Bệnh nội khoa - Hướng dẫn chẩn đoán và điều trị: Phần 2

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Nối tiếp nội dung phần 1 tài liệu Hướng dẫn chẩn đoán và điều trị bệnh nội khoa, phần 2 giới thiệu các kiến thức chuẩn đoán và điều trị các bệnh nội tiết - Đái tháo đường, tiêu hóa, thận - Tiết niệu, cơ xương khớp, truyền nhiễm,... Mời các bạn cùng tham khảo.

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Nội dung Text: Bệnh nội khoa - Hướng dẫn chẩn đoán và điều trị: Phần 2

BENH SARCOID I. O Al C U O N G Benh sarcoid la benh cua to c h u c lien ket, d u a c dac tru n g b a i s u hinh thanh u hat d u g c tao b a i rat nhieu te bao viem va nhieu te bao lien quan, xuat hi£n a bat ki vj tri nao cua c a the. S u xam nhiem te bao co the thoai lui tu phat hay tien trien thanh seo. S u ket h a p cua viem , seo va doi khi de doa cuqc song. II. chAn ooAn 1. C h in d o an xac djnh a. Trieu ch u ’n g la m s a n g - B£nh sarcoid co th e gay ton th u a n g a bat c u c a quan nao cua c a th e bieu hien d u a i dang cap, ban cap hay m an tinh. - D u a n g th a tren: kho th a , sung huyet m ui, polyp, noi khan. - Phoi: kho th a , ho, th a rit, co the co ho m au. - Da: not, m ang. - M at: giam thj lu c , s a anh sang, dau, phi dai tuyen le. - K hap: dau k h a p , co th e co benh II ca. - Than kinh: liet th a n kinh so, dau dau, diec, dong kinh, vie m m ang nao, benh tieu nao, ton th u a n g choan cho noi so. - Tim: ngat, kho th a , roi loan dan truye n, nhjp nhanh, suy tim sung huyet. - Tieu hoa: kho nuot, dau bung, vang da. - Mau: phi dai hach, lach (giam tieu cau, bach cau, hong cau). - Than: suy than, ca lci hoa. - N
406 H irflN G oAn c h An bo An v A o i £ u t r i b En h N oi kh o a III. O l£U TRI. K hoang 30 - 50% cac benh nhan co benh sarcoid tu- th o a i lui tro n g vo n g 3 n£m . K hoang 30% benh tiep tu c tien trien tro n g 5 - 1 0 nam va 20 - 30% on dinh tron g kh o a n g th o i gian nay. Hau n h i/ khdng cd tu vong tron g vai nam dau va ti le tu vong thap vao n h u n g nam sau do. 1. C o rtico id a. C h i djnh Khi co bang c h u n g cua s u suy giam nghiem tron g c h u c nang nhu : - Phoi: benh nhan co m ot tron g cac dau hieu sau + C o ho, kho th a hoa c ho m au. + Roi loan c h u c nang ho hap: T LC < 90% ; FV C < 65% ; D L co < 80% . + X q uang: ton th u o n g phoi m o ke, x a phoi, d u a n g kin h nhanh d u d i d on g m ach phoi phai > 16mm. + Sieu am tim : ap lu c dong m ach phoi trun g b inh khi n g h i > 2 5 m m H g . C hi dinh dieu tri cho n h u n g tru d n g h a p co giai doan benh theo X q uang phoi n h u n g khdng trieu chimg. + G iai doan 0 va giai doan I: khdn g can dieu tri. + G iai doan II: th e o ddi 6 thang. C hi dinh dieu tri khi cd cac dau hieu bien doi lam sang, chuc n§ng hd hap hoa c X q u a n g phoi, sieu am tim neu tren. + G iai doan III va giai doan IV: dieu trj corticoid. N h u n g ton th u a n g ngo ai phoi: dieu trj co rtico id cho n h u n g tru d n g h a p cd to n th u a n g ngoai phoi khi: + Sot, m et nhieu, dau x u a n g kh d p , ton th u a n g gay bien doi nhieu tre n da. + S uy than, tang m en gan hoa c suy gan. + T an g calci m au. + M at: vie m m ang bo dao, giam thj luc. + T ha n kinh: liet th a n kinh so, dau dau, diec, dong kinh, vie m m ang nao, b en h tieu nao. + Tim : ngat, kh o th a , roi loan dan truye n, nhip nhanh, vie m c a tim , suy tim sung huyet. b. C ach d u n g c o rtic o id C o rtico ste ro id : bat dau v d i 30 - 6 0 m g /n g a y b in g d u d n g uong. Sau dd g ia m dan td i lieu thap nhat co hieu qua va duy tri tron g 6 - 1 2 thang. + 4 - 6 tuan dau: dung lieu 30-60m g/ngay. + C d dap u n g : giam dan m oi 10m g/ 4-8 tuan, cho td i lieu th a p n h a t (kh o a n g 10-25m g/ngay). + T rong qua trin h g ia m dan lieu dieu trj, neu xu a t hien cac trie u c h u n g : ho, nang ngu c, kho tha (a khoa ng 60% so benh nhan): tang lieu them 10-20m g tron g 2-4 tu a n de g ia m trie u c h u n g , sau dd lai tien hanh giam dan lieu. N h u n g tru d n g h a p co ton th u a n g tim , than kinh hoa c d u d n g hd hap tren: k h d i lieu corticoid 80- 100m g/ngay. D ung lien tu c cho den khi benh d u a c kiem soat (th u d n g kh o a n g 12 tuan), sau dd giam dan lieu tu a n g tu n h u tren. 2. D i§u trj th a y th § co rtic o id a. C h i din h K hdng d a p u n g v d i die u trj corticoid. K hdng d un g nap co rtico id , cd bien c h u n g xu a t hien khi d un g co rtico id . K hdng giam d u a c lieu corticoid. b. C ac th u o c D ung m ot tron g ca c th u o c sau, dung d a n th u a n h oa c ket h a p v d i lieu th a p corticoid.
H u C j n g d A n c h A n d o A n v a o i £u t r i b E n h N 6 i k h o a 407 • M e th o tre xa t + D u ng d u a n g uong ho # c tiem bSp. + K h a i lieu v a i 7 ,5 m g /tu a n . Tang m oi 2 ,5m g/2 tuan cho den khi dat lieu 10-15m g/tu an. D anh gia hieu qua sau 4 -6 thang. C an th e o doi chat che AST, ALT, cong th u c m au. S inh th ie t gan cho nhu’ng benh nhan dung keo dai qua 18-24 thang hoa c qua 1g m e th o tre xa t (m a c du khong thay b ln g chu’ng ton thu’a n g gan). • C yclo p h o sp h a m id + U ong, nga y 1 lan. + K h a i lieu: 2 5 -5 0 m g /n g a y. T an g dan lieu m oi 2 5m g/2 tuan cho den khi dat hieu qua kiem soat benh (khong v u a t qua 1 5 0 m g /n g a y). Lam cong th u c m au 2 lan/tuan, m uc tieu duy tri so lu’a n g bach cau: 4-7 giga/lit. + T h a i gian dieu tri: th u ’a n g keo dai > 6 thang. + Lu’u y: uong nhieu nu’a c (> 2 ,5 lit/n g a y) va th e o doi dai m au (xet ngh iem nu’a c tieu hang thang). • A za th io p rin + Uong, ngay 1 lan. + K h a i lieu: 2 5m g/ngay, tang dan m di 25m g/2-3 tuan, cho ta i khi dat lieu 100 -15 0m g /n gay. C hu y duy tri so lu’a n g bach cau m au > 4 g ig a /lit. + T h a i gian dieu trj > 6 thang. + T a c dung phu: non, buon non, giam te b£o m au (can phan biet v a i ta c dung i>c che tuy trong benh sacoit), tang e n zym gan. • C ac th u o c dieu trj kh a c co th e dung nhu : ch lo ra m b u cil, n h u n g ch a t u c che te bao T /cyto kin n h u cylosporin va p e n to xifyllin , va cac th u o c chon g sot ret n h u ch lo ro q u in va hyd ro ch lo ro q u in . IV. TIEN LU’Q’NG Benh co tien lu a n g xau a n h u n g tru a n g hap: - Co trieu c h u n g ton th u a n g a nhieu c a quan. - Kho th a : la trie u c h u n g tien lu a n g xau (suy giam c h u c nang phoi th u a n g khon g hoi phuc). - N h u n g ton th u a n g da, x u a n g , k h a p dac biet khi xu a t hien a n h u n g n g u a i > 30 tuoi. - T o n th u a n g th a m nh ie m phoi tien trien. t A i l ie u t h a m k h A o 1. D avid R. M o lle r (2008), “ S yste m ic sarcoidosis", F is h m a n ’s P u lm o n a ry D ise a se and D isorders (4th ed), M cG ra w -H ill, 1 1 2 5 -1 1 4 3 . 2. G ib s o n G J, P re s c o tt RJ, M u ers MF, M id d le to n W G , M itc h e ll D N , C o n n o lly C K , et al (1996), “B ritish T h o ra cic S o c ie ty S a rco id o sis study: e ffe cts o f lo n g te rm c o rtic o s te ro id tre a tm e n t”, T horax; 5 1 (3 ):2 3 8 -4 7 . 3. H u n n in g h a k e G W (1997), “G o a l o f the tre a tm e n t fo r sa rco id o sis. M in im iz e h a rm fo r the patie nt", A m J R e s p ir C rit C a re M ed; 156(5): 1369-70. 4. W o n d e r D rak e, L ee S. N e w m an (2010), “S a rc o id o s is ", M u rra y and N a d e l's T extbook o f R e sp ira to ry M e d ic in e (5th ed), S a u n d e rs Elsevier.
Chtfofng 6 NOI TIET - OAl THAO Ol/CfNG BENH VIEN BACH MAI
OAl THAO OlfCfNG I. DAI CU’CTNG 1. D jn h nghTa D ai th a o d u a n g (D T D ) la tin h tra n g tang du’O’ng huye t m an tin h dac tru n g b o i n h u n g roi loan chuyen hoa ca rb o h yd ra t, co kem th e o roi loan chuye n hoa lipid va protein do giam tu y e t doi hoac tu a n g doi tac dung sinh hpc cua in sulin v a /h o a c tie t insulin. 2. P h an loai - D a i th a o d u a n g typ 1: do b en h tu m ien djch: cac te bao P tu ye n tu y bi pha huy b a i chat trun g gian m ien djch, s u p h a huy nay co th e nhanh hoa c cham . T ien trie n n h a n h gap a n g u a i tre < 30 tuoi, trieu chipng la m s a n g ram rp k h a t nhieu, uong nhieu, sut can, m e t m oi. X u a t hien cac tu khan g the kh6n g d a o tu y (IC A : isle t c e ll a u to a n tib o d ie s ), tu khan g th e khan g in su lin va t u kh a n g th e khan g G A D (g lu cta m ic acid d e c a rb o x y la s e ) tro n g 85 - 90% tru a n g h a p . B ien c h u n g cap tin h hay g§p la hon m e nhiem to a n ce to n . D ie u trj b i t b u p c phai d ieu trj bang in sulin, ti le g a p < 10% . T he tien trie n cham hay g£p a n g u a i la n , g o i la d a i th a o d u a n g tu m ien djch tie m ta n g a n g u a i la n (LA D A : la te n t a u to im m u n e dia b e te s in a d u lts). - D ai th a o d u a n g typ 2: dai th a o d u a n g typ 2 tru a c day d u a c goi la dai th a o d u a n g khong phu th u o c insulin, dai th a o d u a n g a n g u a i la n, benh co tin h gia dinh. D a c tru n g cua dai th a o d u a n g typ 2 la khang insulin di kem v a i th ie u hut in sulin tu a n g doi. Tuoi > 30 tuoi, trieu c h u n g lam sang am tham , th u a n g phat hien m uon. Bien c h u n g ca p tin h hay gap la hon m e tang ap lu c th a m thau. C o the dieu trj b in g che do an, th u o c uong v a /h o a c insulin. T i le gap 90 - 95% . - D ai th a o d u a n g thai ki: dai th a o d u a n g thai ki la tin h tra n g roi loan dung nap d u a n g huyet xay ra trong th a i ki m ang thai. - C ac tin h tra n g ta n g d u a n g h u ye t dac biet khac: giam c h u c nang te bao beta do khiem kh u ye t gen: M O D Y 1, M O D Y 2, M O D Y 3, dai th a o d u a n g ti lap the, giam hoa t tin h in sulin do khiem khuye t gen. Benh li tu ye n tuy: vie m tuy, xa , soi tuy, ung th u tuy,... M ot so benh noi tiet: to cac vie n cu c, hoi c h u n g C u sh in g ,... do th u o c, hoa chat, do nhiem khuan. II. chAn o o An XA C DjNH • T h e o tieu c h u a n ch a n d oa n cua To c h u c Y te T he g ia i nam 1998 (xem bang 1). - D u a n g h u ye t (g lu c o s e m au - G M ) luc doi £ 1 ,26g/l = 7 ,0 m m o l/l (it n h a t 2 lan). - G M lam bat ki th a i d ie m n£o £ 2g/l = 11 m m ol/l co kem th e o cac trieu c h u n g lam sang hoac G M sau 2 g ia lam n g h ie m p ha p ta n g d u a n g huye t £ 11,1m m ol/l. N eu 1,1 g/l < G M < 1,26g/l: can lam ngh iem phap dung nap g lu co se de chan doan xac dinh.
412 H i/O n g d A n c h A n o o A n vA o i£ u t r i bEnh NOi khoa B a n g 1. C h an d o a n d ai thao dw & ng h o a c ro i lo a n d u n g n a p g lu c o s e theo dip&ng h u y e t m ao m a c h h o a c tin h m a c h Mao mach Tinh mach Ket luan (mmol/L) (mmolA) Goi 2:6,1 2 7,0 OTO Sau 2 gid 2 11,1 2 11,1 Roi loan dung nap Odi < 6 ,1 < 7 ,0 glucose Sau 2 gid 2 7,8 2 7,8 III. XET NGHIEM CAN LAM SANG CAN LA m D£ THEO DOI D l£ ll TRj - D u a n g huyet: luc doi, sau an 2 gia. - H bA1c: lan dau phat hien va clp m oi 3 thang/1 lan. - Sinh hoa m au: cre a tin m au, cholesterol, tryglice rid, H D L-C , LD L-C (luc m a i chan doan vd sau m6i 3 thang). - T ong phan tic h n u a c tieu lam th u a n g quy. M icro a lb u m in nieu (sau 2 5 nam doi v a i dai thao (Jirtmg typ 1 va ngay tai th a i diem chan doan doi v a i dai th a o d u a n g typ 2). - D ien tam do: lan dau pha t hien va m oi 6 thang. - Sieu am D o p p le r m ach canh, m ach chan: luc m a i chan doan, khi nghi n g a co ton th u a n g . - C hup tim phoi: luc m a i chan doan va khi nghi n g a co ton th u a n g phoi. - K ham m it: luc m a i chan doan va sau m oi nam . Khi co ton th u a n g m it : m oi 3 - 6 thang. IV. 0 l£ u TRI. 1. M uc tieu dieu trj M uc tieu kiem soat d u a n g huyet theo A D A , 2010. - H b A 1c < 7% d u a c coi la m uc tieu chun g cho ca dai th a o d u a n g typ 1 va typ 2. - G lu co se m au (G M ) luc doi nen duy tri a m u c 3,9 - 7 ,2 m m o l/l (70 - 13 0 m g /d l). - G M sau an 2 g ia < 10m m ol/l (< 180m g/dl). - D ie u tri cac yeu to nguy c a di kem : tang huyet ap (TH A ), roi loan lipid m au (tham khao phan dieu tn bien c h u n g m an tin h cua benh nhan dai thao d u a n g ). 2. P h ac dd dieu trj tan g d u a n g hu y§t a. C h e do an - T h u c hien che dp an h a p li, can doi cac thanh phan: g lucid 50- 60% , protid 15 - 20% , lipid 20 - 30% tong so calo tron g ngay, nen chon loai th u c pham co ch i so tang d u a n g hu ye t (G I) thap, nhieu chat xa (rau 100 - 200g/bu'a), kieng do ngot. D ai th a o d u a n g typ 2 an 3 bCra c h in h (sang, tru a . toi), Benh nhfin dang tiem insulin co the chia th a n h 4 - 5 b u a phong ha d u a n g huyet. b. H o a t d o n g th e lire - Toi th ie u la 30 phut/ngay, 5 nga y/tuan , lu u y kiem tra d u a n g huye t, HA, tin h tran g tim m ach trucrc tap. C ac loai h inh luyen tap di bo, b a i loi, cau long, leo cau th a n g deu d u p e . N h u n g chpn loai nao pha phu h o p v a i tin h h inh slpc khoe va bien c h u n g va benh di kem cua tipng n g u a i benh (lu u y khi 14mmoM < d u a n g huye t doi < 5 m m o l/l khon g luyen tap). C an tham kh a o th e m y kie n cu a cac thay thuoc cfiuy^*1 khoa ve hinh th u c luyen tap va cach theo doi d u a n g huyet tru a c va sau tap.
H u o n g d An c h An o o An v A d i £ u tri b £n h N oi kho a 413 c. D ie u t r i b a n g in s u lin • P h a c d o d ieu trj b ln g insulin C h i dinh: - La b i t bu 0 c v o i dai th a o d u o n g typ 1, dai th a o d u o n g thai ki. - D a i th a o d u o n g typ 2 khi co: + M at bu do stress, nh ie m trung, vet th u o n g cap, tang d u o n g hu ye t v o i tang ceton m au cap nang. M at can khon g kie m soat d u g c . + C an th ie p n go ai khoa. + C o thai. + S uy gan, than. + Di u n g v d i ca c th u o c vie n ha d u d n g huyet. + T ha t bai v d i th u o c vie n ha d u d n g huyet. + C h i d in h ta m th d i n g a y khi cd d u d n g h u y e t ta n g c a o > 2 5 0 - 3 0 0 m g /d l (14 - 1 6 ,5 m m o l/l), H b A 1 c > 11% . - D ai th a o d u d n g cd hdn m e toan ceton hoac tang ap lu c th a m th lu . - D ai th a o d u d n g do b en h li tuy: vie m tuy m an, sau phau th u a t c i t tuy... - T rong m pt so tru d n g h g p nhu cau insulin cua benh nhan tang cao: d ieu tri m ot so th u o c gay tSng d u d n g huye t (co rtico id ). Lie u tiem in sulin: - Lieu Insulin can th ie t d n h u n g benh nhan dai th a o d u d n g typ 1 t u 0,5 - 1 ,0U I/kg can nang. Lieu kh d i dau th u d n g tu 0,4 - 0 ,5 U I/kg /n g a y. Lieu thong th u d n g 0,6U I/kg, tiem d u d i da 1 - 2 lan tron g ngay. Sau dd can c u tren ket q u a d u d n g h u ye t tang hoac giam lieu insulin tu 1 - 2U I/lan . - Lieu insulin d benh nhan dai th a o d u d n g typ 2: b i t dau tu 0,2U I/kg/ngay. T h u d n g 0,3 - 0,6U I/kg/ngay. - Lieu insulin nen 0,1 - 0,2U I/kg . - Vi tri tie m Insulin (xem phu luc s o do vj tri tiem insulin). C ac p h a c do d ie u tri: - Cd nhieu ph £ c do d ieu tri in sulin khac nhau. D oi v d i dai th a o d u d n g typ 1 th u d n g s ir dung phac do 2 den 4 m ui 1 ngay. D o i v d i dai th a o d u d n g typ 2 ngoai pha c do n h u dai th a o d u d n g typ 1 cd the s u dung them ph a c do 1 m ui in su lin phoi h g p v d i th u o c vie n (In su la ta rd hoa c lantus). - D 6i th a o d u d n g th a i ki th u d n g s u d un g pha c do 1 - 4 m u i/n g a y tuy th e o nong d
414 H l/ d N G d A n c h A n o o A n vA o iC u t r i b £ n h NOi khoa B a n g 2. C ac lo a i in s u lin th eo thori g ia n tac d u n g Loai insulin Bat flau tac dung Tac dung tdi da (gid) Tac dung keo dai (gio) (gid) Apart (NovoLog) 1 0 - 20ph 1 3 -4 Lispro (Humalog) Regular 0 ,5 -1 2 -4 6 -8 NPH 1 ,5 - 3 4 -1 0 1 2 -2 2 Lente 2 -4 7 -1 2 1 6 -2 2 Mixtard (NPH/Regular) 0 ,5 -1 4 -1 0 1 0 -1 6 (70/30,80/20,40/60) Ultralente 4 -8 Phu thuoc lieu 1 8 -3 0 Glargin (Lantus) 1 -2 Khong 24 d. D ie u tri b a n g th u o c u o n g C o cac nhom th u o c sau: • N hom th u o c kich th ic h tuy bai tie t insulin (su lp h o n ylu re a ) C ac lo a i su lp h o n ylu re a : gliclazid (D ia m icron M R 30m g, D ia m icro n 80m g, P re d ia n 80m g. Glimepind (A m aryl 2 -4 m g ). G lib e n cla m id (G lib e n h e xa l 3,5m g). G lib urid (1 ,2 5 /2 ,5 /5 m g ). G lip izid (G lucotro l 5/10mg). - C h i d i n h : dai th a o d u ’O’n g typ 2 the trang trung b inh hoac gay. P hoi h g p v o i m e tfo rm in , thiazolidinedion (TZD ), acarbose , insulin. - C h o n g c h i dinh: d a i th a o d u o n g typ 1, s u y th a n , s u y g a n n a n g , d a i th a o d u ’O’ng n h ie m to an ceton, c o th a i h o a c d i u n g v o i s u lfo lilu re a . - T a c dung phu: ha d u o n g huyet, dj u n g , tang can. - Lieu lu g n g : glicla zid tu 30 - 1 2 0 m g/nga y uong tru o c b u a an 15 - 30 phut. + G lim ep irid tu 2 - 8 m g /n g a y uong 1 lan tru o c an 15 - 30 phu t (uong 1 lan tro n g ngay). + G lib e n cla m id tu 3,5 - 2 0 m g /n g a y chia deu tru o c m oi b u a an c h in h 15 - 30 phut. • N hom th u o c lam tang nhay cam insulin a ngoai vi, giam de khan g insulin: m e tfo rm in , thiazolidinedione B ig u a n id : th u o c duy nhat con s u dung la m etform in. - C o che ta c dung: do lam giam tan tao g lu cose a gan, u c ch e hap thu g lu co se a d u a n g tieu hoa va lam tang bat g iu g lu co se a c a van. - C hi djnh: dai th a o d u a n g typ 2, nha t la benh nhan co th u a can ho a c b e o phi. - C h ong ch i dinh: dai th a o d u o n g typ 1, nhiem toan ceton, th ie u o xy to c h u c ngoai bien (suy tim, suy ho hap), suy than, roi loan c h u c nang gan, co thai, che do an it ca lo (de g ia m can), ngay tru a c va sau p h iu th uat hoa c benh nhan > 70 tuoi. - Lieu lu g n g : g lu co p h a g e vie n 500, 8 5 0 ,1 0OOmg; M e g lu co n vie n 85 0 m g . Lieu tu 500 - 2500mg/ngay, uong ngay sau b u a an. - T a c dung phu: cac ta c dung phu tren d u o n g tieu hoa n h u chan an, b uo n non, non, day bung tieu cha y... gap o 20% benh nhan. T ac dung phu nay co lien quan den lieu lu a n g , hay xay ra khi b it dau dieu trj va th u o n g la th o a n g qua. C o 3 - 5% benh nhan phai n g u n g th u o c. it g a p tac dung phu gay doc tren da, huye t hpc. M e tfo rm in khon g gay ha d u a n g m au. N h ie m to a n la ctic th u c chat khong phai la tac dung phu m a th u a n g do khon g ton tron g cac chon g ch i dinh n h u tu o i cao, n g h ie n ru g u , suy gan suy than, suy tim hay suy ho hap. T h ia zo lid in e d io n : - C a che ta c dung: c h u a ro rang n h u n g cac tac dung quan sat d u a c la la m tang chat van ctiuy&n g lu co se (G L U T 1 va G L U T 4). Lam giam cac acid beo tu do. Lam g ia m tan ta o g lu co se a gan. Lam t£ng
H u Ong d An c h An o o An v A o i£u tri b £n h N 0 i khoa 415 b i^t ho£ ca c tien acid beo th a n h cac acid beo. G iong n h u biguam d, th ia zo lid in e d io n (TZD ) khong gay ha d u a n g huyet. - C h i dinh: dieu trj ket h g p v a i sulfo n ylu re a hoac m etform in ho a c insulin. - C h o n g c h i dinh: m an cam v a i th u o c va cac thanh phan cua thuoc, co thai va cho con bu, benh gan (enzym A L T la n h a n 2,5 lan g ia i han cao cua binh th u a n g ), suy tim . - Lieu lu a n g : p io g lita zo n (P io z vien 15m g): lieu 15 - 4 5m g/ngay. T h u o c uong 1 lan tron g ngay, xa b u a cin, co th e uong tru a c b u a an sang. - T a c dung phu: th u g n g gay tang can, chu yeu do lam tang tic h tru m a d u g i da va m ot phan do g iu n u a c . V i vay, can than tro n g khi dieu tri T Z D cho cac benh nhan bi suy tim hoac co benh tim , viem gan hoac co m en gan ta n g cao. • N hom u c che e n zym e a lpha g lu co sid a se lam giam hap thu glucose. - C a che ta c dung: th u o c co anh h u a n g den hap thu glucose: u c che hap thu glucose, lam giam d u a n g huye t sau an. - C hi dinh: ta n g nhe d u a n g huyet sau an. D ieu tri d a n tri lieu ket h g p v a i che do an hoac phoi h a p va i th u o c khac. - Lieu lu a n g va cach dung: + A c a rb o s e (G lu co b a y vie n 50 va 100m g): 50 - 200m g x 3 lan/ngay. + V o g lib o se (B a se n vien 0,2 va 0,3m g): 0,2 - 0,3m g x 3 lan/ngay. + M iglitol (G lise t vie n 25, 50 va 100m g): 75 - 300m g x 3 lan/ngay. U ong th u o c sau m ie n g c a m dau tien. B it dau b ln g lieu t h lp n h lt va tang dan len tuy theo dap ung vg i dieu tri ho a c m u c do tac dung phu. - T ac dung phu: b uo n non, d a y tru a n g bung (20 - 30% benh nhan uong G luco bay). C am giac m ot di ngoai, tieu ch a y (3% benh nhan uong G lucobay). • N hom G lin id - C a ch e tac dung: th u o c kich th ich te bao beta tuyen tuy tie t insulin. T ac dung cua thuoc giong su lfon ylurea n h u n g n g ln h a n va yeu han. - C h i dinh: tang d u a n g h u ye t sau an. U ong th u o c 1 - 1 0 phut tru a c b u a an, th u a n g la bi>a chinh. - Lieu lu a n g va cach dung: m e g litin id (S tarlix), repaglinid (P randin, N o vo n o rm vien 1 va 2m g): 0,5 - 4m g/lan, uong 15 phu t tr u a c bCra an. - T ac dung phu: ha d u a n g huyet. • N hom cac th u o c ta c dung tren he incretin C ac th u o c d o n g p h a n G L P -1 (glu ca g o n - like p ep tide 1) - C a che ta c dung: k ic h th ic h tie t insulin khi nong do d u a n g huye t tang len sau an. G LP-1 cung lam giam tiet glu ca g o n , lam cham tro n g da day va giam cam giac ngon m ieng. H au qua la lam giam d u a n g huyet sau an. - C h i dinh: dai th a o d u a n g typ 2, tang d u a n g huyet sau an. - Lieu lu g n g va cach dun g: th u o c e xen atid (B yeta dang but tie m ), tie m d u a i da 5 hoac 10pg, 2 lan/ngay, tru a c bu'a an 60 phut. Tac dung phu: b uo n non g a p a 15 - 30% benh nhan (th u a n g tu het), ha d u a n g huye t co the xay ra khi dung cung th u o c kich th ic h tie t insulin. T huoc u c ch e D P P IV: - C a ch e ta c dun g: u c che e nzym phan huy G LP-1 la D P P IV (d ip e p tid y l p e p tid a se IV) n h a do lam tang nong do va ta c d un g cua cac G LP-1 noi sinh. - C h i djnh: dai th a o d u a n g typ 2, tang d u a n g huyet sau an. - Lieu lu g n g va ca ch dung: th u o c sitaglip tin (Ja nuvia vien 25, 50 va 100m g). C an chinh lieu a benh nhan suy than.
416 H jC jn g d A n c h A n o o A n vA o i£ u t r i bEnh NO i khoa - T a c dung phu: buon non (nhu’ng it h o n so v a i th u o c dong phan G L P -1 ), dau dau, dau hong Dong phan amylin: - C a che ta c dung: giam d u a n g huye t sau an do ire che tie t glu ca g o n , lam cham tron g da day chong no, tang GLP. - C h i dinh: dai th a o du’a n g typ 1 va typ 2. - Lieu lu’a n g va cach dung: th u o c p ram lin tid (S ym lin dang but tie m ), tie m d u a i da 30pg - 1 20pg. vao ngay tru a c cac b u a an ch in h . C an giam lieu insulin khi k h a i dau dieu tri phoi h a p 2 th u o c nay. - T a c dung phu: non, buon non, chan an, dau dau. e. L ira ch o n th u o c b an d au • D a n trj lieu - B eo phi, roi loan lipid m au: chpn nhom m etform in hoac g lita zo n ho a c u c che alpha glucosidase (li/u y chong chi dinh cua tu n g nhom thuoc). - D u a n g huye t luc doi > 13,7m m ol/l, gay: chpn su lfo n ylu re a ho $ c insulin. - T ang d u a n g huye t sau an: chon nhom u c che a lp h a -g lu co sid a se . - D u a n g huyet > 1 6 ,5 m m o l/l va /h o a c H b A 1c > 10% : dieu tri insulin ngay. • P hoi h p p thuoc: khi dung d a n tri lieu khong dat m uc tieu co th e phoi h a p n h u sau: - M E T + SU, neu tang d u a n g huyet sau an th e m u c che a lp h a g lu co sid a se . N eu khong dat m yctteu them insulin tru a c ngu (insulin nen hoac insulin N P H ) hoac ch u ye n sang tie m insulin 2 - 4 mui/ngay. - U c che a lp h a - g lu c o sid a se + SU + M et. - SU + M et + u c ch e a lpha - glucosidase. - M et + SU + lpc c h e a lpha - g lu co sid a se + insulin. (SU: S u lp h o m ylu re a ; M et: M etform in.) 3. D i§ u tr j c a c y l u to n g u y c a Tang huye t ap, roi loan lipid m au, dieu trj cac bien ch u n g ... V. PHONG BENH - P hong benh cap 1 cho n h u n g n g u a i co nguy c a cao m lc benh dai th a o d u a n g (beo phi. THA, ti&n s u gia d in h co n g u a i bi dai th a o d u a n g , roi loan lipid m au, phu n u co tien s u de con to > 4kg va < 2.5kg. hut th u o c la): bang tu van che do an h p p li, tang c u a n g van dong th e lu c , kh a m va lam xet nghiem mau dinh ki. - P hong benh cap 2: phong lam cham tien trien bien c h u n g cho n h u n g n g u a i da m ac benh b ln g tir van che do an h p p li, ta n g c u a n g van dpng the lu c, tuan thu to t che dp d ieu tri. t A i lieu t h a m k h A o 1 Ta Van Binh. “B enh D ai thao d u u n g - tSng d u v n g h u y e f, trang 535 - 538. N ha xuat ban Y hoc 2006 2. M ai T h § T rach , N g u y ln Thy K hue. “ N o i tie t h o c d a i c u v n g ”, tra n g 375 - 378. N ha xuat ban Y hpc, 2003. 3 A m e ric a n A s s o c ia tio n o f C lin ic al E n d o c rin o lo g is ts . “ C o n s e n s u s D e v e lo p e n z y m e t Conference on In p a tie n t D ia b e te s a n d M e ta b o lic C o n tro l”. P o sitio n S ta te e n z y m e t. D e ce m b e r 2003. 4. A m e ric a n D ia b e te s A s s o c ia tio n . “ S ta n d a rd s o f m e d ic a l ca re in D ia b e te s - 201QT. Diabetes ca^ 2010, 33 (S u p p l 1): S11 - S61.
CAC BIEN CHU’NG CAP TINH DO DAl THAO DISCING GIAI DOAN DAU I. PHAC D C O l£U TR! B l£N CHLFNG HON ME TOAN CETON DO DAl TH AO DU’O NG 1. D ai cu’a n g Hon m e toan ceton la bien c h u n g cap tin h cua benh dai th a o d u a n g co ngu y c a tu vong cao. V iec tang cac ho rm o n gay ta n g d u a n g huye t va thieu hut insulin lam tang san xuat g lu co se tai gan, giam chuyen hoa glucose, li giai lipid tang tong h a p the ceton gay toan ceton. H au qua cuoi cung dan ta i tin h trang la i nieu th a m thau g a y m at n u a c va dien giai, toan ch uye n hoa m au. T h u a n g gap hon m e nhiem toan ceton a b en h nhan dai th a o d u a n g typ 1. 2. C h an doan a. C h an d o a n x a c d jn h • Trieu c h u n g lam sang - Trieu c h u n g lam sang ta n g d u a n g huyet: m et, tieu nhieu, kh a t n u a c , n h in m a. -T rie u c h u n g lam sang m at n u a c : yeu, m et m oi, chan an, khat n u a c , kho da va niem m ac, ch u o t rut, m ach nhanh, tut hu ye t ap. - Roi loan y th u c d o m at n u a c : la m a , ngu ga, hon me. - Trieu c h u n g lam sang toan ch uye n hoa: non, buon non, th a nha nh sau (K ussm aul), h a i th a m ui tao thoi... • C an lam sang - D u a n g huye t > 1 3 ,9 m m o l/l (250m g/dl). - K hi m au d on g m ach: pH < 7,3; H C 0 3' < 15m E q/l; tang khoa ng tro n g anion > 12 ± 2; phoi h a p v a i ceton nieu (+), ceton h u ye t th a n h (+). b. C h an d o a n p h a n b ie t C han doan phan biet hon m e nhiem toan ceton do dai th a o d u a n g va hon m e tang ap lu c tham thau (ALTT) th e o bang phan loai sau (bang 1). B a n g 1. P h a n b ie t h o n m e n h ie m to an c e to n v o i h o n m e ta n g A L T T Nhien toan ceton Tang ALTT Nhe Vita Ndng Ducrng huyet (m m o l/l) > 1 3 ,9 > 1 3 ,9 > 1 3 ,9 > 3 3 ,3 pH mau dong mach 7 ,2 5 -7 ,3 0 7,00 - < 7,25 < 7 ,0 0 > 7 ,3 0 Bicarbonat huyet thanh (mEq/l) 1 5 -1 8 1 0 - < 15 15 Ceton nieu * (+ ) (+ ) (+ ) it Ceton huyet th a n h * (+ ) (+ ) (+ ) it
418 H u Ong d An ch An oo An v A g i Eu t r i b En h NOi khoa B a n g 1. (Tiep) Nhien toan ceton Tang ALTT Nhe Vi/a Nang 06 tham thau huyet thanh huru dung Thay doi Thay (Joi Thay doi >320 (mOsm/kg) * * Khoang trong anion * * * >10 >12 >12
H i/ P n g d An ch An d o An v A o i £u tri b £n h N oi kh o a 419 d u o n g huye t < 11 m m ol/l, benh nhan co the an d u g c thi ch uye n sang pha c do tiem insulin d u a i da de kiem so a t d u o n g huyet. c. B u k a li m a u - Neu nong dp kali m au < 3,3m m ol/l: n g u n g truyen insulin, bu kali 20 - 30rm Eq/gio’ cho den khi K + > 3,3m m ol/l. - Neu nong dp K + t u 3,3 - 5,3m m ol/l, truye n K + nong do 20 - 3 0 m E q /l duy tri K + tu 4 - 5m m ol/l. - N eu K + > 5,3m m ol/l: khon g bu kali, n h u n g phai kiem tra kali m au m oi 2 g ia , khi K + < 5,3m m ol/l thi truyen lai K + . d. B u b ic a rb o n a t - Bu b ica rb o n a t con nhieu tranh cai. T ruyen b icarb onat co the gay ra ca c nguy c a nhu : ha kali m au, toan chuye n hoa he th a n kinh trun g u a n g , keo dai qua trin h ch uye n hoa cac the ceton... - T h e o khuye n cao, co th e tru ye n bica rb o n a te trong n h u n g tru a n g h a p sau: + pH: 6,9 - 7,0: tru ye n 50m E q bica rb o n a t va 10m Eq kali tron g 20 0 m l n u a c tron g 1 gia. + pH < 6,9, tru ye n 100 m E q b ica rb o n a t va 20m E q kali tron g 40 0 m l n u a c tron g 2 gia . e. D ie u t r i n g u y e n n h a n : neu co. f. T h e o d o i - T h e o doi cac dau hieu sinh ton 30 phut/lan trong g ia dau, 1 g ia /la n tro n g 4 gio’ tiep theo va 2 - 4 g ia /la n cho den khi het toan ceton. - D u a n g hu ye t m ao m ach nen d u a c kiem tra 1 g ia /la n de dieu chinh toe do tru ye n insulin. - D ip n giai do, c h u c nang than (ure, creatinin), khi m au, ceton m au va nieu, A LT T m au nen d u p e theo doi m oi 4 g ia /la n ch o den khi benh nhan on dinh. 4. P h o n g b e n h - Benh dai thao d u a n g can d u p e dieu tri dung, hap li va day du. Benh phai d u a c theo doi th u a n g xuyen. - Khong d u a c tu y bo th uoc, thay doi phac do dieu tri neu khong co y kien cua bac s i chuyen khoa. - P hat hien s a m va kip th a i ca c yeu to gay m at bu n h u n hiem tru n g , tai bien m ach nao, nhoi m au c a tim ... II. PHAC D C D l£ U TR! B l£ N C H l>N G TA N G A LTT DO D A I TH A O O l/O N G 1. D ai c u a n g TSng A L T T la bien c h u n g cap tin h cua benh dai th a o d u a n g co ngu y c a tu vong cao. C ung v a i vipc tang cac h o rm o n g a y ta n g d u a n g huyet, th ie u hut insulin lam ta n g san xu a t g lu co se tai gan, giam chuyen hoa glucose, ke t q u a la gay tang d u a n g huyet. H au qua cuoi cung dan ta i tin h trang la i tieu tham thau gay ra tin h tra n g m a t n u a c va dien giai. 2. C h in d o a n a. C h a n d o a n x a c d in h • Trieu c h u n g lam sang - C ac trieu c h u n g xu a t hien tu tit’. - T rie u c h u n g lam sang ta n g d u a n g huyet: m et, tieu nhieu, khat n u a c , n hin m a . - Trieu c h u n g lam sa n g m at n u a c : yeu, m pt m oi, chan an, khat n u a c , kh o da va niem m ac, chuo t rut, m ach nha nh, tu t h u y e t ap. - R oi loan y th u c do m a t n u a c : la m a , ngu g£, hon me. • C an lam sang - D u a n g hu ye t > 6 0 0 m g /d l (3 3 ,3m m ol/l).
420 H u Cng d An ch An bo An v A o i£u tr i b £n h NOi khoa - A p lu-c tham thau m au (ALTT) > 3 2 0 m 0 s m /k g . A LT T m au u a c tin h = 2 x (N a + + K+ ) ♦ ure mau (m m ol/l) + G M (m m ol/l). - pH dpng m ach > 7,3, H C 0 3' > 15m m ol/l. - C eton m au/nieu : it hoa c khon g co. b. C h a n d o a n p h a n b ie t C han doan phan biet hon m e tang A LTT do dai th a o d u a n g va nhiem toan ceton th e o bang 1. - C ac ngu yen nhan anh hucrng ta i he than kinh trun g u a n g : ha d u a n g huyet, ha natri m au. m at nuoc nSng, tang ure m au, ngo doc thuoc... - Tang tham thau khon g tang d u a n g huyet a n g u a i uong qua nhieu ru a u . - T an g tham thau a n g u a i loc m ang bung b in g dung dich g lu co se u u tru a n g . - D ai th a o nhat gay m at n u a c , tang natri m au. c. C h a n d o a n y e u to th u a n Ig i - N hiem trung. - B ^n h li cap tinh: nhoi m au c a tim , nhoi m au phoi, viem tu y cap, tai bien m ach nao, chan thuang. sau mo, roi loan tieu hoa ... - Bo tiem hoa c tiem khon g day du insulin. - Do thuoc: corticoid, la i tie u ... 3. D ie u trj a. B u d jc h Bo sung th e tic h dich n go ai te b a o va tai tu a i m au th a n la v ie c lam rat q u a n tro n g phai th i/c hien dau tien. - Truyen m uoi d an g tru a n g NaCI 9%o toe do 1 lit/g ia a benh nhan, g ia m th e tich n h u n g khong co bieu hien suy tim . - P hy th u o c vao tin h tra n g m at n u a c , roi loan dien giai va lu a n g n u a c tie u de lu a chcpn loai dich thay the tiep sau: + T ruyen m uoi n h u a c tru a n g NaCI 4,5%o toe do 250 - 5 0 0 m l/g ia neu natri hieu chinh binh thuong hoac tang. + Truyen m uoi d in g tru a n g NaCI 9%o toe do 250 - 5 0 0 m l/g ia neu natri hieu ch inh giam . - Khi d u a n g h u ye t < 13,7m m o l/l, truye n bo sung g lu co se 5% cho den khi het tin h trang tang ALTT. b. In s u lin - K hong tru ye n insulin khi K + m au < 3,3m m ol/l. -T ie m tin h m ach in sulin a ctra p id lieu 0,1 Ul - 0 ,1 5U I/kg, sau do tru ye n tin h m ach insulin actrapid lieu 0 ,1 U I/k g /g ia bang b a m tiem dien. - Khi d u a n g hu ye t < 13,7m m o l/l: giam lieu insulin tru ye n tin h m ach xu o n g m o t n u a lieu dang truyen va truye n g lu co se 5% bo sung, duy tri nong do d u a n g hu ye t tu 13,8 - 1 6 ,7 m m o l/l cho den khi het tinh trang tang ALTT, A L T T m au < 31 5 m O sm /kg , benh nhan tinh tao. - N gay sau khi tin h trang tang A LT T d u a c dieu tri on dinh, benh n ha n co th e an d u a c thi chuyen sang phac do tie m insulin d u a i da de kiem soat d u a n g huyet. c. B u k a li m a u - N eu nong do kali m au < 3,3m m ol/l: n g u n g truye n in sulin, bu kali 20 - 3 0 m E q /g ia cho den khi K+ > 3,3m m ol/l. - N eu nong do K + tu 3,3 - 5,3 m m o l/l, tru ye n K + nong do 20 - 3 0 m E q /l d u y tri K + t u 4 - 5mmoM.
H uong d An c h An d o An v A o i £ u t r i b En h Npi khoa 421 - N eu K + > 5 ,3m m ol/l: khon g bu kali, nhu’ng phai kiem tra kali m au m oi 2 g ia , khi K + < 5,3m m ol/l thi truyen lai K + . d. Theo d o i - T h e o doi ca c dau hieu sinh ton 30 phut/lan trong g ia dau, 1 g ia /lin tron g 4 g ia tiep theo va 2 - 4 g ia /la n cho den khi het tcing ALTT. - K iem tra d u a n g huye t m ao m ach 1 g ia /la n de dieu chinh toe do tru ye n insulin, - D ie n giai do, c h u c nSng than (ure, creatinin), A LT T m au nen d u a c th e o doi m oi 4 g ia /la n cho den khi benh nhan on dinh. 4. Ph o n g b£nh - B e n h dcii th £ o d u a n g ca n d u a c d ie u trj d u n g , h a p li va d a y du. B e n h p h a i d u a c th e o doi th u a n g x u y e n . - K hong d u a c t u y bo th uoc, thay doi phac do dieu trj neu khon g co y kien cua bac s i chuyen khoa. - P h at hien s a m va kip th a i cac yeu to gay m a t bu n h u n hiem tru n g , tai bien m ach nao, nhoi m au c a tim ... III. B l£N CHU’NG HA DU’O’NG H U Y £T 1. D a i cu’a n g Bien c h u n g ha d u a n g h u ye t co the xuat hien khi benh nhan dai th&o d u a n g d u a c dieu tri b ln g insulin hoac su lfo n ylu re a . D a y la m pt yeu to gay can tra vie c kiem soat d u a n g huye t a benh nhan dai thao d u a n g . 2. C h an doan a. C h an d o a n x a c d jn h D u a vao ta m c h u n g W h ip p le : - Trieu c h u n g ha d u a n g huyet: + Trieu chung cua roi loan than kinh giao cam: lo ISng, run tay chan, va mo hoi, hoi hpp danh trong nguc, cam gicic doi con c^o. + T ri^u c h u n g cua r6i loan he t h in kinh trung u a n g : m at kha n3ng tap trung, nh in m a , la m a , lu lan, co gi$t, hon me. - N ong do d u a n g tro n g m au th a p < 3,9m m ol/l. - Trieu c h u n g lam sang m at di khi nong do d u a n g huyet ve b inh th u a n g . * Lu>u y: m pt so b en h nhan ha d u a n g huyet khon g co trieu c h u n g , co th e dot ngpt di vao hon me ngay. T h u a n g la benh nhan bi dai th a o d u a n g lau, benh nhan co bien c h u n g th a n kinh, benh nhan da bi ha d u a n g huye t n hieu lan... (xem them phan bien c h u n g than kinh). - T ru a n g h a p nghi n g a n h u n g khong th u d u a c d u a n g huye t nga y co the te st truye n g lu co se uu tru a n g , d £n h gi& tin h tra n g benh nhan sau 15 phut. b. C h a n d o in n g u y e n n h in thu’d n g g i p - Quci lieu th u o c in su lin ho $ c su lfon ylurea. - Bo b i/a ho $ c 3n kh 6 n g day du. - Uong rupu. - D ie u trj kh6n g d un g c h i dan. - H o a t d pn g th e lu c q u a sue.
422 H l f P N G D A N C H A N D O A N V A D | £ u T R| B E N H NOl KHOA 3. D ieu trj - Ngi>ng cac th u o c ha du’a n g huyet hoa c insulin dang dung. - Tru’d n g ho’P ha du’O’ng huyet nhe, benh nhan tinh tao: + An ngay banh, hoa qua co san. + N eu k h o n g d a can to i th ie u 15g du’a n g (3 m ie n g du’a n g h o a c 3 th ia c a fe du’a n g pha trong 100 m l nu’a c ). - Truyen du’a n g g lu co se trong tru’a n g h a p ha du’a n g huye t nang, y th u ’C khon g tinh tao, benh nhan khong the an b ln g du’a n g m ieng. + T iem tTnh m ach 20 - 50m l g lucose 30% . + T iep th e o tru ye n du’a n g g lu co se 5% (hoac g lu co se 10% ) de duy tri du’a n g huyet > 5,6m m ol/l. - G luca gon 1m g (tiem bap hoa c tiem d a a i da): ch i dinh cho benh nhan ha du’a n g huyet n£ng khong co kha nang an bang du’a n g m ieng hoac nhCmg benh nhan khon g th e dat d u ’a n g tru ye n tin h m ach ngay khi cap clpu. 4. P h ong benh - G iao due benh nhan p h a t hien va cach xu* tri tai nha khi co ha du’a n g huyet. - T u ’ van che do an uong, tap luyen, cach sCr dung thuoc. - T h e o doi du’a n g huye t thu’a n g xuyen, kiem soat du’a n g huyet a m u’c do h a p li doi v a i nhu’ng benh nhan dai th a o du’a n g m at kha nang nhan biet cac trieu chu’ng ha du’a n g hu ye t do bien chu’ng th in kinh t y dong. TAl LIEU THAM kh Ao 1. T r ln D ifc Tho. “B e n h D a i thao du-ong”. Benh hpc noi khoa, ta p 1, N h a xuat ban Y hpc (2007): 301 -3 1 6 . 2. J a n e t B .M cG ill. “S ta n d a rd s o f C a re fo r D ia b e te s M ellitus". E n d o c rin o lo g y subsp ecia liti Consult. 2 nd edition; 2009: 228 -2 3 7 . 3. U m esh M a s h a ra n i et al. “P a n c re a tic H o rm o n e s a n d D ia b e te s M e llitu s ”. G re e n p a n 's Basic and clinical E ndocrinology, 8medition, 2007: 661 - 747. 4. E rn e s to B e rn al - M izra c h i et al. “D ia b e te s M e llitu s a n d re la te d d is o rd e rs ”. W ashing ton Manual o f M edical T h e ra p e u tics, 32th edition, 2009: 600 - 623. 5. A m e ric a n D ia b e te s A s s o c ia tio n . “S ta n d a rd s o f m e d ic a l ca re in d ia b e te s - 2 0 1 0 ”, Diabetes care 201 0, 33 (S upp l 1): S11 - S61.
BIEN CHU’NG MACH MAU L0N DO DAl THAO DUONG I. O Al C U O N G Bien chu’ng m ach m au Icm, hau qua cua qua trin h x a vOa cac m ach m au la n va vi>a, chiem ta i 80% cac nguyen nhan gay tCf vong a benh nhan dai thao du’a ng. Bien chu’ng m ach m au la n bao gom : benh dong m ach vanh tim , tai bien m ach nao, benh m ach m au ngoai vi. D ie u tri cac bien ch u ’ng tim m ach noi chung va m ach m au la n tu y theo vi tri ton thu’ang . Tuy nhien, cac loai bien ch u ’ng m ach la n can co nguyen tiic dieu tri chun g nhu1dieu tri bien chu’ng tim m ach la dieu trj cac yeu to ngu y c a gom : khang insulin, tang du’a n g huyet, roi loan lipid m au, hut thuoc la, beo phi. II. O l£U TR| 1. T a n g h u y e t ap a. C h an d o a n ta n g h u y e t a p k h i h u y e t ap > 1 4 0 /9 0 m m H g a 2 lan do h u y e t ap kh a c nhau b. D ie u trj M uc tieu huye t ap (H A ) a benh nhan dai thao du’a n g nen du’a c kiem soat < 130/80m m H g. - H A tam thu = 130 - 139 m m H g hoac HA tam tru’a n g = 80 - 8 9 m m H g: th a y doi loi song trong 3 thang. Neu HA khong dat m u c tieu: dung th u o c ha HA. - HA tam thu £ 1 4 0 m m H g hoa c H A tam tru’a n g > 90m m H g: dung th u o c ha H A ket h a p v a i dieu chinh loi song. - D ieu chinh loi song bao gom : giam can a benh nhan thi>a can, an nhat, tang bo sung kali, han che ru’au, tang hoat dong th e ly c . - N hom th u o c ha hu ye t ap du’a c ly a chpn dau tien cho benh nhan dai th a o du’a n g co T H A la i>c che m en chuye n hoac nho m th u o c chen thu the an g io te n sin II. - Neu H A c h ira dat m uc tieu dieu tri, nhom la i tieu th iazid nen du’a c ke t h a p khi m u’c loc cau than > 30m l/phut hoa c nho m la i tieu fu ro se m id khi m u’c loc cau than < 30m l/phu t. - Phu nCf co thai m ic dai th a o du’a n g va TH A, m u’c HA nen d u 'a c duy tri 110 - 129/65 - 79m m H g. Chong ch i dinh dung th u o c u'C che m en chuye n va chen thu the a n g io te n sin a phu nCr co thai. 2. R 6 i lo a n lip id m a u a. S a n g lo c T at ca bpnh nhan dai th a o d u 'a n g tuoi tru a n g thanh nen du’a c kie m tra lipid m au hang nam . b. M u c tieu k ie m s o a t lip id m au a b en h n h a n d a i th ao dw iyng a m ire - LD L ch o lo s te ro l < 2 ,6 m m o l/l (100m g/dl). B enh nhan dai th a o d u 'a n g co kem th e o benh m ach vanh hoac tu ’a n g du’a n g m u c tieu can dat LD L < 1 ,8m m ol/l (70m g/d l). - H D L ch o le s te ro l > 1 ,0 m m o l/l (4 0m g/d l) doi v a i nam va > 1 ,3 m m o l/l (5 0 m g /d l) doi v a i nu\ -T ry g lic e rid < 1 ,7 m m o l/l (150m g/dl).
424 H i/ P ng d An c h An b o An v A b i £ u t r i b En h NOi khoa c. D ie u trj - T ha y doi loi song: che do an giam chat beo bao hoa, tra n s v3 ch o le ste ro l. Bo sung om ega 3, ch4t xa , giam c^n (neu th a a can), tang cu’a n g hoat dpng the la c. - N hom statin du’a c a u tien ch i dinh dieu tri cho n h a n g benh nhan dai th a o d a a n g dang cd benh li tim m ach ho£c benh nhan khon g co benh li tim m ach n h a n g > 40 tu o i v& co m pt ho$ c nhieu yeu to nguy c a m ic benh tim m ach m a khong can quan tam ta i nong dp lipid m au. - B pnh nhan khon g co benh tim m ach va < 40 tuoi, nhom statin d a a c c h i dinh dieu tri ket hprp von thay doi loi song khi LD L-C > 2 ,6 m m o l/l (100m g/dl). - N hom fib ra t ch i dinh dieu tri cho benh nhan dai th a o d a a n g khi trig lic e rid > 5 ,6m m ol/l (500mg/dl) sau khi da kiem soat che dp an va kiem soat d a o n g huyet. 3. T h u d c ch d n g n g u n g tap tieu c4u -A s p irin lieu 75 - 16 2 m g /n g a y d a p c chi dinh cho m uc tieu p ho ng n g a a tien phcit a benh nhSn 50 tuoi, n a > 60 tuoi co it n h lt m pt tron g cac yeu to ngu y c a n h a tien s a gia d inh m ac benh m ach vanh , T H A , hut thuoc, roi loan lipid m au hoSc album in nieu. -A s p irin lieu 75 - 16 2 m g /n g a y d a a c ch i dinh cho m yc tieu phong n g a a th a p h £ t a benh nhSn dai thao d a o ’ng co tien s a m a c b en h tim m ach. - N eu benh n h ^n di im g aspirin: dung clo p id o g re l 7 5 m g/ng^y. - K e t h p p a sp irin 7 5 -1 6 2 m g /n g a y v a i clo p id o g re l 7 5 m g /n g a y a b en h n ha n sau hpi ch irn g mach va n h cap. M yc tie u ch u n g tro n g d ieu trj cac yeu to nguy c a lam han ch e s a g ia ta n g c£c bien ch irn g mach m au gom : - K iem so&t ch $ t d a a n g huyet: H b A 1c < 7% . - K iem soat to t H A < 130 /80 m m H g. - K iem so£t tin h tran g roi loan lipid m au v a i cac m uc tieu sau: + LD L-C < 2 ,6 m m o l/l (1 0 0 m g /d )l hoa c 1,8m m ol/l (< 7 0 m g /d l) a benh nhan co benh dong m ach vanh). + H D L-C > 50m g/dl. + T ryg lice rid < 150m g/dl. - H an che th u o c la va g ia m can. -A s p irin 75 - 1 6 2 m g /n g a y g iup ngan n g a a nhoi m 3u c a tim va tai bien m a ch nao. III. BENH M ACH M AU NG O AI VI 1. D a i c u ’a n g D a i th a o d a a n g v3 hut th u o c la hai yeu to ch in h gay ra benh m ach m au ngo ai vi. D oi v a i benh nh&n dai th a o d a a n g , nguy c a m ic benh m ach m au ngoai vi gia tang cu n g v a i tuoi, th a i gian m ic benh va si/ xu a t hien cua bien c h u n g th a n kinh ngoai vi. 2. C h an doan: [daa vao dac diem lam sang va can lam sang] - Trieu c h im g I3m sang cua benh m ach m au ngoai vi chi d a a i gom : g iai d oa n s a m la dau cach h6t. dau khi nghi, n3ng co th e dan ta i t i c m ach chi gay hoai ta m o th a m c h i p ha i c i t c y t chi. M pt so benh nhan co the khon g co trieu c h a n g ro ret do co bien c h u n g th a n kin h di kem . - Khcim lam sang: mach ngoai vi yeu tham chi mat mach, ryng long, thieu daang m6ng, da k h i lanh. - Sieu am Doppler mach chi: giup chan doan benh nhan co benh mach mau ngoai vi. - C h y p m ach c h i khi nghi n g a hep tac m ach can can th ie p (o1ca c tu y e n ch u ye n khoa).