycerid24 Bng 3.9Phn loi bnh nhn theo mc tng huyt p.. 25 Bng 3.10Phn loi bnh nhn theo mc suy thn...... 25 Bng 3.11Phn loi bnh nhn theo mc thiu mu 26 Bng 3.12Mc liu s dng Glucocorticoid29 Bng 3.13T l s ln s dng liu pulse.30 Bng 3.14Mc liu pulse Glucocorticoid31 Bng 3.15Bit dc c s dng cho liu pulse..32 Bng 3.16T l s ln s dng liu pulse trong 1 thng..33 Bng 3.17Mc liu pulse cyclophosphamid..33 Bng 3.18Mc liu cloroquin..34 Bng 3.19T l s dng cc nhm thuc h huyt p... 35 Bng 3.20S phi hp thuc li tiu trn bnh nhn... 36 Bng 3.21T l s dng cc thuc li tiu 37 Bng 3.19T l s dng cc nhm thuc h m mu 37 Bng 3.23Cc thuc nhm tiu ha s dng trn bnh nhn38 Bng 3.24Liu lng albumin mi ln truyn.39 Bng 3.25T l s dng cc loi bit dc albumin. 40 Bng 3.26T l s dng cc nhm khng sinh. 41 Bng 3.27T l s dng cc thuc kch thch sn sinh hng cu............... 42 Bng 3.28T l s ln truyn v lng mu mi ln truyn .43 Bng 3.29Tlsdngccthuctcnglnqutrnhngmuvtiu fibrin.43 Bng 3.30T l s dng cc thuc gim au44 Bng 3.31T l s dng cc loi dch truyn v vitamin h tr45 Bng 3.32T l s dng cc nhm thuc khc. 46 Bng 3.33Cc tc dng khng mong mun gp phi47 Bng 3.34S tng tc tra cu c 48 Bng 3.35Cc cp tng tc nghim trng.. 49 Bng 3.36Cc cp tng tc thng gp. 50 DANH MC HNH Hnh 3.1T l gii tnh 18 Hnh 3.2Phn b tui bnh nhn 18 Hnh 3.3 S nm mc bnh SLE trc thi im nhp vin..19 Hnh 3.4T l bnh nhn s dng cc nhm thuc. 27 Hnh 3.5 T l s dng cc phc iu tr cn bn..28 Hnh 3.6S khng sinh s dng trong t iu tr. 41 Hnh 3.7 S lng thuc s dng trn mi bnh nhn 47 1 T VN Lupus c bit n u th k XIX nh l mt bnh ngoi da khng nguy him. Nm 1895-1904, Osler l ngi u tin m t nhng biu hin h thng ca bnhlupusban,vcBaehrmtlbnhlupusbanhthngvonm 1935[9].Minnm1948,yutmindchmicphthin,quanimv mtbnhtmindchmichnhthnh.Cngvisphthinrakhngth khng nhn nm 1957, Coons, Frion v y hc th gii khng nh lupus ban l mt bnh t min [6]. c trng ca bnh lupus l tn thng a h thng, vi s c mt ca khng th khng nhn v nhiu khng th khc. Trn lm sng, bnh biu hin tn thng nhiu c quan ni tng, vi nhng t tin trin xen k cc t lui bnh. T l bnh gp n gii cao hn hn so vi nam gii [6], v trn 80% l tui sinh [7]. Tnthngthntronglupusldocchlngngphchpmindch cu thn, cc mch mu. Vim thn lupus c biu hin lm sng gp 35-75% bnh nhnlupusbanhthng,trongbiuhinlmsnglhichngthnh chim 40-60% [9]. Nh vy, y l mt vn gp vi t l kh ln trn bnh nhn lupus ban h thng. Hichngthnhltinlngxucabnhnhnlupusbanhthng [7]. Gn 50% bnh nhn lupus ban h thng s tvong trongvng 10 nm nu xuthintriuchngcahichngthnhnh:proteinniucao,albuminmu gim[4]. V iu tr bnh lupus ban h thng c hi chng thn h, corticoid vn l thuc iu tr ch o. Phi hp cyclophosphamid nu bnh nhn khng p ng tt vi corticoid hoc nhm tng hiu qu iu tr. Ngoi ra phi s dng cc thuc h triutrccvnthnggpphibnhnhnHCTHnhph,thiumu, tng huyt p, h albumin mu, tng cholesterol mu, Tuy nhin, lupus ban h thng l mt bnh mn tnh, xen k gia cc t tin trin l thi k lui bnh, v iu tr cn gp rt nhiu kh khn, nht l vi bnh nhn lupus c hi chng thn h l tn thng nng, trong iu tr thng phi hp 2 rt nhiu loi thuc, hn na y thng l nhng bnhnhn c tin s lupus ban h thng nhiu nm, iu tr lu di, hoc b thuc gia chng hay t dng thuc, nn trong iu tr gp khng t kh khn. TheobococaTrungtmDng-MindchlmsngBnhvinBch Mai - tuyn cui trong iu tr cc bnh d ng - min dch ca nc ta, hng nm, s bnh nhn n Trung tm khm v iu tr lupus chim t l cao nht, ti 1/3 sbnhnhnvi400-500ltngiminm[35],trongcnhmbnhnhn tn thng thn biu hin thnh HCTH l tn thng nngv chim t l ngk. Do , gp phn tm hiu c im cng nh tnh trng s dng thuc trn bnh nhn lupus ban h thng c hi chng thn hang iu tr ti TTD- MDLS sng Bnh vin Bch Mai, chng ti tin hnh ti: Kho st tnh hnh s dng thuc trn bnh nhn lupus ban h thng c hi chng thn h ti Trung tm D ng- Min dch lm sng Bnh vin Bch Mai vi 2 mc tiu: 1. Kho st c im bnh nhn lupus ban h thng c hi chng thn h iutrnitrtiTTD-MDLSBnhvinBchMaitthng1/2012nthng 12/2012. 2. Kho st tnh hnh s dng thuc trn bnh nhn Lupus ban h thng c hi chng thn h iu tr ni tr ti TTD- MDLS Bnhvin Bch Mai t thng 1/2012 n thng 12/2012. T a ra nhng xut nhm gp phn nng cao tnh an ton, hiu qu trong iu tr lupus ban h thng c hi chng thn h. 3 Chng 1: TNG QUAN 1.1. Cc khi nim - nh ngha Lupus ban h thng (SLE) l bnh t min dch h thng vi tn thng vimmntnhtchclinkt,biuhinbngtnthngngoidalccban km theo cc tn thng ni tng (khp, thn, thnh mch) [7, 10, 21]. Bnh thn lupus (LN) l c tn thng thn th pht bnhnhnSLE,vi biuhinlproteinniu24hlnhn0,2g[2,4].Thnggptnthngcu thn, c hoc cha c biu hin tn thng thn trn lm sng. Hi chng thn h (HCTH) l mt hi chng lm sng v sinh ha, xut hin khi c tnthng cu thn do nhiu tnh trng bnh lkhc nhau, c trng bi ph, protein niu nhiu (>3,5g/ 24h), protein mu gim ( 0,5g/24h hoc tr t bo (+). 8.Rilonthnkinh:cogithocrilontmthn(loitrnguyn nhn khc). 9. Huyt hc: -Thiu mu tan mu hoc -Gim bch cu < 4.000/mm3 t nht 2 ln xt nghim hoc -Gim tiu cu < 100.000mm3 khng phi do thuc. 10. Min dch: -Khng th khng DNA (+) hoc 9 -Khng th khng Sm (+) hoc -Khng th khng phospholipid (+). 11. Khng th khng nhn: ANA (+). 1.5.2.Chn on HCTH [4, 9, 12] 1. Ph. 2. Protein niu > 3,5g/24h. 3. Protein mu gim di 60g/l, albumin mu gim di 30g/l. 4. Tng cholesterol mu 6,5mmol/l. 5. C ht m lng chit, tr m trong nc tiu. Trong tiu chun 2 v 3 l bt buc, cc tiu chun khc c th khng y . 1.6.Tng quan v iu tr lupus ban h thng c hi chng thn h 1.6.1.Nguyn tc iu tr SLE c HCTH [2, 4, 21, 29] - Phi nh gi c mc nng nh ca bnh, cc tn thng, bin chngkm theo c ch nh iu tr thch hp. -VtnthngthntrnbnhnhnSLE:nguyntciutrlkimsot c protein niu; bo v, phc hi v trnh tn thng thm chc nng thn (trnh c tnh trn thn), hn ch tin trin n suy thn mn tnh, sm pht hin v iu tr c hi chng khng phospholipid, kim sot c huyt p v cc nguy c tim mch, bo v xng v trnh ti a cc tc dng khng mong mun ca thuc. 1.6.2.iu tr SLE c HCTH Khng c hng dn iu tr c th cho nhm BN SLE c HCTH khi khng ckt qu sinh thit thn. Tuy nhin,v xploi iu tr, thSLE c HCTH l th tn thng ni tng nng,v l biu hinhi chng cu thn cp bnh nhn lupus. Hn na, theo ti liu c c, th tn thng thn tup 4,5 chim ti 97,4% bnh nhn HCTH c kt qu sinh thit thn [9, 16], nn v iu tr c th cn nhc nh sau: 1. Corticoid: prednisolon,prednison, methylprednisolon - C ch tc dng:10 Nh c ch lm gim s lngcc t bo lympho,cc t bo bchcu v gim s di chuyn ca chngvo vim,hn ch kh nngthc bo v gim tnghpcccht gy p ngvim nhprostaglandin, gim lnghistamingii phngbi ccbch cu a base ;hnnacnctcdngcchchcnngcacctbolympho vccithcbocam,do ,cc GCc tc dngchngvimliuthpv cch min dch liu cao,nhmcliumethylprednisolon20mg/ngyctc dng gim sn sinh khng th [3]. - Liu dng [2, 4, 12, 25]: Liu trung bnh: prednisolon,prednison hoc methylprednisolon khi u 0,5-2 mg/kg/ngyngunghoctimtruyn,khngqu80mg/ngy.Gimliudn dn khi triu chng thuyn gim, duy tr liu 5,0mmol/l)nhngvncchnhpulseGC.Tuyvy,iunyvncchp thun v GC khng c chng ch nh tuyt i [23]. Nn v tnh trng lm sng ca bnh nhn, bc s vn cn nhc v ch nh liu pulse nh vy.3.2.3.1.2. V s dng liu cao ng tnh mch ngn ngy (liu pulse): S ln s dng liu pulse trong t iu tr: Bng 3.13: T l s ln s dng liu pulse S BNT l (N=43) Liu pulse 1 ln4195,3% Liu pulse 2 ln24,7% Tng43100% Nhn xt:Trong t iutr ny, hu ht ch s dng liu pulse 1 ln trn bnh nhn, chim95,3%.Chc4,7%sdngliupulseGC2ln.yulnhngbnh 31 nhn c ph nhiu, ph tng dn trong qu trnh iu tr, c ph tr li sau khi dng liu pulse ln u. Mc ch s dng liu pulse ln th hai l kim tra li pngcabnhnhnviGC,khiliupulselnukhngthiuqumong mun, nhm c gng kim sot bnh v iu tr cho bnh nhn. Cc mc liu s dng: Bng 3.14: Mc liu pulse Glucocorticoid Liu s dng S lt BN Tng s lt truyn T l ng khuyn co 500mg-600mg/ngyX 3ngy 344575,6% 300mg/ngy X 3 ngy3456,7% Khng theo khuyn co 500mg/ngy X 4 ngy1452,2% 300mg X 4-5 ngy74515,6% Tng4545100% Nhn xt: C 82,2% s lt s dng liu pulse ng theo khuyn co v hng dn [2, 23,32].C17,8%ltsdngliupulsekhcvihngdn,mcthlthi gian cho t s dng liu pulse ko di hn, ti 4-5 ngy. Tuy nhin, iu ny cng cghinhntrongmtstiliuvsdngliupulse[19].Tuyvy,cl vnnncntrngnguycxyracctcdngphnghimtrngkhisdngGC vi liu cao v ko di ngy s dng nh vy. Nhnthymcliu300mgmilntruynsdngnhngbnhnhnc triuchnglmsngnhhn:khngphhocpht,chyunhpvindotriu chngkhi pht caSLE nh st, ban , nhcmikhp, pht hin HCTH thng qua xt nghimhay bnh nhn b suy thn nng, cn gim liu GC. Cc bit dc s dng: 32 Bng 3.15: Bit dc c s dng cho liu pulse Bit dcNc SXS lt BNT l (N=45) Solumedron 500mgPfizer - M2657,8% Solumedron 125mgPfizer - M36,7% Medisolu 125mg Hanall Pharmaceutical Hn Quc 920,0% Polono 125mgTW1 - Vit Nam715,6% Nhn xt: Trongtngs45bnhnhnsdngGCtruyntnhmchngnngy,c 64,5% s lt bnh nhn s dng Solumedron ca hng Pfizer - M, 20,0% s lt bnh nhn s dng Medisolu ca Hn Quc, v ch c 15,6% s bnh nhn s dng Polono ca dc phm TW1-Vit Nam. Ngoira,ngtimtnhmchchsdngbitdcSolu-Medrol40mg. DngvinungchsdngbitdcMedrol16mg.yulsnphmca Pfizer - M.GC l thuc s dng chnh cho SLE c HCTH, v c th thy, cc bit dc ca GC c dng nhiu nht u l sn phm ca hng Pfizer - M. 3.2.3.2. c ch min dchC35bnhnhnsdngccthucCMD.C2thucCMDcs dng l cyclophosphamid v azathioprin. C 35 bnh nhn u s dng cyclophosphamid, bit dc Endoxan vi liu pulse.Chc2bnhnhn(5,4%)csdngthmvinungcyclophosphamid (Endoxan)v1bnhnhn(2,9%)sdngvinungazathioprin(Imurel)saukhi s dng liu pulse cyclophosphamid. Azathioprin l thuc CMD c khuyn co s dng duy tr saukhi truyn CYC liu tn cng. iu nygip t hiu qu iu tr vi t tc dng ph [25, 27, 29]. V s dng cyclophosphamid: V s ln s dng liu pulse cyclophosphamid trong 1 thng : 33 Bng 3.16: T l s ln s dng liu pulse trong 1 thng S ln pulse/ thngS BNT l (N= 35) 1 ln/ thng3085,7% 2 ln/ thng514,3% Tng35100% Nhn xt: Vi liu pulse,c 85,7% bnh nhn c truyn 1 ln/thng. Ch c 5 bnh nhn (14,3%) c pulse Endoxan 2 ln/thng. y l cch s dng liu pulse CYC theo cc hng dn ca Chuu, c nghin cu l ph hpvi ngi da trng chuu[21,24].TiTTD-MDLStsdngphngthcny.Tuynhinla chnphcsphthucvotnhtrngvpngcabnhnhn.Nhnthy nhng bnh nhn s dng pulse Endoxan 2 ln thng c biu hin SLE rm r trn lm sng: ban mt, ton thn, aukhp, st, rng tc. C th ll dom bc s mun a liu thuc nhanh hn bng cch pulse 2 ln/thng.V mc liu s dng: Bng 3.17: Mc liu pulse cyclophosphamid Liu truyn 1 lnS lt truynT l (N=41) ng mc liu khuyn co 600mg2868,9% 800mg819,5% 500mg24,8% 1000mg12,4% Thp hn khuyn co 400mg37,3% Tng41100% Nhn xt: Mcliu600mg/ln/thnglphbinnht,chimti68,9%lttruyn. Tip theo l mc liu 800mg/ln/thng, chim 19,5%. C th y l nhng mc liu 34 ph hp vi bnh nhn Vit Nam, theo kinh nghim iu tr ca bc s, tc dng iu tr vi t c tnh nht. 92,7% lt truyn vi liu CYC cho 1 ln truyn ng nhkhuynco,chc3lttruyn(7,3%)viliuCYCthphnkhuynco. y l liu truyn mt ln nhng bnh nhn c pulse CYC ti 2 ln trong 1 thng. c im nhng bnh nhn ny l ang c t suy thn cp trn nn suy thn mn vbnhnhncthtrngkm(cicc,thiumu,suydinhdng).iunyc th c gii thchv CYC l thucgy c ch min dch c thi tr 100% qua nctiu.dotrongsdngcnthntrngvibnhnhnsuythnvnhng bnh nhn suy nhc c th [3, 30, 31]. 3.2.3.3. Khng st rt tng hp C 46 bnh nhn s dng KSRTH trong iu tr, chim 56,1%. Trong tt c u s dng vin ung Cloroquin 1 ln vo bui ti. T l ny thp hn so vi t lsdngCloroquinchobnhnhnSLEchungiutrtikhoa[1].Vcloroquin tc dng ch yu ln cc triu chng v da, khp,[25], m biu hin ny nhm bnh nhn chng ti khng nhiu. Tuy nhin nghin cu v HCQ cho thy thuc c lm chm tin trnh dn ti suy thn bnh nhn vim thn lupus [24]. c th l l do m cloroquin c cn nhc s dng trn nhm bnh nhn SLE c HCTH, d cthtriuchnglmsngvda,khpchanhiu.Thucttcdngph,tuy nhin dng lu di c gy c tnh trn vng mc Mc liu dng c th nh sau: Bng 3.18: Mc liu cloroquinLiu dngS BNT l (N=46) Cloroquin 250mg1839,1% Cloroquin 500mg2860,9% Tng46100% Nhn xt:Cloroquin c s dng trongSLE mc hm lng150-300mg hot cht cloroquin (ngvi 250-500mg cloroquin phosphat) cho tikhi triu chng thuyn gim th duy tr mc liu 150mg [36]. Nghin cu cho thy trn nhm bnh nhn c 35 60,9% s dng hm lng 500mg cloroquin phosphat. 39,1% cn li s dng hm lng 250mg.3.2.4. Cc nhm thuc khc 3.2.4.1. H p Bng 3.19: T l s dng cc nhm thuc h huyt p Nhn xt:Trong s 75 bnh nhn c s dng thuc h p, nhm thuc chn th th AT1vnhmchnknhCanxicsdngnhiunhtvitlul69,3%. Thuccdngnhiunhlosartan(Cozaar),nifedipine(NifedipinT20).Nhm cchmenchuyncngcsdngnhiu,chim49,3%,bitdcchyul Renitex. Cc thuc nhm chn th th AT1 v nhm c ch men chuyn, ngoi tc dng h HA cn c tc dng gim protein niu, do c khuyn co s dng cho bnh nhn. cng l l do thuc c ch nh cho hu ht bnh nhn, trong khi chc24bnhnhn(29,2%)cTHA.SovinhmcchmenchuynACEI, Nhm thucS BN T l (N= 75) Hot cht chnhHot cht khc Nhm chn th th AT1 5269,3% losartan (Cozaar) (63,5%) telmisartan (Micardis), valsartan (Diovan, Co-diovan), losartan (Hyzaar) Nhm chn knh canxi 5269,3% nifedipin (Nifedipin T20, Nifehexal, Adalat) (65,4%) amlodipin (Amlor) Nhm c ch men chuyn 3749,3% enalapril (Renitex ) (89,2%) lisinopril (Zestril, Zestoretric) Nhm gin mch trc tip 68% Glycerin nitrat (Nitralmyl)(83,3%) Nitroglycerol Nhm kch thch alpha 2 GC 45,3% Alpha methyldopa (Dopegyd) (100%) 36 nhm chn th th AT1 hiu qu tng ng m khng gy ho nn c s dng nhiu hn.Nhm chn knh Canxi l nhm thuc h p an ton, hiu qu, li it c tnh trnthnnnclachnnhiu[18].Ccnhmthucginmchtrctiphay nhnkchthchalpha2giaocmcngcthcphihpthmhHA. NifedipindngvinAdalatnhdili-nhmchnknhCanxilthuchp thng dng trong cc cn THA cp tnh do tc dng nhanh v trnh b chuyn ha qua gan [3]. 3.2.4.2. Li tiu V s phi hp thuc li tiu: Bng 3.20: S phi hp thuc li tiu trn bnh nhn Phi hp hot chtS BNT l (N= 68) furosemid6597,0% spironolacton23,0% furosemid + spironolacton11,5% Tng 68100% Nhn xt: Trongs68bnhnhnsdngccthuclitiu,cti66bnhnhn (97,0%)chsdngthuclitiufurosemid,2bnhnhn(3,0%)sdng spironolacton n c v 1 bnh nhn (1,5%) phi hp c hai thuc li tiu.Furosemid l thuc li tiu quai mnh, mc ch s dng furosemid gim ph,phihpiutrTHAbnhnhncTHAhocgiphKalimubnh nhn c Kali mu cao hockt hp tt c cc mc ch trn [3, 30, 31]. C khi s dngtimcliu400mg/ngynhmhKalimu.Spironolactonctcdngli tiu yu hn, c s dng n c bnh nhn c ph nh hoc khng ph (vo vinvcogit),haysdngphihpnhmtrnhhKalimuqumcbnh nhn ph nhiu phi dng furosemid liu cao. V s dng cc loi thuc li tiu: 37 Bng 3.21: T l s dng cc thuc li tiu Hot cht ng dng S BN Tng s BN T l (N= 68) Bit dc furosemid Tim196633,3%Tim: Vinzix(83,3%), Furosemid (Mekophar, Traphaco) (10,4%) Ung: Furosemid-c(43,5%), Furosemid-VnhPhc (32,6%), Furosol (26,1%) Ung236634,8% Tim+ ung 216631,8% spirono lacton Ung33100% Verospiron(66,7%), Alacton Nhn xt:Furosemid c s dng c dng ung v dng tim tnh mch. T l ch s dng dng ung, ch s dng dng tim hay kt hp c hai trong qu trnh iu tr lxpxnhau.BitdcchnhsdnglVinzix(dngung)hayFuresemidc (dngtim).CthnhnthymtsbitdccaVitNamnhFurosemidca Traphaco, Mekophar hay Vnh Phc.3.2.4.3.H m mu Bng 3.19: T l s dng cc nhm thuc h m mu Nhm thuc S BN T l (N= 50) Hot cht chnh Hot cht khc statin4896% simvastatin (66%) (Zocor, Simvahexal) rosuvastatin (Crestor), Atovastatin (Lipitor) fibrat36% fenofibrat (100%)(Lipanthyl) 38 Nhn xt:Trongnhmnghincuc50bnhnhnsdngccthuchmmu, trong 48 bnh nhn s dng statin, chim ti 96%. Ch c 3 bnh nhn (6%) s dng fibrat do ch tng triglycerid mu. Ch c duy nht 1 bnh nhn c s dng phi hp statin v fibrat, chim 2%. Cn lu tc dng ph ln c vn bnh nhn ny,dosphihpcnglmtngthmnguyc[29].Hotchtchnhcs dng l simvastatin vi bit dc l Zorcor, Simvalhexal. Trongiutrtnglipidmu,statinllachnttnht.Hnnacbng chng ghi nhn tc dng ca statin trn bnh nhn thn lupus gip lm gim bin c tim mch v h tr thm iu tr bnh thn. Nn la chn statin gip h m mu bnh nhn SLE c HCTH [29]. 3.2.4.4.Nhm thuc tiu ha Cc nhm thuc tiu ha s dng trn bnh nhn nh sau: Bng 3.23: Cc thuc nhm tiu ha s dng trn bnh nhn NhmS BNT lHot cht chnhHot cht khc c ch bm proton 5870,7% omeprazol(Omez, Helizol, Lomazol) (100%) pantoprazol (Pantoloc), esomeprazol (Nexium) Khng H223,4% ranitidin (Zantac) (100%)- D dy khc813,8% nhm sulfat(Gastropulgit) (75%) ribapimid (Muscota) Chng nn4048,8% metoclopramid(Primperan) (82,5%) haloperidol, doperidol (Moprel, Molium M10) Chng co tht 56,1% hyoscine- N - butylbromid (Buscopan) (100%)- 39 Nhn xt:Khuynconnsdngccthucdphngnhmbovddykhis dngGChayccNSAIDs,dthuccthlmgimhpthuccnguyntnh St,CalcihayvitaminB12cdngkmhtrchobnhnhn[24].Trong nghin cu ca chng ti c 70,7% bnh nhn phi s dng nhm thuc iu tr d dy, t trng. Trong , 100% bnhnhn sdngthuc c ch proton, c 2 bnh nhn c phi hp thmnhmkhngH2vi hot cht ranitidin (Zantac)v 13,8 % bnh nhn s dng thm cc thuc h trnh Gastropulgit, Muscota. Hot cht chnhtrongnhmcchbmprotonlomeprazol,vibitdcchnhlOmez, Helizol,ngoiracththayihocsdngthmcchotchtkhcnh esomeprazol (Nexium), patoprazol (Pantoloc). V c ch tc dng, nhm thucc ch bm proton gim tit acid trit hn, nn hiu qu s tt hn nhm khng H2. Cc hot cht chnh u c trong danh mc ca Dc th Quc gia Vit Nam [3]. C48,8%bnhnhncsdngthucchngnn,chyulmetoclopramid(Primperan),doADRthnggpcaCYClbunnnvnn. Primperan c th dng dng ung hoc tim. Primperan thng c ch nh ngay khitruynEndoxannhmdphngADRcathuc,vsdngsaugii quyt ADR khi thc t c xy ra trn bnh nhn. C 6,1% bnh nhn s dng cc thuc chng co tht Buscopan. 3.2.4.5.Truyn AlbuminC71bnhnhn(chim86,6%)ctruynalbuminvi78lttruyn khcnhaudomtsbnhnhncthayithtch,hmlnghaybitdcs dng. C th c c cc kt qu sau: Liu lng mi ln truyn: Bng 3.24: Liu lng albumin mi ln truyn Liu lngS lt truynT l (N= 78) 20%,50ml4658,0% 25%, 50 ml2633,3% 20%, 100ml67,7% Tng78100% 40 Bit dc s dng: Bng 3.25: T l s dng cc lai bit dc albumin Bit dcNc SX S lt truyn T l(N=78) Human albumin 20%n 2734,6% Albuminar 25%M2633,3% Human albumin Octapharma 20%Australia1316,7% Human albumin Berhing 20%c1114,1% Human albumin Biotes 20%c 11,3% Tng 78100% Nhn xt:Albumin c s dng nhm b li protein thot ra ngoi qua nc tiu bnh nhn SLE c km HCTH. T l bnh nhn s dng albumin l 86,6%, cao hn nhiusoviccbnhnhniutrHCTHtikhoaThntitniuBnhvinNhi trungng(42,8%)[14].Lngalbuminbvotrongmilntruynchyu mc 10-11g/ln truyn (20% - 25%, vi th tch truyn l 50ml), chim ti 91,3%. Chc7,3%lttruynbalbuminvilnglnti20g/lntruyn.yl nhngbnhnhnchalbuminmunhiu(chsalbuminmu:18,8g/l),bnh nhn sau phu thut nh ch thai nghn Human albumin 20% can vAlbuminar 25% ca M l 2 bit dc c s dng nhiu nht, chim ti 67,9% vi t l xp x nhau. Ngoi ra, ti Trung tm cn s dng sn phm albumin ca Australia v c vi t l thp hn. 3.2.4.6.Khng sinh C 52 bnh nhn s dngkhng sinh trong qu trnh iu tr. Kt qukho st c th nh sau: V s khng sinh s dng trn mt bnh nhn: 41 Hnh 3.6: S khng sinh s dng trong t iu tr Nhn xt: 78,8%bnhnhnsdng1loikhngsinhtrongiutr.21,2%bnhnhn cnliphidngti2-5loikhngsinhvimcchphihpkhngsinh,i khng sinh hay kt hp c hai mi iu tr dt im bin chng nhim trng. Cc nhm khng sinh s dng: Bng 3.26: T l s dng cc nhm khng sinh H khng sinh T l (N= 52) Hot chtMt s bit dc Bata lactam92,3% cephalosporin III (51%) cephalosporin IV (25,5%) cephalosporin II (17,6%) penicilin phi hp (5,9%) Fortum, Spokid, Dixapim, Supercep Alaxim, Zinnat Augmentine 625 Quinolon 19,2% levofloxaxin (46,2%) ciprofloxacin (38.5%) nofloxacin (7.6%) moxifloxacin (7.6%) Tavanic, Grepiflox Ciprobay Nofloxacin Avelox Macrolid v licosamid 15,4% clarithromycin (75%) azithromycin (12,5%) clindamycin (12,5%) Cleron, Remeclar Zithromax Dalacin Betalactam khc7,7% imipenem (75%) meropenem(25%) Tienam, Siaraci Ronem tetracyclin3,9%doxycyclin Medaxon, Doxycyclin Dit k sinh trng1,9%MetronidazolMetronidazol Khng nm1,9%flucoralFluconazol Nhn xt: NhmkhngsinhcsdngnhiunhtlB-lactam,chimti92,3%, trongchyusdngcccephalosporinthh3,4viccbitdcnh 42 Fortum,Spokid, Dixapim. Quinolon l nhmkhng sinh s dng nhiu th 2. Mt sB-lactamqucngcsdngnhimipenem(Tienam)haymeropenem (Ronem).Nhnthyccnhimkhunthnggptrongmunghinculvim phi mc phi bnh vin. y l loi nhim khun kh iu tr do nguy c khng khngsinhcao.Hnna,bnhnhnSLEthngcgimbchcu,sdnglu diGChayangsdngCYCgysuygimhmindch.Do,vicsms dng cc khng sinh ph rng, th h mi c th l la chn hp l khi m phn ln cc trng hp s dng khng sinh m khng c xt nghim khng sinh .Mt t l nh s dng cc thuc dit k sinh trng hay thuc khng nm nh metronidazol, flucoral. 3.2.4.7.Thuc kch thch to mu, truyn mu C17bnhnhnsdngthuckchthchtomu,trongcti16bnh nhn(94,1%)sdngerythropoietintithpnhmgipsnsinhHC,2bnh nhn (11,8%) c phi hp thm r-metHuG-CSF nhm gip sn sinh BC v ch 1 bnhnhn(5,9%)sdngyutsnsinhBCnc.yulnhngbnh nhn c gim BC nhiu, xung ti 2000 t bo/ mm3. V hm lng v bit dc s dng c th nh sau:Bng 3.27: T l s dng cc thuc kch thch sn sinh hng cu Hot chtHm lngBit dc erythropoietinti t hp 2000 UI (57,9%) Epokin (63,6%), Ior epocim (27,3%), Epocim (10%) 4000 UI (47,4%) Epokin (55,6%), Erypotin (45,4%) r-metHuG-CSF300mcgLeukokin (100%) Nhn xt:V s dng erythropoietin, hm lng 2000UI c dng nhiu hn, chim 57,9%, hm lng 4000UI c dng t hn, chim 47,4%. Bit dc dng nhiu lEpokin(63,6%)hayIorepocim(27,3%).Dngdngultimdida. 43 Erythropoietin khng c tc dng khi ung. Tim di da gip thuc gii phng t t, t hiu qu iu tr tt hn [3, 30, 31]. C14bnhnhncchnhtruynmu,vitlslttruyntrnmi bnh nhn trong c t iu tr v th tch mi ln truyn c th hin trong bng sau: Bng 3.28: T l s ln truyn v lng mu mi ln truyn Tiu chPhn loiS BNT l S ln truyn Truyn mu 1 ln857,1% Truyn mu 2 ln525,7% Truyn mu 3 ln17,2% Lng mu truyn mi ln Ti 350ml1990.5% Ti 250ml29,5% Nhn xt: C 14 bnh nhn c ch nh truyn mu. Ch yu bnh nhn c truyn mu 1 ln vi th tch truyn l 350ml. Nhng cng c nhng bnh nhn huyt sc tgimnhiu,truynmu1lnchacithinccchscnlmsngnh hemoglobin, t bo hng cu, nn phi truyn mu nhiu ln. Bnh nhn lun c theo di v tc truyn, mch, thn nhit, HA, trong qu trnh truyn mu. 3.2.4.8.Thuc tc dng ln qu trnh ng mu v tiu fibrin Bng 3.29: T l s dng cc thuc chng ng v chng kt tp tiu cu Nhm thuc T l (N=25) Hot chtT lBit dc Chng ng 14 (56%) heparin phn t lng thp 14 (100%) Fraxiparin Lovenox coumarol1 (7%)Sintrom Chngkt tptiu cu 12 (48%) acid salycilic12 (100%) Aspegic, Aspirin cilostazol1 (8,3%)Pletaal Tiu fibrin 1 (4%) acidtranexamic1(100%) Tranexamic acid 44 Nhn xt:Trong s 82 bnh nhn trong nhm nghin cu, ch c 25 bnh nhn s dng cc thuc tc ng ln qu trnh ng mu v tiu fibrin. Trong , 56% bnh nhn s dng cc thuc chng ng, 48% bnh nhn s dng cc thuc chng kt tp tiu cu v ch 4 % bnh nhn s dng thuc tiu fibrin.100%cc thuc chng ng s dng u l cc heparin phn t lng thp (Fraxiparin,Lovenox),ch1bnhnhncphihpthmcoumarol(Sintrom). Nhm chngkt tp tiu cu cng c s dng nhacid salicilic (Aspegic) hoc phi hp thm cilostazol (Pletaal).Nhmphngtrnhnguychuytkhitnhmch,thucchngkttptiu cu khuyn co s dng nhm i tng bnh nhn dng tnh vi khng th khng phospholipid.Cnnubiuhinhichngkhngphospholipidtrnlmsng, cn phi s dng thuc chng ng [21, 28, 29]. Hn na, bnh nhn HCH vi lipid mucaocnglmtngnguychuytkhi.ycnglldochnhnhm thuc chng kt tp tiu cu, chng ng v tiu fibrin cho bnh nhn [3, 30, 31].3.2.4.9.Gim au, h st Bng 3.30: T l s dng cc thuc gim au Hot chtS BNT l(N=19)Bit dc paracetamol1368,4% Paracetamol500,Efferalgan codein piroxicam27,2%Felden 20mg etoricoxib414,4% Etotab 60mg, E Arecoxia 60, 90mg morphin13,6%Morphin 10mg

Nhn xt:Sbnhnhnsdnggimaukhngnhiu,ch19bnhnhnchim 23,2%.Thucgimaucsdnggimaukhpvauu.Trong paracetamol c s dng nhiu nht v an ton trn thn. Etoricoxib v piroxicam 45 ccnnhcsdnggimauchobnhnhn[2].Sovipiroxicamth etoricoxibtnhhngtiddydotcdngchnlctrnCOX2.Ch1bnh nhn s dng morphin gip gim au v an thn cho bnh nhn. Sau s dng bnh nhn ht kch thch.3.2.4.10.Thuc iu tr ri lon tm thn C 14 bnh nhn s dng thuc iu tr ri lon tm thn, trong : - C 11 bnh nhn s dng thuc an thn: do ri lon tm thn, mt ng, co git: Seduxen (diazepam) - C 3 bnh nhn s dng thuc iu tr tm thn phn lit, chng ng kinh: Zoloft (setraline),.. Nhn xt:Ri lon tm thn c th l do din bin ca bnh hoc l tc dung ph ca GC.ylnguynnhngytvongth3bnhnhnSLE.Chyusdng thuc an thn cho bnh nhn. iu ny l hp l theo hng dn [21]. 3.2.4.11.Dch truyn h tr v cc vitamin Bng 3.31: T l s dng cc loi dch truyn v vitamin h tr Nhm thucS BN T l (N=82) Hot chtBit dc Gii c3947,6% Ccglutathion,ion amoni,ccacid amin phn nhnh Thioxen,Vietmax, Philorpa,Pomulin, Reamberin, Morihepamin Tng to mu2732,9% StIInguynt, acidfolic,VTM B12 TardyferolB9, Ferrovit B sung canxi1518,3% Canxinguynt, calcitriol, calcitonin Canxiumsandoz, Dongdocalio, Rolcalcic 100UI B sung vitamin, khong, dinh dng 1518,3% Ccacidamin,cc vitamin nhm B PMKiddiecal, Nephorosteril, Ketosteril, Epinosin 46 Nhn xt: C 47,6% bnh nhn s dng cc glutathion, cc ion gip gii c t ra khi c th, cn bng acid-base mu v gip li tiu nh Thioxen, Vietmax, C 32,9% bnhnhnsdngStnguynt,aicdfolic, VTMB12nhmhtrqutrnhto mu.Canxicngcbsungcho18,3%sbnhnhn.Tuynhin,trnthct, cc thuc iu tr h tr phi s dng nhiu ngy. Vic s dng thi gian ngn trn bnh nhn iu tr ni tr nh l mt liu php h tr, tm l gip tun th iu tr v nng cao hiu qu iu tr. 3.2.4.12.Thuc khc Bng 3.32: T l s dng cc nhm thuc khc Nhm thucS BN T l (N= 82) Hot chtBit dc Khng virus3643,9% acridonacetic acid,dimethyl- biphenyl- dicarboxylat, lamivudin, Newferon, Incycferon,RB 25, Zeffic H K mu1113,4%KClKali clorua Tim mch78,5% digoxin, dobutamin, diosmin Digoxin, Dobutamin, Daflon H hp33,7% salbutamol,formoterol, codein Ventolin, Symbicort, Terpincodein Khc78,5% caobchqu, hormon, Taikana, Oxyctocin, Nhn xt:Ngoi cc biu hin chnh ca bnh SLE v HCTH, mt s bnh nhn cn b ccbnhmckm,ccbinchnghaytcdngphcathuc,nhlsuygim min dch nn d nhim cc loi virus,hay ri lon Kali mu do s dng cc thuc li tiu v GC,. Do cn s dng thm cc thuc khc. C 43,9% bnh nhn s 47 dngthuckhngvirus,13,4%bnhnhnphisdngKalicloruaiutrh Kali mu, 3.2.5.S lng thuc (hot cht) s dng trn mi bnh nhn Kho st v tng s thuc (hot cht) s dng trn bnh nhn, nhn thy: Hnh 3.7: S lng thuc s dng trn mi bnh nhn Nhn xt:S hot cht s dng trn bnh nhn kh ln, c 68,3% bnh nhn s dng t 10-15loihotchttrongiutr.Cbitcbnhnhnsdngti27loihot cht. Nhn thy s hot cht s dng trn bnh nhn SLE c HCTH cao hn hn so vishotchtsdngtrnbnhnhnSLEchungtikhoa[1].iunycng khng nh thm tnh cht phc tp v dai dng ca bnh. 3.2.6. Tc dng khng mong mun Bng 3.33: Cc tc dng khng mong mun gp phi ADRS BNT l (N= 82) Vim lot d dy- t trng2429,3% H Kali mu1926,8% Tng Kali mu56,1% Nn, bun nn1012,2% Mt ng44,9% Ho khan22,4% 22.40%68.30%17.10%2.40%< 10 thuc10-15 thuc15-20 thuc> 20 thuc48 Nhn xt:Bnh nhn thng gp tc dng ph nh vim lot d dy - t trng (29,3%) dosdngGCliucao.Hnna,bnhnhnvnctinsSLE,trongiutr thng s dng GC v cc NSAIDs, do c th c tin s vim lot d dy - t trng. Tc dng ph khc nh h Kali mu (26,8%) do s dng cc thuc ACEI, nn - bun nn (12,2%) do CYC,. 3.2.7. Tng tc thuc 3.2.7.1. Tng qut Bng 3.34: S tng tc tra cu c Tiu chCh s S bnh n c tng tc54 Tng s tng tc163 S tng tc nhiu nht/ 1 bnh n11 S tng tc t nht/ 1 bnh n0 Nhn xt: Cti65,9%bnhncthxuthintngtcthuc-thuc,vitngs tng tc c th gp l 163 tng tc. Nhiu nht c th gp 11 tng tc trong mt bnh n. 3.2.7.2. Cc tng tc nghim trng: chng ch nh-nghim trng: Theo phn loi ca Micromedex, tng tc chng ch nh l tng tc cm phi hp s dng ng thi, do nguy c rt cao cho bnh nhn. Tng tc nghim trng l nhng tng tc c th e da tnh mng bnh nhn v/hoc phi c nhng can thip nhm ngn nga gim thiu tc hi nghim trng .Stngtcgpphitythucvohotchtsdng.nh aspirin,.quinolon,c1cptngtcchngchnhlsimvastatin- clarithromycin, gp trong 1 bnh n. C 4 cp tng tc nghim trngvimc bng chng c tin cy cao, xut hin trong 31 bnh n. y l nhng tng tc 49 cnguyccaogyvim,tiucvn;haynguyckodikhongQThocthay i nng K+ mu. C th nh sau Bng 3.35: Cc cp tng tc nghim trng STTCp tng tc S TT Mc ti liu Mc TT Nguy c 1 simva- statin clarithromycin1ttCC Tngnguyc gp cc bnhv choctiuc vn 2 simva-statin, rosuva-statin ciprofloxacin, azithromycin, fluconazol, amlodipin 9tt Nghim trng 3cloroquin clarithromycin azithromycin moxiloxacin haloperidon 14cha r Nghim trng Kodikhong QT 4enalapril spironolacton KCl 6tt Nghim trng Lmthayi nngK+ mu 5enalapril lovasartan telmisartan 3tin cy Nghim trng TngccADR canh:tt HA,tngK+ mu, suy thn 3.2.7.3. Cc tng tc thng gp Methylprednisolonv furosemid l ccthucbnh nhn s dng nhiu. Tra cu cho thy methylprednisolon to ra 5 cp vi 26 lt tng tc. Furosemid to ra 3cpvi30lttngtc.TheophnloicaMicromedex,yulnhng tng tc mc trung bnh - l mc c th khin tnh trng bnh nng thm hoc dn n mt vi thay i trong iu tr. Do methylprednisolon v furosemid l nhng thuc chnh c s dng nhiu cho BN SLE c HCTH, do trong k n cnlucnnhckhisdngccthuciutrphihpnhenalapril,khng sinh nhm quinolon hay cc NSAIDs Cc cp tng tc c th nh sau: 50 Bng 3.36: Cc cp tng tc thng gp STTCp tng tc S TT Mc Mc ti liu Nguy c 1 methylprednisolon floro quinolon 11TBtin cy Tngnguyctiuc vn 2 methylprednisolon clarithromycin 3TBttTng c tnh ca GC 3 methylprednisolon aspirin10TBtt Tngnguyclnh tiu ha 4 methylprednisolon dicoumarol1TBttTng nguy c chy mu 5 methylprednisolon hydrocloro thiazid 1TBcha r NguyctngK+mu v lon nhp tim 6furosemidenalarpil20TBtt NguycttHAliu u 7furosemidNSAIDs9TBtt Gim tc dng h p v li tiu 8furosemiddigoxin1TBtt Tngctnhca digoxin (bun nn, nn, lon nhp tim..) 3.2.8V s dng thuc trn bnh nhn mang thai C3bnhnhnmangthai.Sthucsdngtrnbnhnhnt:ch5-6 thuc.KhngsdngliupulseGC,chsdngGCliu40-80mg/ngy.Khng sdngCYCvccstatinvnguycgyquithai[3,31].Khngthysdng cloroquin v d c ghi nhn l c hiu qu an ton v i vi ph n c thai [23], tuy nhin vn c vi ghi nhn thuc c gy qui thai [3]. Thuc h p s dng t, l mtsartanhocmethyldopa,yulnhngthucantonhnchobnhnhn mang thai nh ti liu ghi nhn. Ngoi ra bnh nhn c s dng cc thuc h tr nh albumin, calci, B9 v acid folic. Khng thy tng tc xut hin trn tra cu. 51 Chng 4: KT LUN V XUT 4.1. c im bnh nhn - Bnhnhnlngiichim91,5%,gpnhiunhtlatui20-29tui (43,9%) v la tui t 30-39 tui (19%). Nhm bnh nhn pht hin SLE t 1-5 nm chim t l nhiu nht: 39%. - Thi gian iu tr ca bnh nhn thng t 10-20 ngy (54,9%). - Mt s triu chng lm sng gp phi trn bnh nhn: ph: 85,4%, trong ph chichimnhiunht:65,9%;ban:35,4%;st:20,7%;mt:18,3%;aukhp: 18,3%. - C25,6%bnhnhncdchtdotrongbng,19%bnhnhnctrndch mng tim v 17,1% bnh nhn trn dch mng phi. - C88,1%bnhnhndngtnhvikhngthkhngnhnANAv69,5% bnh nhn dng tnh vi khng th khng Ds-DNA. - C 81,4% gim b th C3 v 52,9% gim b th C4. - C84,1%bnhnhncproteinniulnhn5g/24h.C94,7%sbnhnhn xut hin HC trong nc tiu v 61,3% s bnh nhn xut hin bch cu trong nc tiu. - Protein mu trung bnh: 50,17,1g/l. albumin mu trung bnh: 20,94,5g/l. - C88,0%bnhnhntngcholesterolmu;93,2%bnhnhntngtriglycerid mu. - C 29,2% bnh nhn c THA, trong ch yu l giai on 1 (25,6%). - C27,2%bnhnhnbsuythnccmc1,2v3a.Suythnmc2 gp nhiu nht: 18,5%. - C 84,8% bnh nhn thiu mu, vi t l thiu mu nh l 54,4%, thiu mu va l 30,4%. Khng c bnh nhn thiu mu nng. 4.2. Tnh hnh s dng thuc trn bnh nhn 4.2.1. V cc nhm thuc Glucocorticoid: 52 - 100% bnh nhn s dng GC trong iu tr. Hot cht l methylprednisolon. - C52,4%bnhnhncsdngmcliupulse250-1000mg/ngy;46,3% bnhnhnsdngliutncngtimtnhmchchn40-80mg/ngyvch1,3% bnh nhn s dng mc liu thp 16mg/ ngy, dng ung. -95,3%bnhnhnsdngliupulse1lntrongtiutr.Mcliupulse thngcchnhl500-600mg/ln/ngy,lintctrong3ngy(75,6%).C 17,8% bnh nhn s dng liu pulse di ngy hn so vi khuyn co. Bit dc s dng nhiu nht l Solumedron ca Pfizer - M (57,8%). Thuc c ch min dch: 42,7% bnh nhn s dng thuc c ch min dch, trong 100% bnh nhn s dng liu pulse CYC. Ch5,4% bnh nhn s dngthmvin ung CYCv 2,9% bnhnhnsdngthmvinungazathioprin(Imurel).85,7%bnhnhnc pulseliu1ln/thng.Liutruynmilnthngl600mg/ln,chim68,9%s lt truyn. C 7,3% lt truyn liu Endoxan 400mg/ ln. Thuc khng st rt tng hp: 100%bnhnhnsdngcloroquin.Mcliu500mg/ngylnhiunht, chim 60,9%. Cc nhm thuc khc: - C 91,5% bnh nhn s dng cc thuc h p. C 69,3% bnh nhn s dng cc thuchpnhmchnththAT1;69,3%bnhnhnsdngnhmchnknh Canxi; 49,3% s dng nhm c ch men chuyn. - C82,3%bnhnhnsdngccthuclitiu,tronghuhtsdng furosemid n c (97,1%). - C61%bnhnhnsdngccthucgiphmmu,trongs96%s dng cc statin. - C 70,7% bnh nhn s dng cc thuc chng lot d dy - t trng. C 48,8% bnh nhn s dng cc thuc chng nn d phng v iu tr ADR khi s dng CYC liu cao. 53 - C 86.6% bnh nhn c s dng albumin, ch yu l hm lng 20%, 50 ml cho mi ln truyn (58%). Bit dc dng nhiu hn c l Human albumin ca n (38,3%) v Albuminar ca M (36,6%). - C 63,4% bnh nhn s dng cc khng sinh, trong hu ht ch s dng mt loikhngsinh(78,8%).Nhmbetalactamsdngnhiunht(92,3%),trong chyulnhmcephalosphorinthh3(51%skhngsinhtrongnhm betalactam). - C 23,2% bnh nhn s dng cc thuckchthch to hng cu erythorpoietin v 17,1% bnh nhn c ch nh truyn mu. - C30,5%bnhnhnsdngccthuctcdnglnqutrnhngmuvtiu fibrin;23,2% bnh nhn s dng cc thuc gim au v 14,6% bnh nhn s dng cc thuc iu tr ri lon tm thn. - C47,6%bnhnhnsdngccdchtruynhtrvccvitaminv36,6% bnh nhn s dng cc thuc khc . 4.2.2.Tc dng khng mong mun Gp nhiu nht l vim lot d dy - t trng (29,3%), h Kali mu (28%) 4.2.3.S thuc s dng trn bnh nhn S thuc s dng trn bnh nhn ch yu t 10 - 15 thuc, chim 68,3%. Mt s bnh nhn s dng di 10 thuc (24,4%), t 15 - 20 thuc (17,1%). Rt t bnh nhn s dng trn 20 thuc (2,4%). 4.2.4.Tng tc Tra cu thy c 54 bnh n c xut hin tng tc vi 163 tng tc. C mt stngtcnghimtrngnhsimvastatin-clarithromycindonguycgytiu c vn, hay cloroquin - clarithromycin c nguy c lm ko di khong QTMt s cp tng tc thng gp l furosemid - enalapril (20 tng tc), methylprednisolon -cc floroquinolon (11 tng tc), 54 XUT 1. Lu mt s tng tc nghim trng, tng tc hay gp phi v theo di s xut hin ca tng tc trn lm sng t c nhng quyt nh s dng thuc tt nht.2. Coi trng ch n cho bnh nhn c thgpphn trong iu tr bnh. Cn giodcbnhnhnthcmbochnnhiuproteinvhnchmui. TI LIU THAM KHO Ting Vit: 1.Nguyn Th MaiAnh (2008), Kho st tnh hnh s dng thuc iu tr bnh Lupus ban h thng ti Khoa Min dch - d ng lm sng Bnh vin Bch Mai, Lun vn tt nghip dc s, i hc Dc H Ni. 2.TS.NguynQucAnh,PGS.TS.NgQuChu(2011),Hngdnchn on v iu tr Bnh ni khoa, B Y T, Nh xut bn Y hc, H Ni. 3.B Y T (2009), Dc th quc gia Vit Nam, Nh xut bn Y hc, H Ni. 4. PGS. TS Ng Qu Chu (2012) Bnh hc ni khoa, Nh xut bn Y hc, H Ni. 5.NguynCngChin,PhanQuangon(2007),"iutrlupusbanh thngbngmethylprednisolonliucaotruyntnhmchngnngykthp prednisolon ng ung", Y hc lm sng, 21, pp. 56-60. 6.PGS.TS. PhanQuang on (2009), "Lupus ban h thng (SLE)", Dng- min dch lm sng, B Y T, Nh xut bn Gio dc Vit Nam, pp. 174-186. 7.PGS.TS.LnhDoanh(2010),"Tmindchvccbnhtmindch", Bnh hc i cng, B Y T, Nh xut bn Gio dc, pp. 343-350, H Ni. 8.Quch Th H Giang (2008), Nghin cu c im lm sng v cn lm sng bnh lupus ban h thng c hi chng thn h, Kha lun tt nghip bc s a khoa, i hc Y H Ni. 9.PGS. TS. H Hong Kim (2010), Thn hc lm sng, Nh xut bn Y hc pp. 392-410, 336-343. 10.L Th Luyn (2010), Bnh hc, Nh xut bn Y hc, pp. 188-192, 36-40. 11.RichardJ. Glassock Barry M. Brenner - Dng Trng Ngha,"Hi chng thn h",CcnguynlyhcnikhoaHarison(2000),NhxutbnYhc.pp. 625-637, H Ni. 12.GS.VS.PhmSong,QunhPGS.NguynHuQunh(2008),"Thnh", Bch khoa th bnh hc, Nh xut bn Gio dc, 1, pp. 268 - 272, H Ni. 13.GS.VS. Phm Song - PGS. TS. Nguyn Hu Qunh (2008), "Bnh Luput ", Bch khoa th bnh hc, Nh xut bn gio dc, 3, pp. 35-39. 14.NguynTunThnh(2011),Khostsdngthucvnhgitnhhpl cavicdngcorticoidtrongiutrhichngthnhtinphttikhoa thntitniubnhvinNhitrungng,KhalunttnghipDcsi hc, i hc Dc H Ni. 15.PhmHuyThng(2004),Nghincuchnonsmvktquiutr LupusbanhthngtikhoaDng-mindchlmsngbnhvinBch Mai, Lun vn thc s Y hc, i hc Y H Ni. 16.NguynThPhngThy(2002),Sosnhcimlmsng,sinhhcm bnh hc ca hi chng thn h nguyn pht v hi chng thn h do Lupus ban h thng ca ngitrng thnh, Lun vn tt nghip bc s ni tr bnh vin, i hc Y H Ni. 17.TierneyMcPhee,Papadakis(2008),Chnonviutryhchini, Nh xut bn Y hc, 2, pp. 235, 1193-1200. 18.PGS.TS.MaiTtT,TS.VThTrm(2007),"Thuciutrtnghuyt p", Dc l hc, B Y T, Nh xut bn Y hc, 2, pp. 66-67. Ting Anh: 19.F.Buttgereit,JAPdaSilva,MBoers,"Standardisednomenclaturefor glucocorticoiddosagesandglucocorticoidtreatmentregimens:current questions and tentative answers in rheumatology",(2002), Ann Rheum Dis, 61, 718-722. 20.M.A.Chisholm-Burns,BarbaraG.Wells,etal.,Pharmacotherapy Principles & Practice. (2008), p. 9 - 33, 373-403, Mc-Graw-Hill, M. 21.J.Claude bennett M.D., Fred plum, M.D, Cecil textbook ofmedicine, Saunder Esevier, pp. 1153, 1475-1483. 22.J.T.Dipiro,RobertL.Talbert,etal.,PharmacotherapyAPathophysiologic Approach, 7th, p. 723-744, Mc-Graw-Hill, M. 23.S. Dolff, J. HM Berden, M. Bil (2010), "Treatment of lupus nephritis", Expert Rev. Clin. Immunol, 6(6), pp. 901-911. 24.G.K.McEvoy,Pharm.D,etal(2011)AHFSDrugInformationEssentinal, American Society of Health-System Pharmacists, M. 25.Dr.Fauci,Dr.Longo,etal.,"SystemicLupusErythematosus",Harrison's Principles of Internal Medicine, 17th, McGraw-Hill, M. 26.A.Gatta,A.Verardo,M.Bolognesi(2012),"Hypoalbuminemia",Intern Emerg Med, 7, pp. S193-S199. 27.B.H.Hahn,MaureenA.McMahon,etal.(2012),"AmericanCollegeof Rheumatolog Guidelines for Screening, Treatment, and Management of Lupus Nephritis", Arthritis Care & Research, 64, no 6, pp. 797-808. 28.M.Y.Karim,DavidPD'Cruz(2010),"Practicalmanagementoflupus nephritisinpregnancyandthepuerperium",ExpertRev.Clin.pharmacol, 3(6), pp. 777-784. 29.S.Masood,D.JayneandY.Karim(2009),"Beyondimmunosuppression- challenges in the clinical management of lupus nephritis", Lupus, 18, pp. 106-115. 30.G.R.-I.G.Espinosa,M.A.Frutos,Diagnosisandtreatmentoflupus nephritis, 2012, Spanish Nephrology Society, p. 7. 31.Press.Pharmaceutical,Martindale36:TheCompleteDrugReference(2009), 36th, M. 32.Rahman(2001),"Drugtreatmentofsystemiclupuserythematosus",Hospital Pharmacist, 8, pp. 69-73. 33.Rheumatism&Arthritis(1999),Guidelinesforreferralandmanagementof systemiclupuserythematosusinadults,LippincottRavenPublishers,42(9), pp. 1783-1794. 34.Royal Hospital for Sick ChildrenYorkhill Division, (2007), Guideline for the Management of Nephrotic Syndrome, NHS.Bo in t: 35.http://www.vnexpress.net/Vietnam/Suc-khoe/2005/th by, 17/12/2005. 36. http://www.dieutri.vn/kk/30-9-2011/s1433/Kenacort-retard.htm. Ph lc 1: MU PHIU THU THP BNH N 1.Thng tin bnh nhn: H s s:H v tn:Tui: Gii: Ngy nhp vinngy ra vin Thi gian iu tr:..ngy Tiu s: S nm iu tr SLE: . Thuc ang s dng:.. 2.Thm khm lm sng: Triu chng:C Ph : -Chi -Mt -M mt . Ban St Mtau c, khp 3. Cn lm sng: STTThng sMc , ch s 1Huyt p0123 2HGB0NhVa Nng 3Protein mu (g/l) 4Albumin mu (g/l) 5Cholesterolmu (mmol/l)0tnggim 6Triglycerid mu (mmol/l)0tnggim 8Creatinin (umol/l) 12Protein niu (g/24h) 13Bch cu niuDng tnhm tnh 14Hng cu niuDng tnhm tnh 15ANADng tnhm tnh 16Ds DNADng tnhm tnh 17C30tnggim 18C40tnggim 19V nc tiu (ml) 20Siu m, ni soi:Trn dch mng tim Trn dch mng phi Dch t do bng 3.ADR gp phi: STT Triu chng CSTTTriu chng C 1au d dy6Ho khan 2Nhim khun7Tng huyt p 3Nn, bun nn8Tng K+ mu 4Mt ng9H K+ mu 5Ri lon tm thn 4. Thuc s dng: 1.Glucocorticoid: a.Pulse:CKhng Bit dc...liu s dng:. b.Tim liu cao Solu - medrol 40-80mg/ ngy c.Ung Medrol 16mg/ ngy 2.Endoxan: CKhng Bit dc...liu s dng: 3.Cloroquin: C Khng Bit dc...liu s dng: 4.Nhm h p: (bit dc) 1.. 2. 3. 4. 5 5.Nhm li tiu: Bit dcng dng ( ung/ tim) 1....U/T 2. .U/ T 3.U/ T 6.Nhm bo v d dy, chng nn: (Bit dc) 1.. 2.. 3... . 7.Nhm h m mu: (Bit dc): 1. 2 3 8.Nhm khng sinh: (Bit dc) 1. 2. 3.. 9.Nhm sn sinh hng cu: (bit dc) 1.. 2.. 3.. 9.Truyn mu: S ln truyn:.lng V mu s dng: . 10. Nhm chng ng: (bit dc) 1 2 3 11. Truyn albumin: Loi albumin s dng.s ngy truyn:. . 12. Cc dch truyn: (bit dc) 1.. 2. 3. 13. Cc vitamin h tr: (bit dc) 1. 2. 3... 4.nh gi :ko t vongxin v 5.Tra tng tc: S TTcp tng tcmc ti liunguy c 1 2 3 4 5 6 Ph lc 2: DANH SCH BNH NHN LUPUS BAN H THNG C HI CHNG THN H IU TR TI TTD-MDLS BNH VIN BCH MAI NM 2012 STTH tnM BANgy vo vinNgy ra vin 1Trn Th H103328/9/201219/10/2012 2Nguyn Th H94110/4/201223/4/2012 3L Th Vn A93218/9/201227/9/2012 4V Th Thu H19496/11/201212/11/2012 5L Th Phng A93121/9/20124/10/2012 6Phong Phet Sour S93012/9/201223/9/2012 7Bi Th Thanh H120016/12/201230/12/2012 8 Th T7601/8/201220/8/2012 9Nguyn Th Phi Y7475/9/201226/9/2012 10Phm Th C79212/6/201229/6/2012 11ng Th 78111/7/201231/7/2012 12 Th H78029/8/201211/9/2012 13Nguyn Ngc L6585/6/20129/7/2012 14Nguyn Th Ng105418/9/201216/10/2012 15Nguyn Th Thanh Nh77029/6/20124/7/2012 16Trn Th Th5586/6/201229/6/2012 17Nguyn Th L5693/4/201218/4/2012 18Tng Th D58528/8/201211/9/2012 19Trnh Th M5902/7/201231/7/2012 20V Th H5999/8/201217/8/2012 21Hong Th H6245/7/201223/7/2012 19Phm Th D70111/6/201229/6/2012 23Bin Th H71019/8/201231/8/2012 24 Th Hng T7263/8/201214/8/2012 25Lng Th H83817/7/201217/8/2012 26Trnh Th 9152/10/201212/10/2012 27Nguyn Th Bch L108714/12/201228/12/2012 28H Th H111623/11/201228/12/2012 29on Th H116321/11/201210/12/2012 30Nghim Th Nh29015/5/201215/6/2012 31Quch Th Huy H928/2/201213/1/2012 32Lm Ngc T417/1/201216/1/2012 33Trn Th Thy Ng6717/1/20121/2/2012 34V Th Mai H1033/1/201218/1/2012 35L Thy L11217/2/20121/3/2012 36inh Th Thu H12013/3/201228/3/2012 37Trnh Thu H1325/3/201212/3/2012 38Bi Vn H1442/2/20126/3/2012 39Phm Th H1541/3/20128/3/2012 40Nguyn Minh H1619/2/201227/2/2012 41Nguyn Th Nhung16920/2/201213/3/2012 42Hong Th L17029/1/201215/2/2012 43Nguyn Th L19231/1/201215/2/2012 44Nng Th M19430/1/20127/2/2012 45Phm Th S20912/3/201227/3/2012 46Trn Th N21814/3/201226/3/2012 47Nguyn Th D21931/1/201216/2/2012 48V Th S28019/2/20121/3/2012 49Nguyn Th Q19310/5/201212/5/2012 50Phm Th Ph23617/2/201227/2/2012 51L Th H24017/4/201227/4/2012 52V Th Lc N24429/12/201110/1/2012 53ng Th H2462/2/20126/2/2012 54Phm Th Thanh Th25314/5/201228/5/2012 55Trn Thanh H2738/5/201218/5/2012 56Phm Th Th31610/5/201225/5/2012 57Phm Th G31920/3/201229/3/2012 58ng Vn H35520/3/201211/4/2012 59V Th S3576/3/20125/4/2012 60Bi Th H35828/3/201224/4/2012 61Nguyn Th H36110/5/201219/5/2012 62Nguyn Th Nh36828/2/201214/3/2012 63Ging Seo Ph3693/4/201226/4/2012 64Nguyn Th L38426/12/201111/1/2012 65L Th Thu H4003/1/201213/1/2012 66Trn Th Q40121/3/201226/4/2012 67Nguyn Thanh Ph44225/6/201226/7/2012 68Trng nh Ng4767/6/201215/6/2012 69Trn Th B49015/5/20121/6/2012 70Phm Th Ngc Ch73629/6/201213/7/2012 71L Huy T75319/8/201228/8/2012 72Phm Th Giang Th84327/6/201219/7/2012 73Nguyn Thu H11196/11/201225/12/2012 74Phm Th Ngc H11771/11/201223/11/2012 75Nguyn Th Diu Th205223/10/201226/11/2012 76Khng Th Q7712/7/201213/7/2012 77Nguyn Th Thanh H8022/7/201218/7/2012 78Nguyn Th V311/12/20115/1/2012 79Nguyn Th H49119/5/201214/6/2012 80Phng Th Diu N50029/3/20126/4/2012 81Nguyn Th Tuyt Nh50919/2/201212/3/2012 82Nguyn Th T51327/8/20126/9/2012 Ph lc 3:BNG CC CH S XT NGHIM Yu cu XNCh sCSBT NamCSBT Nn v Huyt hc RBC4,3 - 5,83,9 - 5,4T/l HGB140 - 160125 - 145g/l Sinh ha Protein ton phn 66 - 8766 - 87g/l Albumin34 - 4834 - 48g/l Cholesterol ton phn 3,9 - 5,23,9 - 5,2mmol/l Triglycerid0,46 - 1,880,46 - 1,88mmol/l Creatinin Ngi ln: 62 - 106 Ngi ln: 44 - 80 umol/l Tr em: 15 - 77Tr em: 15 - 77umol/l in gii Natri133 - 147133 - 147mmol/l Kali3,4 - 4,53,4 - 4,5mmol/l Min dch C390 - 18090 - 180mg/dl C410,0 - 40,010,0 - 40,0mg/dl Ferritin30 - 40013 - 150ng/ml Tng phn tch nc tiu LEUm tnhm tnhcells/ ul PROm tnhm tnhg/l ERYm tnhm tnhcells/ ul Nc tiu 24h nh lng protein g Xt nghim khng nguyn - khng th ANA - SCreen m tnh: < 0,7 Nghi ng: 0,7 - 1,0 Dng tnh: > 1,0 OD ( mt quang) Ds - DNA m tnh: < 40 Nghi ng: 40 - 50 Dng tnh: >50 IU/ml