Case LS

D LIU CA LM SNG
1. Ca lm sng tng huyt p dng thuc gim au NSAID

Ca lm sng:
B B., 59 tui, c iu tr tng huyt p bng Aldactazine (spironolactone thuc li tiu gi
kali) v Triatec 10 mg (ramipril c ch men chuyn). B thng xuyn theo di huyt p bng
my o huyt p t ng v ch s huyt p b duy tr quanh mc 135/85.
6 thng trc, b i gp 1 bc s chuyn khoa khp khm tnh trng thoi ha t sng c
m b ang phi chu ng. Bc s ny k cho b 1 thuc chng vim Bi-profenid
(ketoprofen) dng 20 ngy/thng gim au. Ngy hm nay, b mang ti mt toa thuc mi do
bc s iu tr ca b k: Aldactazine, Triatec, Loxen 10 v 20 (nicardipine hydrochloride thuc
chn knh calci). B B. gii thch cho bn bit rng: B pht hin ch s huyt p trung bnh
(sau 3 ln o) gn y tng ln 145/95 khi b tin hnh kim tra huyt p nh thng l trc khi
i bc s khm li. Sau thm khm, bc s iu tr ca b khng nh vn tng ch s huyt
p, do k b xung thm thuc mi.
Ti sao bnh tng huyt p ca b B. li nng thm?

C th l theo thi gian, tui tc, huyt p b B. tng ln Nhng trong trng hp c th ny,
cn phi nh gi hiu qu, tc ng ln hiu qu iu tr chung ca bnh nhn khi thm 1 thuc
vo trong liu trnh iu tr.
Phn tch ca:

S dng cc NSAID iu tr di ngy (k c cc thuc c ch chn lc COX-2) lm tng huyt
p ng mch nhng bnh nhn tng huyt p v lm gim hiu qu iu tr ca thuc h huyt
p. Nhng tc dng ny ch yu l do gim tng hp cc prostaglandin gin mch v do gi
natri. Hn na, cc NSAID cn lm gim ti mu thn nhng bnh nhn c ti mu cu
thn ph thuc nhiu vo hiu qu gin mch ca cc prostaglandin, bao gm nhng bnh nhn
b hp ng mch thn, gim th tch tun hon hoc mt nc. y l l do chnh gy nguy c
suy gim chc nng thn gy bi cc thuc c ch men chuyn nhng i tng bnh nhn
ny.
Mt kh nng ln l cn phi thm mt thuc chn knh calci khi ch s huyt p bnh nhn tng
ln hoc khi hiu qu ca thuc h huyt p b gim do dng Bi-profenid
Hng x tr:
Cn phi bit liu b B. c dng thuc gim au khc trc khi dng Bi-profenid khng v liu
rng bc s iu tr ca bnh nhn c c thng bo v vic iu tr bng NSAIDs khng?
Trong thc t, s hp l hn nu dng mt thuc gim au (paracetamol) khng c tng tc vi
vic iu tr h huyt p. Trong trng hp hiu qu gim au khng , vic thm thuc Biprofenid iu tr gim au cn i km vi theo di ch s huyt p cng nh thanh thi
creatinin v kali huyt. Ti cc hiu thuc, khng phi lc no dc s cng bit c liu rng
bc s k mt thuc mi khi cn nhc cc thuc m bnh nhn ang dng hay khng. V vy,
vic to mt h s theo di vic iu tr c nhn ca mi bnh nhn l mt cng c hu ch cho
cc cn b y t.
Cn lu : Trnh t s dng NSAIDs cc bnh nhn tng huyt p. Trong trng hp

n thuc c k bi hai hay nhiu bc s khc nhau, vic trao i thng tin gia l cn
thit xc minh s hp l ca vic k n.
2. Ca lm sng Tng huyt p gp ADR Sng bn chn v mt c do dng
thuc chn canxi
Copied and edited by Trng Cng Bng from Nhp cu DLS
Ca lm sng :
B A., 71 tui, c iu tr bng Clectol 200 (celiprolol hydrochloride) v Hyperium
(rilmenidine) 5 nm nay. Ngoi ra b cn thng xuyn dng Daflon 500 (vitamine P). Trong ln
thm khm gn nht, huyt p ca b tng ln: 160/100. Bc s iu tr thm Loxen LP
(nicardipine hydrochloride) vo n thuc ca bnh nhn. Sau nm ngy, b A. tr li hiu thuc
mua Doliprane (paracetamol 500mg) v b nhc u v ch cho dc s thy mt c chn ca
b ang b sng phng. Theo li khuyn ca dc s, b tr li gp bc s ca mnh. Bc s iu
tr thng xuyn ca b ang i ngh php, v vy b ti 1 phng khm gn . B quay li
hiu thuc vo ngy hm sau vi toa thuc c Lasilix 20 (furosemide).
Phi hp Loxen (nicardipine) v Lasilix (furosemide) c hp l ?
Vn ca ca lm sng ny l khng bit liu Lasilix c k l thay th hay b sung cho
Loxen? B A. khng bit cu tr li do khng c bc s gii thch.
Phn tch ca :
Nicardipine (Loxen) l mt thuc chn knh canxi nhm dihydropyridin. Nhng tc dng ph
chung ca cc thuc chn canxi xut pht t chnh c ch tc dng dc l ca n: gin mch
qu mc dn n h huyt p, mt bng, nhc u, chng mt, ph chi di v nhp tim
nhanh.
Nguyn nhn ca s xut hin tnh trng ph n trong trng hp ny l do s thay i tnh thm
thnh mch hn l do gi nc. Do , vic ch nh mt thuc li tiu l khng thch hp cho
trng hp ny. Thng tnh trng ph c quan st thy khi bt u liu trnh iu tr v c th
mt i khi ngng thuc.
Hng x tr:
Bc s (k Lasilix) khi c lin h tha nhn khng nm c ht tnh trng ca bnh nhn
ny, ng khng bit rng bnh nhn dng Loxen gn y.
Do bnh nhn b au u v ph chi di, bc s mun thay i phc iu tr. ng quyt nh
k n Micardis 40 (telmisartan) mt ln/ngy thay cho Loxen, ng thi cng b Lasilix. Tnh
trng ph v au u ht sau 4-5 ngy. Bc s iu tr c ca bnh nhn cng c thng bo v
vic ny ngay khi tr v.
Lu : Ph do cc thuc chn Canxi thng cn phi thay i nhm thuc iu tr khc.
3. Ca h glucose mu v m ti pht bnh nhn i tho ng typ 1
CA LM SNG
Mt bnh nhn nam 39 tui mc T type 1 c nhp vin km nhim toan ceton nng v
nhim trng ng h hp trn. Cc xt nghim sinh ha lc nhp vin: Glucose huyt tng
tnh mch 933 mg/dl (51.8 mmol/L) (gii hn bnh thng: 72 140 mg/dl hoc 4.0 7.8
mmol/L), bicarbonate: 14.7 mmol/L (22 31 mmol/L), hydroxybutyrate > 6 mmol/L (< 0.6
mmol/L) v pH ng mch 7.28 (7.35 7.45). Bnh nhn c cha tr bng truyn dch tnh
mch v truyn Insulin tnh mch qung ngn, v bnh nhn phc hi nhanh.
Bnh nhn c chn on T type 1 nm 33tui khi c biu hin cn nhim toan ceton.
Khng th Glutamic acid decarboxylate tng ti thi im chn on 10.6 U/mL (gi tr bnh
thng < 1 U/mL) v nng peptide C sau ba n khng pht hin c. Vic kim sot
glucose mu ca bnh nhn sau l km, vi HbA1c tng trong khong 8.9% n 15.6%, iu
ny dn n cc bin chng v thn kinh ngoi vi v t ng nh cn au thn kinh ngoi bin
v ri lon cng dng. Tin s bnh nhn gm c sa van tim, tng huyt p v ri lon lipid
mu. BN c k ch Insulin tim qung ngn nn (basal bolus insulin) gm: insulin tc
dng di 2 ln/ngy (insulin detemir 10U trc ba sng v 7U trc ba ti) phi hp insulin
tc dng nhanh 3 ln/ngy (insulin aspart 5U trc ba sng v 3U trc ba tra v 4U trc
ba ti), simvastatin, sildenafil, pregabalin, v omeprazol. BN khng dng sulfonylurea v
khng dng thc ung c cn.
Sau khi x l nhim toan ceton, bnh nhn c bt u li ch Insulin tim qung ngn nn
nh trc khi nhp vin. sau , ch insulin ca bnh nhn c iu chnh trong ln nhp
vin ny, v bnh nhn thay i glucose mu trong khong rng v b h glucose mu ti pht v
m. in hnh, glucose mu tng nghim trng trong ngy (glucose mao mch: 205- 553 mg/dl
hay 11.4 30.7 mmol/L) nht l sau ba n. Trong khi cc biu hin h glucose mu xy ra lin
tc lc 24h 2h30 hng m (glucose mu mao mch: 34 58 mg/dl hay 1.9 3.2 mmol/L) i
cng vi cc triu chng p ng giao cm nh tot m hi, nh trng ngc, cng thng.
CC IM CN XEM XT:
1.
Nhng nguyn nhn gy h glucose mu ti pht bnh nhn ang dng liu php
insulin l g ?
2.
Cc phng php no gip chn on cc nguyn nhn gy h glucose mu ti pht?
3.
Khng th khng insulin c th gy ra h glucose mu khng ?
Khm lm sng cho thy cc du hiu sng n nh v bnh nhn gy vi ch s khi c th thp
(BMI = 16.4 kg/m2). Khng c chng tng sc t in hnh ca bnh Addison. Tuyn gip khng
to ln v chc nng gip bnh thng. Khm tim mch v h hp bnh thng. C lon dng
m di da nh v tr tim insulin.
Kt qu sinh ha c lin quan khc: albumin 4.0 g/dl (3.8 4.8 g/dl), AST 10U/L (14 50 U/L),
ALA 10U/L (10-55 U/L) , gama glutamin transferase 30 U/L (10 70 U/L) v creatinine 0.6
mg/dl hay 53 micromol/L (0.7 1.4 mg/dL hay 65 -125 micromol/L). Nng insulin v peptide
C o ti 1 trong cc cn h glucose (glucose tnh mch 2.8 mmol/L) trong ln nhp vin ny l
83.6 mU/L (0.0 25.0 mU/L) v 36 pmol/L (364 1655 pmol/L) v sinh ha tuyn gip ca
bnh nhn bnh thng.
THO LUN:
H ng huyt l mt bin chng thng gp ca liu php insulin bnh nhn T v gy
cn tr mc tiu kim sot ng huyt. N gy ra bnh l v th cht v tinh thn nghim trng,
thnh thong gy t vong. Nguyn nhn c bn ca h ng huyt cn c nh gi v xc
nh nhm ngn chn cc cn h ng huyt ti pht.
H glucose mu bnh nhn T thng thng nht l c gy ra bi liu php insulin qu

mc tuyt i hay tng i. Nhng nguyn nhn ca qu mc insulin tuyt i bao gm qu
mc hoc cht kch thch tit insulin khng ng lc; hoc qu mc insulin; hoc do gim thi
insulin trong suy thn. Insulin qu mc tng i xy ra khi lng insulin hin ti khng tng
xng vi lng glucose cung cp (ngoi sinh), s dng hoc sn xut. D tha qu mc insulin
tuyt i hay tng i lun d dng nhn ra t bnh s bnh nhn thng qua cc biu hin trc
cc t h ng huyt. Sau khi kim tra tin s bnh chi tit ca BN ny, d tha insulin
khng l nguyn nhn ca cc cn h glucose. V liu insulin bnh nhn l ph hp vi lng
calo thu nhn hng ngy v bnh nhn kh nng tim chnh xc liu insulin. Bnh nhn
khng t s dng thm insulin. Lon dng m ti ni tim c th nh hng hp thu insulin
v l nguyn nhn thng thng gy bt thng nng glucose. Bnh nhn ny ch b lon
lng m nh, v thay i v tr tim khng ci thin c cc cn h glucose mu ti pht.
Do , loi tr nguyn nhn ny.
Suy gan v suy thn c loi tr qua khm lm sng v cc xt nghim nng men gan,
albumin v creatinin trong gii hn bnh thng. Suy gim tuyn thng thn, c bit l bnh
Addison bnh nhn i thi ng type I c th gy h glucose mu. Kim tra ACTH cho thy
nng nh ca cortisol l 34.8 microgram/dL (960 mmol/L) [p ng bnh thng : >20
microgram/dL (> 550 mmol/L)] v loi tr chn on . Bnh nhn khng dng alcohol, v
khng ang dng cc thuc gy ra h glucose mu (tr insulin).
Chng lit d dy bnh nhn T (chim t l 30-40% bnh nhn T) l tnh trng c
trng bi s chm lm rng d dy khng c tc rut c hc do bnh l thn kinh t ng. Tnh
trng ny c th gy h glucose mu do s chm tiu thc n khin lng insulin cung cp v
carbohydrate hp thu l khng tng xng. Mt kho st v tnh trng lm rng d dy c
thc hin trn bnh nhn cho thy bnh nhn c tnh trng ny. Tuy nhin, biu hin chng tng
glucose sau n 2-3h (c bit sau n ti), theo l s gim glucose mu gia m l khng ph
hp vi chng lit d dy, nn nguyn nhn ny c loi tr.
Sau khi loi tr cc nguyn nhn thng thng ca chng h glucose mu bnh nhn T s
dng liu php insulin, tin hnh cc kho st khc su hn trn bnh nhn ny tm ra nguyn
nhn ca h ng huyt ti pht. Nng insulin v peptide C c o trong cc t h
glucose xy ra. Nng peptide C khng pht hin c trong 3 cn h glucose ring bit
loi tr kh nng bnh nhn b tng insulin ni sinh, v d u o ty.
Sau khi loi tr cc nguyn nhn trn, khng th khng insulin (IA) c cn nhc l nguyn
nhn trong bi cnh nng insulin tng khi cn h glucose xy ra. S dng lu di insulin ngoi
sinh c th lm tng khng th khng insulin, cc khng th ny gn kt vi Insulin. Bi vy, liu
insulin ng dng (insulin analog) ln hn c th c yu cu b cho lng insulin gn kt
v cho php lng insulin t do c hot ng. Insulin t do v insulin gn kt tn ti cn
bng ng vi nhau. Khi dng t do c chuyn ha, insulin dng gn kt s c gii phng
t IA. iu ny c tc dng lm chm v ko di hot ng insulin ban u v gy tng glucose
mu ban ngy; ngc li, s gii phng insulin tip theo t IA c th gy h glucose mu v m
nu lng insulin gii phng khng cn xng vi lng calo nhn vo.
IA c trng bi dung lng gn kt v i lc gn kt. Nhng bnh nhn c IA c dung lng
gn kt thp, i lc cao thng khng b gy h glucose mu. Tri li, cc bnh nhn vi IA c
dung lng gn trung bnh, i lc thp c th gp cn h glucose mu v m. Cn cc bnh
nhn vi IA c dung lng gn cao, i lc thp c nguy c gp cn tng glucose nghim trng
ban ngy v h glucose ban m, v c th cn cha tr vi thuc c ch min dch.
IA c th xem nh l mt cht cn tr insulin (do to i phn t insulin dng phc hp IAInsulin). Tuy nhin, khng nh cc cht cn tr cc hormone khc, nh gi phi tuyn tnh bng
cch pha long cc mu xt nghim ca bnh nhn hay kim tra li nng insulin trn cc mu
xt nghim thay th l khng hu ch nghin cu IA cc bnh nhn T s dng liu php
insulin. Bi v hu ht mu insulin xt nghim khng th hin s hi quy tuyn tnh vi insulin
analog v c phn ng cho khc nhau i vi loi insulin analog khc nhau. V l do ny, nh
gi hi quy sau khi thm insulin vo mu xt nghim l khng ph hp.
Sc k dng gel c th c dng chng thc chn on ca insulin dng phc hp IAInsulin v do khng nh s hin din ca IA, th hin bng nh insulin trn vng globulin
min dch. IA cng c th c o trc tip. Nhng xt nghim ny thng thng khng c sn
ti a s phng labo. Khi nghi ng c IA, o lng nng insulin t do,insulin trc tip v
insulin tng. Insulin trc tip (direct insulin) c o trc tip trn mu mu gc t bnh
nhn. Insulin t do (free insulin) thu c bng cch o phn ni trn b mt sau khi lng ng
mu mu bng polyethylen glycol (PEG). Insulin tng (total insulin) thu bng cch: u tin,
thm acid vo mu mu tch phn insulin gn kt khng th thnh dng t do, cc bc tip
theo ln lt l lng ng mu mu bng thm PEG v trung ha pH.
ngi bnh thng, insulin tng , insulin t do, insulin trc tip c nng gn bng nhau, v
insulin trong h tun hon gn protein khng ng k. Do , s tng t l insulin trc tip/t do,
hoc t l insulin tng cng/trc tip l gi c s tn ti ca IA. Nhng t l ny c tnh c
hiu ph thuc ty vo my phn tch. bnh nhn ny, t l insulin trc tip/t do v t l
insuin tng/trc tip tng ng l 1.03 v 0.98, s dng my xt nghim Advia Centaur
(Siemens Healthcare Diagnostic). o trc tip nng IA c 0.01 nmol/L (gi tr bnh
thng: khng ln hn 0.02 nmol/L, Mayo Medical Laboratories). Nhng kt qu ny loi tr IA
l nguyn nhn gy h glucose mu.
V nguyn nhn ca h glucose mu ti pht vn cha tm ra, chng ti o insulin v glucose
trong 24h ca bnh nhn. Insulin trong 24h cho thy nh bt thng gia lc 24h 2h30, iu
ny ph hp vi s h glucose nghim trng lc (1.9 mmol/L). nh ny khng th gii thch
bng phc k insulin cho bnh nhn (Hnh 1). Chng ti nghi ng rng nh ny c th do mt
cht tng t insulin (insulin analog) tc ng ngn c tit ra mt cch m thm. Sau khi
gii thch kt qu insulin 24h cho bnh nhn, cn h glucose mu v m khng xy ra na.
BN sau c chuyn sang khoa tm thnh c chm sc v pht hin BN c nhng yu
t gy stress kh nghim trng.
Chng ti i n quyt nh rng bnh nhn ny mc chng h glucose mu gi to (factitious

hypoglycemia) mt hi chng m bnh nhn t cm ng gy h glucose nhm c chm
sc y t hoc chng t l mnh khng khe. y l mt chng bnh rt kh chn on v
thng khng chn on c trong nhiu nm bnh nhn b T khng kim sot c. Cc
biu hin lm sng thng bt chc rt ging vi bnh tht. Bnh nhn thng t ra lo lng v
yu cu thng xuyn c kim tra cng nh can thip iu tr. BN thng c tin s nhiu ln
nhp vin v n khm nhiu ni khc nhau. Bnh nhn ny cng vo vin nhiu ln, c th
18 ln trong vng 2 nm do h glucose ti pht v tng glucose mu.
iu quan trng l phi nhn ra y l mt chn on loi tr v ch nn thc hin sau khi loi
tr cc nguyn nhn c kh nng khc trc trnh nhm ln trong chn on trnh cc
hu qu nghim trng v x hi, php l v lm sng do chn om sai. Tuy nhin, vic cn thn
ny cng cn phi cn bng vi s cn thit phi nhn bit sm trnh cc chn on v can
thip iu tr khng cn thit gy lng ph vt cht cng nh em nguy hi cho bnh nhn.
(Hnh 2).
NHNG IU CN NH:
1.
Chng h glucose mu l thng thng bnh nhn T v nguyn nhn thng gp
nht l s d tha insulin tuyt i hay tng i. Lon dng m di da ti ni tim c th
tc ng ti s hp thu insulin v c th lm nng glucose khng n nh. Chm tho rng
d dy (30%-40% bnh nhn T) gy ra bi lit d dy c th gy h glucose mu.
2.
Khng th khng insulin v vic ln lt s dng insulin ngoi sinh c th lm tng nng
insulin bt hp l trong h glucose mu.
3.
H glucose mu gi to l thch thc ln vi chn on v iu tr. N nn c xem l
mt chn on phn bit trong h glucose mu khng r nguyn nhn v l mt chn an
loi tr (chn on khng nh sau khi loi tr cc nguyn nhn khc).
4.
o lng nng peptide C v insulin trc tip v t do c th gip phn bit h glucose
gi to vi cc nguyn nhn khc.
5.
Nng insulin cao vi s tng t l insulin trc tip/t do ghi li trong cc cn h
glucose gi mt nguyn nhn l do lm dng insulin. (Li bnh ca ngi hiu nh: theo
nh cch hiu logic th nng insulin cao v t l insulin trc tip/t do xp x 1 trong cc
cn h glucose gi mt nguyn nhn l do lm dng insulin. Cn nng insulin cao v t
l insulin trc tip/t do tng th nghi ng nguy c l do IA ?).
4. Ca lm sng bnh nhn tng huyt p v dng mui
Do mc bnh tng huyt p v suy tim nn ng B. ang c iu tr bng Lopril (captopril)
50mg 2 vin/ngy, Lasilix 40 (furosemid) 1 vin vo bui sng v Cardensiel 2,5 mg (bisoprolol)
2 vin/ngy. ng B. tun th ch n khng c mui v theo di cn nng thng xuyn. Hm
nay, v ng cho dc s bit rng ng do ny hay b ba n do ng B khng cn cm nhn
c hng v ca cc mn n. Ch n khng c mui dng nh khng ph hp vi ng. B
v bn khon liu b c th s dng loi mui thay th ginh cho ngi n king mui cho
chng ng y n ngon ming hn khng ?
C nn khuyn b B s dng mui n king cho chng ?

Khng, mui n king cng c th gy ri lon kali huyt tng
Phn tch ca
Mui c tc dng lm tng hng v ca thc n. V vy khi bnh nhn phi thc hin ch n
khng c mui mt cch nghim ngt (bnh nhn suy tim, suy thn), h c th gp phi tnh
trng n ung khng ngon ming. Bn cnh , ng B. ang c iu tr bi captopril- mt
thuc c ch men chuyn thng gy chng ri lon v gic, thm ch l mt v gic. Cc tc
dng khng mong mun ny ca captopril xut hin ph thuc liu dng.
Tuy nhin, vic s dng mui n king tng hng v cho mn n khng phi l mt gii php
tt. Trn thc t, cc sn phm ny c th khng cha natri nhng li c th cha kali vi mt
hm lng khng nh (v d, 100g mui Xal c cha 32g kali).
Thm na, ng B. cn ang c iu tr bi 2 thuc h huyt p cho php n nh kali trong
huyt tng : captopril mt thuc c ch men chuyn c tc dng lm tng kali mu v
furosemid, mt thuc li tiu quai lm gim kali mu. Do , khng nn lm thay i mc kali
huyt tng n nh ny bng cch s dng mt loi mui cha nhiu kali. Khi nng ion kali
trong huyt tng > 5 mmol/L, n c th gy ra mt s triu chng bnh nhn nh vn c
bp (mi c, t lit), thm ch c th nh hng n nhp tim (ri lon nhp tim v ngng tim).
Dc s khuyn b v khng nn mua mui n king khi cha c kin ca bc s. trnh vic
b v t mua loi sn phm ny ca hng, dc s cn phi gii thch rng loi sn phm ny
c th lm tng nng kali v iu ny rt nguy him cho chng b. Ngoi ra, dc s goi
in thoi v tho lun v vn ri lon v gic v mt v gic ca ng B. vi bc s k n v

cn nhc captopril c th l nguyn nhn ca cc triu chng ny. Theo , bc s thay th
captopril bi Acuitel 5mg (quinapril) v thuc ny khng gy ra cc tc dng khng mong mun
trn. Mt thi gian sau, b v bo li rng ng B. n ngon ming hn.
Thi x tr
Li khuyn v ch n dnh cho bnh nhn tng huyt p
Nu bnh nhn tha cn, cn nhn mnh tm quan trng ca vic gim cn, vic gim
10kg trng lng c th c th cho php gim huyt p t 5mmHg n 20mmHg
Gim lng mui s dng n di 6g/ngy (ch n khng mui l bt buc cc

bnh nhn suy tim v suy thn): hn ch s dng khoai ty chin, bnh quy gin, tht ngui,
pho mt cng, thn trng i vi cc thc phm qua ch bin v cc loi nc khong si
bt c lng natri cao hay cc loi ng n king giu kali.
C ch n lnh mnh v cn bng vi nhiu rau, hoa qu, u tin s dng cc thc
phm giu acid bo khng bo ho.
Hn ch s dng cc cht cha cn (ung di 2 cc/ngy n gii v 3 cc/ngy vi

nam gii), c ph v cam tho.
Vn ng th cht mt cch thng xuyn, v d i b (l tng nht l 30 pht mi

ngy, tuy nhin mt vi bnh mc km ca bnh nhn c th khng cho php vn ng)
Nhn mnh tm quan trng ca vic b thuc l

Thn trng vi vic t dng thuc, mt vi loi thuc c th lm tng huyt p, v d
nh cc thuc NSAIDs hay cc thuc co mch dng xt mi.
iu cn nh
Cc loi mui n king c cha kali c th gy ri lon kali mu cc bnh nhn c bnh v c
v tim. Vic s dng sn phm ny mt bnh nhn ang c iu tr bi mt thuc tr tng
huyt p c tc dng lm tng kali (nhm c ch men chuyn, nhm chn th th angiotensin II,
aliskiren) cn c kin ca chuyn gia y t v cn c gim st nghim ngt nng kali mu.
5. Ca lm sng tng tc thuc ca NSAID bnh nhn tng huyt p
ng S., 58 tui ang ang c iu tr bi thuc Lodoz (bisoprolol + hydrochlorothiazide)
10/6.25 1 vin mi sng t 3 nm nay. Thi gian gn y, ng nhn thy huyt p ca mnh
khng n nh. Do , cch y 15 ngy, bc s ca ng k thm thuc Amlor 5mg
(amlodipine) 1 vin/ngy dng trong 1 thng. Hm nay, ng S. gh quy thuc mua thm
thuc ibuprofen tr au u bt thng v mt .
Vic dng ibuprofen c hp l ?
Khng, y khng phi loi thuc gim au thch hp vi ng S. Thm ch, nhng cn au u
m ng S. gp phi c th l tc dng khng mong mun do thuc ang dng.
Phn tch ca
Cn trnh s dng cc thuc gim au nhm NSAID (c bit l t dng thuc) cc

bnh nhn tng huyt p. Cc thuc NSAID c ch tng hp prostaglandine, gy co mch v
lm gim tc dng ca cc thuc tr tng huyt p. Bn cnh , cc thuc ny lm gim ti
mu cu thn do lm tng nguy c suy thn cp cc bnh nhn ang iu tr
bng thuc li tiu, thuc c ch men chuyn v thuc chn th th angiotensin II.
Hn na, cn thit phi hi ng S. v nguyn nhn ca cc cn nhc u xut hin
khng lu sau khi bt u dng amlodipine. Trn thc t, cc thuc nhm dihydropyrin l cc
loi thuc gin mch c tc dng khng mong mun thng gp l au u, hay nng mt.
Cc triu chng ny thng xut hin khi bt u iu tr v sau gim dn. Ph mt hoc
chn cng c th xy ra.
Thi x tr
Dc s cn khuyn ng S. khng nn s dng ibuprofen m thay vo t vn cho ng s
dng paracetamol dng vin (khng dng dng si bt v c cha nhiu natri). Dc s cng cn
khuyn ng S. lin h ngay vi bc s nu cc cn au u khng thuyn gim.
iu cn nh
Cn trnh t s dng cc thuc NSAID cc bnh nhn tng huyt p do nguy c lm gim
hiu qu ca thuc iu tr tng huyt p v suy gim chc nng thn cp tnh.
6. Ca lm sng bnh nhn i tho ng c nng cholesterol thp

Ca lm sng:
Mt bnh nhn (BN) nam 54 tui biu hin bnh thng, b i tho ng typ 2 5 nm nay,
pht hin nng cholesterol rt thp. Tin s bnh nhn khng b m nng, km hp thu, bnh
tim mch hay ri lon chc nng thn kinh no. Bnh nhn ht thuc 30 nm nay, khng ung
ru hay dng bt k thuc h lipid no. Ngoi ra, bnh nhn khng n king. Tin s gia nh
gm t qu (cha BN cht tui 52) v suy thn mn (anh trai bnh nhn lc 57 tui). Con trai
c ca BN cht tui 21 nghi ng do nhi mu c tim. BN c huyt p 120/80 mmHg, nhp
tim 78 ln/pht v BMI l 32kg/m2. Kt qu kim tra sc khe bnh thng. Siu m bng cho
thy c thoi ha m gan v gan to nh. Siu m tim qua thnh ngc bnh thng, v kt qu
kim tra gng sc (Bruce protocol) m tnh.
Cc chn on cn lm sng c thc hin. Nng huyt thanh ca cc enzym gan, kt qu
kim tra chc nng tuyn gip, gi tr cc thng s huyt hc bnh thng, tng t vi bilirubin,
creatinin, urea nitrogen, acid uric v calci huyt thanh. ng huyt lc i cao [155 mg/dL (8,6
mmol/L); so vi khong tham chiu 60 110mg/dL (3,33 6,11 mmol/L)], v kt qu HbA 1c ca
bnh nhn l 7% (mc bnh thng 4 6%). Kt qu chn on cn lm sng cc lipid,
lipoprotein, apolipoprotein, protein, immunoglobulin, cc vitamin tan trong du v cc tin
vitamin huyt thanh xem trong bng 1. Ghi ch: Nng huyt thanh ca cholesterol ton phn
(TC), cc triglycerid (TG), LDL cholesterol (LDL-C), v apolipoprotein B (apo B) tt c u
gim nhiu. Nng huyt thanh ca protein ton phn v globulin u cao. Kt qu kim tra
huyt thanh cc virus vim gan A, B, C v HIV m tnh.
Bng 1. Kt qu xt nghim cn lm sng.
Cc thng s
Lipid, lipoprotein, v apolipoprotein
TC, mg/dL (mmol/L)
TG, mg/dL (mmol/L)
LDL-C, mg/dL (mmol/L)
HDL-C, mg/dL (mmol/L)
apo A-1, mg/dL (g/L)
apo B, mg/dL (g/L)
Cc thng s
Serum protein v immunoglobulin
Protein ton phn, g/dL (g/L)
Albumin, g/dL (g/L)
Globulin, g/dL (g/L)
2-Microglobulin, mg/L (nmol/L)
IgA, mg/dL (g/L)
IgG, mg/dL (g/L)
IgM, mg/dL (g/L)
Cc tin vitamin v vitamin tan trong lipid
Vitamin E, mg/dL (mol/L)
-Carotene, g/dL (mol/L)
TG, triglycerides. Gi tr mong mun c ghi trong ngoc n. Gi tr ti u c ghi trong ngoc n.
Nhng cu hi tho lun ?
1.
2.
Loi lipid no thay i bt thng bnh nhn T typ 2 ?

Nhng nguyn nhn no c th dn n lng cholesterol, LDL, v apo B huyt tng
thp ?
3.
Tin hnh thm th nghim no c th lm r nguyn nhn gim nng lipid trong
trng hp ny?
4.
Da vo kt qu protein ton phn v globulin huyt thanh ca bnh nhn th nn lm
thm th nghim no na khng?
BN LUN
Tng quan v h beta-lipoprotein mu
H betalipoprotein mu (hypobetalipoproteinemia HBL) c nh ngha l nng huyt
tng ca TC, LDL-C, hay apo B thp hn bch phn v th 5 (ch thch bch phn v ca
ngi hiu nh cui bi). HBL nguyn pht gm mt nhm cc bnh lin quan n ri lon di
truyn: abetalipoproteinemia (ABL), bnh tch ly chylomicron (chylomicron retention disease

CMRD), v HBL c tnh gia nh (familial Hypobetalipoproteinemia -FHBL).
ABL v CMRD l bnh do ri lon gen ln rt him gp vi s t bin cc gen MTTP (m ha
protein vn chuyn triglycerid) v gen SAR1B [m ha SAR1 homolog B (S. cerevisiae)]. ABL
thng c chn on sm vi cc c im nh tiu phn m (steatorrhea), khng dung np
vi cht bo ng ung, bnh hng cu gai (acantocyte), vim vng mc sc t v bt thng
h thn kinh. Kt qu xt nghim lipid huyt tng ca bnh nhn ABL c c im nng
huyt tng TC, VLDL v LDL cc k thp, v gn nh hon ton khng c apo B. c im
ca CMRD l khng c s hin din ca apo B-48 trong huyt tng. Chng tiu phn m , suy
dinh dng v chm ln l biu hin lm sng chnh ca CMRD. Bi v s tng hp Apo B
gan vn c duy tr, LDL vn hin din trong huyt tng.
FHBL l mt ri lon ng tri (codominant disorder) vi tn sut dng d hp t t 1/500 n
1/1000. Cc FHBL d hp t thng khng c triu chng nhng cng c th xut hin bnh
gan nhim m khng do ru vi nng ca cc enzym gan tng nh. FHBL ng hp t c
th gy ra hp thu km cht bo nghim trng, biu hin lm sng v ha sinh d di ging nh
bnh ABL. Th v ch, nng apo B huyt tng thp hn d kin i vi vic ch mt gen
b thiu ht nh trong ca lm sng ny. Xp x 50% cc bnh nhn FHBL mang t bin gy
bnh gen APOB [m ha apolipoprotein B (bao gm khng nguyn Ag(x)]. Hu ht nhng t
bin gen APOB dn n s hnh thnh cc dng apo B b rt ngn (truncated apo B), lm gim
kh nng vn chuyn lipid t cc t bo gan nh lipoprotein. Nhng dng apo B b rt ngn c
kch thc nh hn apo B-30, khng th pht hin c trong huyt tng v chng b loi b
nhanh chng. Cc dng b rt ngn c th pht hin c c v thng gp bnh nhn HBL
mc va, v cc phn t apo B b rt ngn nhng loi di vn cn gi kh nng lin kt lipid
to thnh cc phn t lipoprotein. Cc phn t apo B b rt ngn dng ngn hn apo B-70,5
c lc ht khi huyt tng ch yu bi thn, trong khi cc phn t apo B b rt ngn c kch
thc >= 70% so vi apo B-100 c o thi bi gan.
HBL cng c th gy ra do vi yu t khng di truyn, nh ch n king nghim ngt, thiu
dinh dng, dng mt s thuc v mt s bnh. Nhng yu t ny c xem nh l nguyn nhn
th pht gy ra HBL. Bi v gan ng vai tr chnh trong chuyn ha hu ht cc phn t
lipopprotein v apolipoprotein huyt tng, cc loi lipid trong huyt tng s c s thay i khi
c cc tn thng t bo gan, v d nh nhim virus vim gan B v C, x gan hay ung th gan.
Nhng bnh v nhu m gan mn tnh (bao gm ung th biu m t bo gan) lm gim
cholesterol huyt tng do suy gim tng hp v chuyn ha cholesterol. Hn na, vic gia tng
tiu th cholesterol ca cc t bo khi u ng vai tr gim cholesterol huyt thanh trong ung th
biu m t bo gan. Nhim HIV cc giai on sau c c im nng TC, HDL-C v LDL-C
gim v nng TG trong huyt tng tng. Tng bi tit cholesterol v tng ti to LDL c
cho l nguyn nhn gy ra h cholesterol mu ngi cng gip. Suy dinh dng v vim
nhim c cho l nguyn nhn ca h cholesterol mu nhng bnh nhn chy thn mn.
Phn tch su hn v nng thp Apo B v LDL-C

Tng lipoprotein mu (hyperlipoproteinemia) th cp c nng VLDL-C tng v nng
HDL-C gim cng vi i tho ng typ 2 (T typ 2). ng ch l mc du ang b T
typ 2, nhng bnh nhn ny c nng lipid huyt tng rt thp. Khi bnh nhn c hi c
th, bnh nhn nh trc y nng cholesterol cng thp (nhng khng c d liu c th).
loi tr tnh gy nhiu trong php o, chng ti nghin cu cc phn ng ng hc ca cc
thng s lipid c o lng bi h thng Roche Modular v cc kit thng mi. Cc th
phn ng bnh thng v d liu t bnh nhn ph hp vi tt c cc tiu chun sinh ha khng
nh chn on bnh nhn b HBL.
Trong chn on phn bit, nguyn nhn th pht ca HBL c loi tr u tin. V bnh nhn
khng n king v khng s dng bt k thuc no lm gim lipid. Hn na, bnh nhn khng
c du hiu, triu chng hay xt nghim ca bt k bnh no c th lin quan n HBL th cp.
Do bnh nhn ny c chn on thuc kiu HBLnguyn pht.
Bnh ABL, CMRD v FHBL ng hp t thng c tnh cnh lm sng nng, c bit tr em
v ngi tr. Tuy nhin bnh nhn ny khng c biu hin km hp thu, vim vng mc sc t
hay bnh h thn kinh v khng c triu chng no ca bnh hng cu gai. Nhng biu hin lm
sng nh gi mt cch kh chc chn chn on lm sng ca bnh FHBL d hp t. Trn c
s tin s gia nh c con trai cht t ngt lc cn tr v nhng ngi mang gen FHBL d hp
t dng cu trc on ngn c nguy c tin trin bnh gan nng hn khi c mt nhng yu t
khc c th gy tn thng gan, chng ti xc nhn li chn on thng qua chn on phn
t bng vic xc nh t bin trn gen APOB. Phn tch chui gen APOB cho thy c s thay
th 1 nucleotid n exon 26 (c.7692C>T) tnh trng d hp t. S thay i ny lm bin
i codon arginine v tr 2495 thnh mt codon kt thc (p.R2495X), dn n s hnh thnh

mt apoB b rt ngn cha 2494 acid amin n phn (thay v 4536 acid amin protein apoB y
). on ngn apoB ny c gi l apoB-55 theo danh php quy c, trc y c m t
trong bnh FHBL.
Bnh h betalipoprotein mu c tnh gia nh (FHBL), i tho ng typ 2 v bnh tim
mch
Bnh tim mch l mt bin chng nng n c bit n nhiu ca T typ 2. Nhng kt qu
tin cu t nghin cu Bruneck cho thy T typ 2 l mt yu t d bo kh chc chn bnh x
va ng mch cnh. Dng b dy lp ni trung mc ng mch cnh lm ch im ca bnh tim
mch c p dng trong nhiu th nghim nghin cu bnh nhn T typ 2. Mc d bnh
nhn trn c vi yu t nguy c tim mch, bnh nhn vn cha c biu hin ca bt k bin
chng v mch mu ln no. Thm na, b dy lp ni trung mc ng mch cnh ca bnh
nhn l bnh thng (0,53 0,58 mm) v khng c mng x va ng mch. Nhng pht hin
ny cho thy tc dng bo v ca nng thp LDL-C trong bnh h betalipoprotein mu c tnh
gia nh v ph hp vi nghin cu ca Pulai v cng s. Nghin cu cho thy khng c bin
chng mch mu ln trn 2 trng hp b T typ 2 v c hai loi apo B-55.
Th nghim tin hnh i vi s tng protein huyt thanh ton phn
Vi kt qu nng ca protein ton phn v cc globulin huyt thanh tng, mt s th nghim
su hn c tin hnh trn bnh nhn. nh lng immunoglobulin cho thy nng IgA tng
nhiu, nng IgM gim r rt, v nng IgG ranh gii thp (bng 1). in di protein huyt
thanh pht hin thy mt nh nhn n dng 1,57 g/dL (15,7 g/L) vng . Di n dng
ny c m t nh mt di IgAk thng qua in di c nh min dch (immunofixation) huyt
tng. in di protein v in di c nh min dch ca nc tiu khng pht hin s c mt ca
protein n dng. Cc t bo mu tng t (t 5%-6%) trong ty xng (gii hn bnh thng
0,2%-2,2%). Kho st Xquang xng pht hin khng c tn thng hy xng. V bnh nhn
khng thy c biu hin lm sng lin quan ti tng globuline n dng (monoclonal
gammopathy) nh tng calci huyt, thiu mu, suy thn hay tn thng xng, bnh nhn c
chn on b bnh l gama n dng cha xc nh (monoclonal gammopathy of undetermined
significance -MGUS). MGUS l s ri lon tin c tnh khng triu chng, c xc nh thng
qua cc test mu thng quy, thng thy nhng ngi trn 50 tui. MGUS c xc nh vi
nng protein n dng huyt thanh 3,0 g/dL ( 30g/L) v cc t bo mu trong ty xng
10%, m khng c bng chng v a u ty hay ri lon c tnh khc c lin quan.
Nh vy, ca ny, bnh nhn b i tho ng khng triu chng v nng cholesterol huyt
thanh rt thp, sau khi tin hnh cc kho st, bnh nhn c chn on c lp xc nh b
ng thi bnh FHBL v MGUS. Bnh nhn sau c chuyn n khoa ni tit v khoa tiu
ha theo di bnh T typ 2 v gan nhim m . Thm vo , khoa huyt hc cng s theo
di bnh nhn v bnh nhn b MGUS lm tng nguy c b a u ty.
NHNG IM CN NH:
1.
H betalipoprotein mu (HBL) c xc nh bng cc nng TC, LDL-C hay apo B

huyt tng thp hn bch phn v th 5. HBL c th do t bin gen (HBL nguyn pht) v
do cc yu t khng thuc di truyn (HBL th cp) nh ch n king h khc, khng
dinh dng, mt s thuc hay b mt s bnh.
2.
H betalipoprotein mu c tnh gia nh (FHBL) l mt ri lon nhim sc th ng
tri nguyn nhn c th do t bin gen m ha apo B dn n vic hnh thnh nhng on
ngn apo B.
3.
FHBL d hp t thng khng c triu chng nhng cng c th gp bnh gan nhim
m khng do ru v nng cc enzyme gan trong huyt tng tng nh. FHBL c th c
c tnh bo v chng li s pht trin ca chng x va ng mch, v n hn ch thi gian
phi nhim ca nhng lipoprotein apo B gy x va ng mch.
4.
Bnh l gama n dng cha xc nh (monoclonal gammopathy of undetermined
significance MGUS) l bnh ri lon tin c tnh khng triu chng vi nng protein
n dng trong huyt thanh 3,0 g/dL ( 30g/L) v cc t bo huyt tng trong ty xng
10% m khng c bng chng v a u ty hay ri lon c tnh khc c lin quan.
Ch thch cc thut ng bi ngi dch/hiu nh:
Bch phn v (a percentile or a centile): l mt o lng c dng trong xc sut ch gi tr
m c tnh t l d liu trong mt tp hp cc s liu ri vo vng cao hn hoc vng thp
hn mt gi tr cho trc. S phn v th X l mt gi tr m ti nhiu nht c X% s trng
hp quan st trong tp hp cc s liu c gi tr thp hn gi tr ny v nhiu nht l (100 X)%
s trng hp quan st c gi tr ln hn gi tr ny. Do :
+ Bch phn v th 5 l gi tr m ti c nhiu nht l 5% s c th c gi tr quan st l km
hn gi tr ny.
+ Bch phn v th 25 (cn gi l nht t phn v (the first quartile Q1)), l gi tr m ti
nhiu nht l 25% s quan st l km hn gi tr ny.
+ Bch phn v th 50 (cn gi l trung v hay nh t phn v (median or second quartile Q2)) l
gi tr m ti nhiu nht l 50% s quan st l km hn gi tr ny.
+ Bch phn v th 75 (cn gi l tam t phn v (the third quartile Q3)) l gi tr m ti
nhiu nht l 75% s quan st l km hn gi tr ny.
+ Bch phn v th 90 l gi tr m ti nhiu nht l 90% s quan st l km hn gi tr ny.
ng tri (codominance): c dng m t mt trng hp trong hai alen c biu hin
c lp nhau trong c th d hp. C th d hp c kiu hnh khc vi c th dng hp nhng
khng phi l kiu hnh trung gian. Mt th d v hin tng ng tri c tm thy nhm
mu A-B-O ca ngi. Ngi mang nhm mu A c alen A v ch biu hin glycoprotein A trn
t bo hng cu, ngi mang nhm mu B c alen B v ch biu hin glycoprotein B. Tuy nhin,
ngi mang nhm mu AB c c hai alen A v B v biu hin c hai glycoprotein, v vy kiu
hnh ca h khc bit so vi hai kiu hnh trn. Trong trng hp ny, c hai alen A v B u c
biu hin nh nhau.
7. Ca lm sng ho dai dng nghi ng do thuc c ch men chuyn bnh

nhn tng huyt p
Bnh nhn nam 65 tui, c theo di tim mch nh k (1 ln/nm) bi 1 bc s tim mch.
Trong cc t thm khm, bc s iu tr s kim tra v cho tip n thuc cho giai on tip
theo: Tahor 40 (atorvastatine), Coversyl 4 (perindopril) v Lodoz 2.5/6.25 (2,5 mg
bisoprolol/6,25 mg hydrochlorothiazide). Vo thng 2, bnh nhn bt u phn nn v nhng
cn ho khan xut hin v m khin bnh nhn kh ng ko di khong mt thng gn y. Bnh
nhn s dng Aerius (desloratadin khng H1), sau l Xyzall (levocetirizin khng H1
th h mi) v Helicidine (thuc gim ho) nhng tnh trng ho khng c nhiu ci thin. Bnh
nhn quay tr li nh thuc vi 1 n thuc gm: Solupred 20 (prednisolone) v Hexapneumine
(pholcodin thuc ho opiat phi hp chlorphenamin khng H1).
Lu g v n thuc mi ca bnh nhn
gim ho, bc s k cho bnh nhn cc thuc iu tr d ng, tuy nhin trong trng hp
ny, cn thit phi xc nh r nguyn nhn gy ho cho bnh nhn.
Phn tch ca
Cc thuc c ch men chuyn angiotensin (IEC) t lu c bit n v tc dng ph thng
gp l gy ho khan, cn ho dai dng, vo ban ngy hoc ban m, cc biu hin ny s ht sau
khi dng thuc mt vi ngy. Ho c th xut hin trong khong thi gian t 1 vi tun n vi
thng, sau khi bt u iu tr. Ho c cho l h qu ca tc dng dc l ca thuc, do gy
tng nng , tc ng ca bradykinin trn ng h hp (bi tc dng c ch men chuyn
angiotensin). Mt s bnh nhn d b ho hn khi s dng cc thuc IEC so vi cc i tng
khc, v d trn nhng ph n khng ht thuc l.
Danh sch cc thuc c th gy ho
X tr:
Bc s iu tr ca bnh nhn c lin h xut thay th thuc Coversyl bng mt thuc

h p nhm khc, v d: nhm i khng th th angiotensin II (sartan) t c kh nng gy ho
hn (thng gp 2-4% bnh nhn). Thng tin ny cng c ghi r trong h s bnh n
trnh vic s dng IEC cho bnh nhn ny trong nhng ln tip theo.
Lu
Cc thuc IEC gy ho khong 10% bnh nhn c iu tr. Cn cn nhc, phn tch, r sot
mt cch c h thng cc thng tin khi gp mt trng hp ho khan khng r nguyn nhn.
8. Ca lm sng gp c mng khi ng khi dng thuc chn beta giao cm

bnh nhn tng huyt p
Bnh nhn n 58 tui c iu tr tng huyt p khong 4-5 nm nay. Ba thng trc, bc s tim
mch ca bnh nhn i n thuc ca b t thuc li tiu sang dng Avlocardyl LP 160
(propanolol). Hm nay, bnh nhn n khm bc s do bnh eczema v c k mt ch
phm corticoid dng ngoi da cng vi Alprazolam 0.25, 1 vin trc khi ng (ung khi cn)
do bnh nhn phn nn gn y mnh ng khng yn gic v thng thc gic gia m do gp
phi c mng.
K mt thuc nhm benzodiazepin c phi l gii php cho bnh nhn ny ?
Alprazolam l mt thuc an thn nhm benzodiazepin c tc dng gip bnh nhn khng b
thc gic v m nhng bn thn n li c th hnh thnh cc cn c mng trong gic ng. Cn
lun ghi nh rng iu tr bng thuc ny nn c dng trong thi gian ngn nht c th do kh
nng gy ra hin tng ph thuc thuc tng i nhanh.
Phn tch ca
C nhiu loi thuc c th gy ra cn c mng cho bnh nhn, c trng l cc thuc c tc dng
loi tr giai on gic ng nghch o hay cc thuc kch thch h dopaminergic. Trong s
cc thuc ny, nhng thuc hay gy ra tc dng ny nht l cc thuc an thn/gy ng, mt vi
cc thuc thuc nhm dopaminergic v mt s thuc chn beta giao cm, c bit l cc
thuc c cu trc phn t thn du (nh propranolol v oxprenolol) do d i qua hng ro mu
no.
X tr :
Do bnh nhn gp tc dng khng mong mun khi mi bt u s dng benzodiazepin nn
cn phi trao i vi bc s v kh nng gp tc dng khng mong mun ca Avlocardyl. Bc s
tim mch quyt nh thay Avlocardyl bng Clectol (celiprolol), c cu trc t thn du hn.
Hai tun sau, bnh nhn B. khng nh khng cn gp cc ri lon v gic ng na.
Lu
Cc thuc chn beta c th gy ra cc ri lon thn kinh trung ng v tm thn kinh. Ri lon
thng gp nht l cc bt thng v gic ng (mt ng, gp c mng).
Mt s thuc c th gy cn c mng
Thuc tr ri lon tng ng gim ch : methylphenidate, lisdexamfetamine, amphetamine + dextroam

Thuc tr AIDS: efavirenz
Thuc an thn: duloxetine, venlafaxine
Khng sinh: ciprofloxacine
Thuc tr trm cm: nhm ba vng; c ch ti thu hi serotonine; c ch MAO
Khng histamin
Thuc tr ng kinh: phenobarbital, clonazepam
Thuc tr l ln (Alzheimer): donepezil, risperidone, rivastigmine
Thuc tim mch: chn beta giao cm thn du (atenolol, nadolol, propranolol v oxprenolol); digoxin, co
Thuc tr tng huyt p: ACE-inhibitors; nhm chn calci; chn beta giao cm ; clonidine, losartan
Thuc gim au: naproxen, ketamine, morphine
Thuc tr Parkinson: amantadine, ropinirole
Thuc tr tm thn phn lit : clozapine, risperidone, olanzapine
Thuc gy ng: temazepam, triazolam, zolpidem, eszopiclone
Thuc gip cai thuc l: varenicline, ming dn cha nicotine, bupropion
Thuc nhm statin: atorvastatin, simvastatine, rosuvastatine
9. Ca lm sng lin quan n ADR ca furosemid bnh nhn tng huyt p

83 tui
Bnh nhn n R. l mt ngi c vc dng nh nhn (nng 36 kg, cao 1m45) v rt vui ti,
nhanh nhn d b 83 tui. Vo thng 7, bnh nhn n hiu thuc mua li thuc theo n,
gm c Lasilix 20 (furosemid), Coversyl 4 (perindopril) v Kardgic 75 (aspirin), v yu cu
dc s do li huyt p do BN cm thy mt mi. Ti thi im yu cu, bnh nhn c biu hin
hi l ln , gp kh khn khi din t suy ngh ca mnh, v than phin v cc cn au u
ngy cng ti t hn. Sau vi pht ngh ngi, huyt p ca bnh nhn o c l 110/75.
Biu hin l ln ca bnh nhn R. c phi l du hiu chng t b bt u b bnh
Alzheimer khng ?
Trong trng hp ny, nhng biu hin l ln c th l do tc dng khng mong mun ca
thuc.
Phn tch ca
Furosemid l thuc li tiu quai mnh v lm mt nc, gy tnh trng h natri mu trn bnh
nhn.
H natri mu l tnh trng ri lon tin trin dn dn theo thi gian, c th c pht hin thng
qua cc xt nghim sinh ha (gi tr bnh thng khong 135 mmol/L). N c th gy ra tnh
trng h huyt p ng mch. H natri mu nh thng khng c triu chng nhng cng c th
gy au u, ri lon thc, bun nn, nn v mt mi. Nu nng c th gy ph no, hn m
v ngng th.
X tr:
Dc s lin lc vi bc s iu tr ca bnh nhn mi bit bnh nhn khng ti khm trong 2
thng gn y. Bc s yu cu bnh nhn dng Lasilix hon ton v ng thi theo di huyt p
thng xuyn ti nh thuc theo tn sut 1 ln/ 2 ngy. Nh thuc chu trch nhim thng bo kt
qu ch s huyt p ca bnh nhn cho bc s. Sau 2 tun, huyt p ca bnh nhn tng tr li
mc 147/85. Sau , bnh nhn c nh gi li phc iu tr tng huyt p. Vi thng sau,
huyt p ca bnh nhn vn gi n nh trong khong chp nhn c tng ng vi tui ca
b.
Lu
Trong giai on iu tr tch cc , nhng bnh nhn cao tui ang c iu tr bnh l tim
mch hay tm thn d gp phi cc tc dng c hi ca thuc. Cn phi ngh n cc tc dng c
hi ca thuc khi bnh nhn phn nn v cc triu chng mi c nh au u, chng mt, to
bn, tiu chy, chut rt, au d dy
10. Ca lm sng trm cm nghi ng do dng thuc chn beta giao cm

bnh nhn tng huyt p
Bnh nhn C. nam 81 tui iu tr bnh tng huyt p hn 15 nm nay bng Lopril 25mg
(captopril c ch men chuyn), 2 vin/ngy. Thng 10 nm ngoi, bc s chn on bnh nhn
b vim khp cn iu tr bng corticosteroid cho n khi ht au. Bnh nhn do vy c ch
nh Medrol 16mg (methylprednisolone), 2 vin/ngy trong vng 1 thng, sau chuyn sang
ch 1 vin/ngy. K t thng 1, bnh nhn vn dng Medrol 16mg liu 1 vin/ngy. Cn au
ca bnh nhn c ci thin ng k. Cng vi , liu thuc iu tr tng huyt p ca bnh
nhn c thay i: tng liu ca Lopril ln 75 mg/ngy, sau l 100 mg/ngy chia 2 ln.
Thng trc, ch s huyt p ca bnh nhn vn mc cao v bc s k thm thuc
Tenormine (atenolol, nhm chn beta) kim sot tnh trng ny. Hm nay, v bnh nhn khi
n mua thuc mi theo n cho chng: Medrol 16 mg, 1 vin/ngy; Lopril 50, 3 vin/ngy v
Tenormine 100, 1 vin/ngy. B c cho bit do ny tinh thn ca chng b khng tt. ng
thng hay lo lng, bn chn v khng hiu l do ti sao thuc c k khng th kim sot tnh
trng tng huyt p. Thm na, bnh nhn cn rt mt mi v cm thy kh khn khi i b mi
sng theo thi quen. Thi gian gn y, bnh nhn cn thy chn n do khng cm thy ngon
ming. May mn l bn cnh , tnh trng au do vim khp ca bnh nhn c ci thin
tt hn rt nhiu.
Liu c phi bnh nhn C. bt u c du hiu trm cm ?
Nhng biu hin c m t bnh nhn (tinh thn km, mt mi v chn n) phi c nh
gi thn trng v c th l du hiu ca hi chng trm cm. Tuy nhin, cc du hiu ny xut
hin sau khi thay i n iu tr nn cng cn phi cn nhc c th l do phn ng c hi ca
thuc.
Phn tch ca
Liu Medrol bnh nhn ang dng iu tr l tng i cao i vi phc iu tr ko di
trong nhiu thng v thng d gy ra cc phn ng bt li, bao gm tc dng gi nc l
nguyn nhn gy tng huyt p ca bnh nhn. Chnh do s tng ch s huyt p ny m bc s
phi:
Thm vo phc iu tr bnh tng huyt p bnh nhn mt thuc chn beta-giao cm
atenolol, gy chm nhp v gim cung lng tim, c th l nguyn nhn khin bnh nhn mt
mi trong mt, hai thng u tin dung thuc.
Tng liu ca Lopril, c th dn n thay i v gic, lm bnh nhn thy chn n. y l tc
dng ph c trng ca captopril liu cao.
X tr:
Bnh nhn C. cn c gii thch v s cn thit phi tng liu, thay i phc iu tr tng
huyt p ca mnh. i vi i tng bnh nhn trn 80 tui, vic iu tr tng huyt p em li
nhiu li ch, c bit trong vic ngn nga tai bin mch mu no. ch kim sot huyt p
trong trng hp ny l huyt p tm thu di 150 mmHg v khng c h huyt p th ng.
Khi ht triu chng ca bnh vim khp, liu php corticosteroid s c ngng dng, huyt
p ng mch ca bnh nhn nn c kim sot, ti thip lp li nhng gi tr trc .
S mt mi bnh nhn ang gp s bin mt sau khi tip tc iu tr bng thuc chn beta mt
thi gian. i vi chng ri lon v gic, bnh nhn cn ni chuyn vi cc bc s gim liu
ca Lopril hoc i sang mt IEC khc. Vic thay th Lopril bng Triatec (ramipril) gip lm
gim cc ri lon v gic trong mt vi ngy v bnh nhn s c li cm gic ngon ming sau .
Lu
Bt u iu tr bng thuc chn beta c th gy ra mt mi trong mt hoc hai thng u. S
mt mi ny s bin mt khi tip tc liu php iu tr nhng thng sau .
Mt s tc dng c hi ca nhm chn beta giao cm
11. Ca lm sng qu liu morphin bnh nhn suy thn

Bnh nhn (BN) n 56 tui ngi M gc Phi, c iu tr khn cp tnh trng nhim khun.
Bnh nhn nut kh, n ung qua ng PEG (ng xng d dy t trng qua da), au nng th
pht do lot v t th nm III- IV. Ngoi ra, BN cn c nhng triu chng au khc gm au
bng rt, au nhi t ngn chn n u gi. Hin ti BN cm thy rt kh chu trong ngi, c
tnh im au t nht l 8-9/10 im.
Tin s bnh
Lit tay chn bn tri do tai nn t cch y 1 nm, i tho ng type 2, suy thn giai on
cui, ang lc mu 3 ln/ tun vo th 2/4/6.
Thuc gim au
Duragesic (ming dn fentanyl) 75 mcg/gi, 3 ngy/ln.

Dilaudid (hydromorphone) 2 mg tim tnh mch mi 3 gi gim au.
Lm g kim sot cn au?
Tng liu thuc gim au nhng tng nh th no?
Dng ming dn Duragesic 100 mcg/gi v thay th Dilaudid bng Roxanol (morphine) 20 mg/
ml, t di li 1.5ml mi 3h khi cn thit gim au. Bnh nhn cng c dng 100mg
Neurontin (Gabapentin) 3 ln/ ngy thng qua ng xng PEG.
iu g xy ra?
Bnh nhn gim au t t. Vo ngy th 3, bnh nhn gn nh hn m trong qu trnh lc mu,
huyt p tm thu xung di 80 mm Hg. Bnh nhn tnh tr li khi c tim tnh mch 1 ng
Narcan (Naloxone gii c khi qu liu morphine) v truyn nc mui ng trng.
Chn on s b?
Bnh nhn c nhng triu chng th pht do qu liu morphin.
C phi morphine c thi tr trong qu trnh bnh nhn ang lc mu?
ng vy, morphine c thi tr trong qu trnh lc mu, nhng cc cht chuyn ha ca
morphin th khng. 90% morphin chuyn ha qua gan ln u khi dng ng ung. Thi tr
qua thn ch chim khong 10%. Gn 70% morphine lin hp vi acid glucuronic. Sn phm lin
hp vi acid glucuronic c 2 dng chnh l M3G v M6G (cht chuyn ha chnh ca morphine).
Cc dng chuyn ha chnh ca morphin:
Morphin-3- glucuronide (M3G) c i lc vi receptor yu hn 300 ln so vi morphin, tuy
nhin nng cao, M3G l cht i khng ca receptor opioid, c tc dng kch thch dn
truyn thn kinh v gy nn triu chng git c v d cm sau khi dng morprhin liu cao.
Morphin-6-glucuronide (M6G) c i lc vi receptor cao hn 10 ln so vi morphin. M6G
chn lc hn trn receptor 2, gip gim au, gim bun nn, nn, v gim nguy c suy h hp.
M6G ang c tin hnh th nghim pha III vi tc dng gim au sau phu thut.
Dng lin hp vi glucuronic c bi tit qua ng thn. V vy, trong trng hp b suy thn,
cc sn phm lin hp ny s khng c o thi m tch lu li trong c th v gy c tnh
opioid.
Nhng cu hi t ra l, cc sn phm lin hp gluccuronide c b thi tr trong qu trnh

lc mu khng?
Khng. Theo 1 nghin cu nh trn 2 nhm bnh nhn: nhm khng lc mu gm 8 ngi v
nhm lc mu gm 9 ngi, mi bnh nhn c truyn morphine vi liu 0,1 mg/kg. Nhm lc
mu tin hnh lc mu 2- 4 gi sau khi truyn. Kt qu thu c: nng dng lin hp
glucuronide trong mu c hai nhm cao nh nhau, v nng morphin dng t do trong mu
khng o c (Osborn et al.)
Mc d y khng phi l th nghim quy m ln, nhng nghin cu ny ch ra rng dng
glucuronide khng b thi tr trong qu trnh lc mu trong khi morphin t do c b thi tr. Do
, cht chuyn ho glucuronide s tch ly trong c th khi dng morphin thng xuyn c 2
nhm bnh nhn suy thn c lc mu v khng lc mu, v c th gy ng c opiate.
Chn on cui cng
Qu liu morphin bnh nhn suy thn giai on cui.
Bi hc rt ra t bnh nhn ny?
Khng dng morphin sulphat (MS) gim au cho bnh nhn suy thn, d bnh nhn c lc
mu hay khng, thn trng khi dng MS gim au trong trng hp au cp.
Vi bnh nhn suy thn, c gng s dng nhng opiates thi tr khng ng k qua thn, v d:
fentanyl, hydromophone hay oxycodone.
12. Ca lm sng tiu chy v aliskiren bnh nhn tng huyt p
B L. thng trng nom a con trai nh H. ca b mi ti sau khi n hc t nh tr v. u
tun ny, b n hiu thuc vi n thuc gm: Ralisez 150mg (aliskiren, mt thuc c ch
renine) 1 ln/ngy, y l thuc mi c b sung vo n thuc thng l gm Amlor 10mg
(amlodipine, mt thuc chn calci) 1 ln/ngy v Tenstaten 50mg (cicletanin, mt thuc li tiu
nhm thiazide) 2 ln/ngy iu tr bnh tng huyt p ca mnh. B cng mua n thuc
gm: Vogalne (mtopimazine, mt thuc thuc nhm phenothiazine) tr nn v Smecta
(diosmectite) tr tiu chy cho H. Hm nay, b quay tr li quy thuc v b y b tiu chy.
B y ngh rng mnh b ly bnh t H. v mun bit rng liu b y c th dng Smecta vn cn
nh c khng?
Dc s tr li b th no?
Vo thi tit ma ng nh hin ti, c th b L. b nhim virus, v l nguyn nhn ca bnh tiu
chy. Tuy nhin, khng nn loi tr nguyn nhn tiu chy c th do tc dng c hi ca thuc
gy ra.
Phn tch ca
Theo C quan Y t khuyn co, vic xut hin nhng triu chng mi sau khi dng mt loi
thuc mi th cn phi iu tra xem liu c phi l tc dng c hi do thuc mi gy ra hay
khng. y, bnh tiu chy ca b L. xy ra ngay sau khi dng Ralisez.Theo t thng tin sn
phm, aliskiren thc s c th gy ri lon tiu ha nh tiu chy thng xuyn v au bng
(gp 1-10% bnh nhn). Nhng tc dng ph ny ph thuc vo liu lng s dng thuc.
Thi x l
Ri lon in gii v mt nc l mi lo ngi c th xy ra bnh nhn b tiu chy v c bit
bnh nhn ny cn ang c iu tr thm bng thuc li tiu thiazide. Do , dc s cn ni
r cho bnh nhn tm quan trng ca vic b nc. ng thi, nn khuyn bnh nhn n cm v
trnh cc thc phm giu cht x. tr tiu chy, dc s khuyn b L. dng Smecta (ung cch
xa t nht 2h vi thuc tr tng huyt p) v cui cng l dung loperamide.
Tuy nhin, dc s cng nn tnh n kh nng nhng ri lon tiu ha trn bt ngun t vic s
dng Ralisez. Nn khuyn bnh nhn nu tnh trng tiu chy vn ti din trn 3 ngy, cn phi
bo ngay cho bc s.
iu cn nh
Aliskiren c th gy tiu chy ph thuc vo liu s dng (tc dng c hi ph thuc liu).
13. CLS chng ch nh thuc chn beta giao cm bnh nhn tng huyt p v COPD
B K., 69 tui, ang c iu tr bng Celectol 200mg (celiprolol) 2 ln/ngy v Triatec 5mg
(ramipril) 1 ln/ngy bnh tng huyt p. B c tin s ht thuc l, va c chn on b bnh
phi tc nghn mn tnh (COPD). B y n quy thuc mua thuc theo mt n thuc do
khoa h hp k, gm c Zeclar 500mg (clarithromycin) 2 vin/ngy ung trong 5 ngy v
Bricanyl turbuhaler (terbutalin) ht mt ln khi cn. B K. cng nhn c hi ny mua thm thuc
tr huyt p. Dc t T. c mt ti quy bn thuc.
Nhng vn dc t lo lng l g ?
Thc t b K. b COPD v bc s k thuc terbutalin (kch thch th th ) trong khi b y
ang iu tr bng celiprolol (thuc chn th th ).
Dc s phn tch trng hp
Thuc chn th th l thuc khng h -adrenergic. Trong khi mt s c tc dng chn lc trn
tim mch, ch tc dng ln recepter 1 ca h adrenalin; mt s khc chn khng ch recepter 1
m cn chn c recepter 2.
Nhng thuc khng chn lc gy mch chm (bng cch chn recepter 1 trn tim mch) v gy
co mch v hp kh qun (do chn recepter 2 ph qun). Do , n c th gy ra cn co tht ph
qun lm nng thm bnh hen suyn hay COPD. Do , thuc chn th th khng chn lc
chnh thc b chng ch nh trong trng hp hen suyn hay COPD.
Trong khi v mt l thuyt, thuc chn th th chn lc trn tim mch khng c tc ng (hoc
tc ng rt t) trn recepter 2 ph qun. Trn thc t, ngay c khi vic chn mt s lng rt t
recepter 2 cng hn ch vic gin ph qun. Do , thuc chn th th chn lc trn tim
mch cng chng ch nh trong trng hp hen suyn v COPD, nhng ch trong nhng trng
hp hen suyn v COPD nghim trng.
Tuy nhin, celiprolol l 1 thuc chn c bit: l cht i vn chn lc trn th th 1 nhng
li c hot tnh ng vn , iu gii thch cho tc dng km trn s co ph qun. Celiprolol
l cht chn duy nht khng chng ch nh trong trng hp hen suyn hay COPD.
X l
Dc s dnh thi gian gii thch cho dc t v thuc celiprolol, vi c im c bit ca
thuc ny, v gii thch bnh nhn ny c th s dng thuc ny mt cch an ton. Hn na,
dc s khuyn dc t T. tham kho sch tra cu Tng tc thuc xem c s tng tc
gia terbutalin v celiprolol (s i khng gia thuc chn th th v thuc kch thch th th
2) hay khng. Kt qu tra cu cho thy s phi hp ny khng b chng ch nh. Do , dc
t T. c th pht c 2 loi thuc ny cho bnh nhn.
Tnh cht ca thuc chn th th :
- Thuc chn th th khng chn lc gy co tht ph qun v co mch mu.
- Celiprolol c tnh ch vn 2 v khng chng ch nh trong trng hp hen suyn v COPD.
- Mt s thuc chn th th (nh nebivolol) lm tng tng hp NO v lm gin mch.
- Thuc chn th th vi hot tnh giao cm ni ti t lm chm nhp tim.
- Thuc chn th th tan trong du qua c hng ro mu no, tnh cht ny c th ng dng
trong iu tr bnh au na u, nhng cng l ngun gc ca tc dng ph gy ra nhng cn c

mng.
14. CLS tng tc thuc vi thuc nhun trng kch thch gy nguy c xon nh
B H., 60 tui, b cao huyt p nhiu nm. Gn y do tnh trng huyt p ca bnh nhn
c kim sot km, cng vi vic nhp tim tng nh dn n vic bc s thm thuc ISOPTIN
(verapamil) 120mg/ ngy vo phc iu tr c bng FLUDEX (indapamide) 1,5mg/ngy v
ODRIK (trandolapril) 2mg/ngy. Hm nay, b H. n mua thuc theo n mi v than phin v
vic b to bn. B tranh th hi kin dc s v thuc nhun trng m b nhn thy trn
qung co truyn hnh DULCOLAX (bisacodyl). Tuy nhin dc s cn phi suy ngh k trc
yu cu ny.
Chng ta c th cung cp thuc DULCOLAX c khng?
- Khng! u tin khi cp n vn ny cn nhn mnh: Dulcolax khng phi l thuc
nhun trng ph hp cho bnh nhn ny. Hn na, cn phi t cu hi v nguyn nhn to bn
ca b H.
Phn tch:
- DULCOLAX (bisacodyl) l thuc nhun trng kch thch, tc ng nhanh (t 5 n 10h). S
dng ko di thuc ny c th lm mt cc cht in gii v gy ra h kali huyt, dn n tnh
trng lon nhp tim nng, hoc gy xon nh. Trong trng hp phi hp thuc nhun trng loi
ny vi mt thuc gy h kali huyt khc, ch s kali huyt bnh nhn cn phi c gim st
cht. y l tng tc cn phi thn trng khi s dng.
- ca ny, b H. ang c iu tr tng huyt p bng indapamide, mt thuc li tiu nhm

thiazid gy h kali huyt. Tnh ti thi im hin ti, nng kali huyt ca bnh nhn kh cn
bng bi v b cng ang c iu tr bng mt thuc gy tng kali huyt, trandolapril. Tht
vy, cc thuc c ch men chuyn lm gim s tng hp angiotensin II, dn n gim tng hp
aldosteron v do lm tng nng kali huyt (aldosteron c tc ng lm thc y bi tit
kali qua nc tiu).
- Do , khng nn khuyn bnh nhn dng thuc nhun trng ny v n nh hng n cn
bng ny, c bit khi b H. cn bt u c iu tr bi verapamil, thuc chn knh calci.
Thuc ny l mt thuc trong nhm IV tr lon nhp, gy chm nhp tim. Tuy nhin chnh
nhp tim chm cng l 1 yu t nguy c gy xon nh. Do , s dng verapamil cn nng
kali huyt cn bng.
Thi x l:
Dc s cn khng nh nguy c h kali huyt ca thuc DULCOLAX, c th dn n xon nh
bnh nhn ny. Mc khc, cn t ra cu hi ngun gc to bn ca b H., c th do Isoptine.
Cn ngh b H. bo v tnh trng gn y ca b v s thay i khng r nguyn nhn cho bc
s, v khuyn tng cng b sung nc cng nh thc phm cha cht x trong ch n. Mc
tiu th hai, cn khuyn dng mt thuc nhun trng thm thu nh lactulose (DUPHALAC),
macrogol (FORLAX), sorbitol (SORBITOL) v nhng thuc ny khng lm gim nng kali
huyt.
Thuc v tnh trng xon nh
- Xon nh l 1 tnh trng ri lon nhp tim c bit, c th gy t vong, vi nhp tht nhanh,
c trng bi hnh nh in tm (ECG) in hnh vi qung QRS tng rng bin ri gim
co hp.
- Kh nng xut hin tnh trng xon nh tng bnh nhn c khong QT ko di (bm sinh
hoc mi mc phi).
- Tnh trng h kali huyt, c xc nh khi nng ion kali trong huyt tng < 3.5 mmol/L
v biu hin bng cc triu chng: mi c v chut rt, l mt yu t nguy c gy xon nh,
cng nh nhp tim chm.
Nh vy, c nhiu loi thuc c th gy xon nh. Chng l nhng loi thuc:
- Ko di khong QT : nh cc thuc chng lon nhp (disopyramid, flecainid, quinidin,
amiodaron v c bit l sotalol), thuc chng lon thn, mt vi thuc khng histamine H1 nh
mizolastine, v ebastine; thuc chng st rt nh halofantrine, mefloquine v quinine; mt vi
thuc khng nm nhm azol nh fluconazol, posaconazol v voriconazol; mt vi thuc chng
trm cm (c bit thuc chng trm cm ba vng).
- Thuc h kali huyt, nh thuc li tiu quai hoc thiazid; thuc nhun trng kch thch; thuc
corticoid
- Thuc chm nhp tim, nh mt lng ln thuc chng lon nhp, thuc chn , thuc chn knh
Calcium lm chm nhp tim (diltiazem v verapamil), ivabradin, digoxin, thuc h huyt p
tc ng ln h thn kinh trung ng, thuc khng cholinesterase.
15. CLS Tng tc thuc bnh nhn tng huyt p v b hng cm nh

Bnh nhn S., nam 48 tui, gn y c nhng biu hin kch ng bt thng, thch lm v ni
v nhng k hoch rt to ln. Bc s tm l m BN ti khm ln u quyt nh rng bnh
nhn cha cn nhp vin nhng cn phi iu tr theo n nh sau : Tralithe 250mg (lithium) 3
vin/ ngy, v Tmesta 2,5mg (lorazepam). Khi t vn cho bnh nhn S., dc s pht hin ra
rng bnh nhn ang c s dng thng xuyn thuc Micardis Plus (telmisartan +
hydrochlorothiazide) (Mua 1 hiu thuc khc).
Liu rng c th bn thuc chng lon thn cho bnh nhn ny khng ?
Khng, do nguy c xut hin tng tc thuc Cn trnh gia cc thuc iu tr tng huyt p
v lithium.
Theo T chc ANSM (Cc quc gia v an ton thuc v sn phm y t), tng tc thuc c
phn thnh 4 mc .
Phn tch ca
Bc s k 1 thuc chng lon thn (lithium) cho bnh nhn S. Lithium l thuc iu tr u tay
dnh cho cc bnh nhn hng cm nh c biu hin kch ng. Nhng n l mt thuc thi tr
qua thn v l thuc c khong iu tr hp, rt d xy ra tnh trng qu liu trong qu trnh s
dng vi cc biu hin nh: nn, chong ngt, ri lon nhp tim, v hn m. Rt nhiu thuc c
kh nng lm tng nng lithium trong mu, khi dng cng, nh : cc thuc li tiu, thuc
chn th th angiotensine II, thuc c ch men chuyn do gy gim thi tr lithium qua ng
nc tiu. Vic phi hp cc thuc ny vi lithium c khuyn co l "Cn Trnh". Khi khng
th trnh c, th cn phi theo di cht ch nng lithium huyt bnh nhn.
X tr :
Dc s quyt nh gi cho bc s iu tr ca bnh nhn S. thng bo vi bc s l hin ti

bnh nhn ang s dng 1 thuc chn th th angiotensin II v 1 thuc li tiu, c kh nng
tng tc vi lithium. Sau khi cn nhc, bc s quyt nh thay th lithium bng valproat. V
valproat s thch hp hn cho bnh nhn ang c iu tr bng thuc li tiu
hydrochlorothiazid so vi carbamazepin d gy h natri huyt. Bc s fax mt n thuc mi
ca bnh nhn cho dc s dc s bn cho bnh nhn.
Lu
Phi hp thuc chn th th angiotensin II, thuc c ch men chuyn hoc thuc li tiu vi
lithium c khuyn co l "Cn trnh", do nguy c lm tng nng lithium trong mu bnh
nhn.
16. CLS Hen ph qun v tng huyt p

B G., 53 tui. B b hen ph qun t khi thiu nin (hen suyn nh dai dng). B c iu tr
nn bng SERETIDE (salmeterol, fluticasone), v dng VENTOLIN (salbutamol) khi cn. Hai
nm trc, b b bnh tim nghim trng v c iu tr vi COUMADIN (warfarin),
DETENSIEL (bisoprolol ) v TAHOR (artovastatin) cho n by gi.
Hm nay, b n mua tip n thuc v b c k b rt mt, kh th v bnh h hp th ngy
cng nng.
Khai thc tin s dng thuc, dc s nhn thy trong 1 nm gn y, b G. 3 ln dng kh
dung, 5 t iu tr khng sinh v 8 chai VENTOLIN. B hi liu c phi giai on mn kinh
ca b lm nng thm bnh hen suyn khng ?
Chng ta c th tr li th no ?
Tht vy, bnh hen suyn c th chu nh hng ca ni tit t, v tn s cn hen t ti a trong
thi k mn kinh. Tuy nhin, cn xem xt n cc nguyn nhn khc.
Phn tch ca
Cn lu tnh trng ca bnh nhn khi bnh nhn c s gia tng nhng t hen suyn nng,
cng nh vic lm dng thuc gin ph qun tc dng ngn.
C th bisoprolol (thuc chn beta) l nguyn nhn lm bnh hen suyn nng hn. Thc t, mc
d bisoprolol c coi l c tc dng chn lc trn tim (ngha l tc dng u tin trn th th
beta-1 tim), tt c cc thuc chn th th beta vn c th lm trm trng thm bnh hen suyn
hin c, do chn cc th th beta-2 ph qun v gy co tht ph qun nng, bt k ng dng
no, k c thuc nh mt. V l thuyt, celiprolol l mt cht chn beta-1 nhng li l cht ch
vn beta-2, nn celiprolol l thuc duy nht s t gy nh hng ln tnh trng hen suyn.
Thi x l
Vi cu hi ca bnh nhn v bnh hen ph qun nng ln, nn khuyn bnh nhn lin h vi
bc s ca mnh. Vi s ng ca bnh nhn ( Php, dc s phi hi s chp thun ca bnh
nhn trc khi trao i vi bc s v tnh trng bnh ca mnh tr khi tnh hung khn cp
nghim trng), dc s in thoi bo vi bc s k toa v vic lm dng cc thuc gin ph
qun ca bnh nhn ,v hi bc s liu vi bnh tim ca bnh nhn, c th thay bisoprolol bng
thuc khc khng. Sau khi cn nhc, dc s quyt nh thay bisoprolol bng thuc c ch men
chuyn BRIEM (benazepril) 5 mg. Su thng sau, bnh hen c ci thin ng k v vic s
dng VENTOLIN gim xung cn mt chai trong 6 thng.
Ch
Vi nhng bnh nhn b tng huyt p, nu c mc km bnh hen suyn kim sot km, cn
kim tra s hp l trong la chn cc thuc h huyt p.
17. CLS. Thuc chn beta bnh nhn tng huyt p v i tho ng
Bnh nhn M., 42 tui nng 60kg, b i tho ng (T) typ 1. ng thng xuyn tim
insulin 4 ln/ngy, HUMALOG (insulin lispro - insulin tc dng nhanh) 7UI/ln, tim 10 pht
trc ba n sng, tra, ti (7h, 12h, 19h); v LANTUS (insulin glargine - insulin c tc dng
ko di) 10UI/ln vo 20h. BN hay gp nhng cn h ng huyt vo bui ti, c ng ghi li
cn thn trong s theo di ng huyt. Vi nm trc, bc s pht hin ng b tng huyt p nh
v cho dng RENITEC (enalapril). Hai nm li y, ng dng CO-RENNITEC (enalapril +
hydroclorothiazide) v trong ln khm cui, huyt p ca ng l 140/85, khin bc s phi k n
thm thuc h huyt p th ba: bisoprolol (chn beta).
C th bn thuc theo n thuc ny khng ?
Cc thuc chn beta khng c chng ch nh nhng bnh nhn tiu ng, nhng phi c
t vn c th.
Phn tch ca
Cc du hiu lm sng ca h ng huyt thay i ty theo mi c th v cc t h ng
huyt. Chng bao gm cc du hiu ca tng adrenaline p ng vi tnh trng h ng
huyt: nhp tim nhanh, nh trng ngc, run ry, m hi, ti nht, i cn co.
Cc thuc chn beta i khng tc dng vi catecholamin ni sinh (c sn xut ra chng li
tnh trng h ng huyt). Do , n lm che khut cc triu chng ca h ng huyt nh run
v triu chng trn tim.
X l
Bnh nhn T c nguy c tim mch cao, v vy, huyt p mc tiu cc bnh nhn ny l
130/80 trong trng hp khng c bin chng thn. t c huyt p ny, cn thit phi
s dng mt loi thuc h huyt p th 3. Ngoi nhng li khuyn s dng tt thuc, iu quan
trng l t vn bnh nhn bnh nhn c kh nng nhn ra cc du hiu ca cn h ng
huyt. Bnh nhn cn tng cng t theo di ng huyt, nht l trong u t iu tr bng
thuc chn beta. Da theo mc ng huyt theo di, bnh nhn nn gp li bc s c
iu chnh liu insulin.
Ch
Cc insulin, cc sulfamide h ng huyt v repaglinide c nguy c gy h ng huyt khi
dng qu liu. Vic dng km chn beta c th che giu triu chng ca h ng huyt.
Clopidogrel v bnh a chy mu mc phi

Bnh a chy mu mc phi l mt bnh kh him gp, chim khong 1-4 bnh nhn trn 1 triu
ngi 1 nm, nht l nhng ngi trn 50 tui. N xut hin do s c mt ca cc khng th
chng li nhng tc nhn ng mu, dn n chy mu nghim trng. Bnh a chy mu mc
phi xut hin t ngt trong nhng trng hp: vim khp dng thp, ung th, lupus ban ri
rc, v c ph n c thai v sau sinh.
12 cas v bnh a chy mu mc phi b quy cho do clopidogrel (Plavix hoc cc thuc khc)
c bo co trn th gii, phn ln nhng ngi c tui t 65 tr ln.
Pht hin ny c tin hnh trn c s ca mt phng php o lng hot ng cephalin b ri
lon trong mu theo thi gian, thnh thong lin quan ti s chy mu, vi nguy c sng cn.
Chn on sau c khng nh bi liu cc tc nhn ng mu. Nhng triu chng xut hin
trong nhiu ngy ti 4 thng sau khi bt u dng clopidogrel. Nhng bnh nhn ny khng c
tin s trc v ng mu bt thng, cng nh cc yu t nguy c chy mu. Nhng vn
ny tn ti 2 ti 3 thng sau khi dng clopidogrel 5 trong s 8 bnh nhn dng thuc lin tc.
C ch xut hin t ngt bnh a chy mu mc phi ny cha c bit.
Trn thc t, mt s tc dng khng mong mun nghim trng nhng him gp ca mt thuc
vn cha c bit n sau mt thi gian di s dng. Tt hn hy ghi nh iu . Clopidogrel
tc ng ti mu bi tc dng chng kt tp tiu cu. Trong trng hp rt him, n c th lm
bin i cc yu t ng mu lin quan ti bnh a chy mu mc phi, v trong trng hp
cn dng dng clopidogrel.
Mi lin h gia metoclopramide v tc dng ph v thn kinh (cc ri lon

ngoi thp) tr em
Metoclopramide c ph duyt ti Canada iu tr chng chm tho rng d dy v h

tr khi tin hnh th thut t ng thng rut non.
Cc hng dc phm sau khi tham kho kin ca B Y T Canada ra thng bo cc thng tin
mi nht v vn an ton thuc lin quan n cc ri lon ngoi thp tr em khi dng
metoclopramid
liu
khuyn
co
0.5mg/kg/ngy.
Ri lon ngoi thp c th xy ra tr em s dng liu metoclopramid theo khuyn co, tc l
khng
vt
qu
0.5mg/kg/ngy
Metoclopramide c chng ch nh tr di 1 tui do nguy c xut hin cc ri lon ngoi
thp
Metoclopramide khng c s dng tr trn 1 tui tr khi c nhng li ch r rng vt tri
so vi cc nguy c tim n.
Cc ti liu chuyn kho ca Canada gn y i vi cc sn phm c cha metoclopramid
c sa i b sung cc chng ch nh v hn ch lin quan n vic s dng thuc ny
tr em.
Vic kim sot v qun l cc tc dng ph ca cc ch phm thuc lu hnh trn th trng ph
thuc vo bo co ca nhn vin y t v ngi s dng. T l cc tc dng ph ca thuc c
bo co mt cch t nguyn thng thp hn thc t. Do , bt k trng hp no gp phi tc
dng ph nghim trng v thn kinh hoc cc phn ng c hi nghim trng hoc tc dng c
hi mi cha c ghi nhn trong y vn khi bnh nhn s dng APO-Metoclop, Metoclopramide
hydrochloride tim, Metoclopramide Omega hoc METONIAMC cn phi c bo co tng

ng cho cc hng dc phm hoc B Y t Canada.
EDOXABAN
New anticlotting drug treats atrial fibrillation, deep vein thrombosis, pulmonary embolism
FDA has approved the anticlotting drug edoxaban to reduce the risk of stroke and dangerous
blood clots in patients with atrial fibrillation that is not caused by a heart valve problem.
Edoxaban also has been approved to treat deep vein thrombosis (DVT) and pulmonary embolism
(PE) in patients who have already been treated with an anticlotting drug administered by
injection or infusion for 5 to 10 days.
Safety and efficacy of edoxaban in treating patients with atrial fibrillation not caused by cardiac
valve disease was studied in a clinical trial of 21,105 participants.The trial compared two dose
levels of edoxaban with the anticlotting drug warfarin for their effects on rates of stroke and
dangerous blood clots.
Trial results showed the higher dose of edoxaban to be similar to warfarin for the reduction in the
risk of stroke. While warfarin is highly effective in reducing the risk of stroke in patients with
atrial fibrillation, it increases the risk of bleeding. Edoxaban demonstrated significantly less
major bleeding compared with warfarin.
Edoxaban for treatment of patients with DVT and PE was studied in 8,292 participants. The
study compared the safety and efficacy of edoxaban to warfarin for treating patients with a DVT
and/or PE to reduce the rate of recurrence of symptomatic venous thromboembolism (VTE)
events (which includes DVT, PE, and VTE-related death). In the trial, 3.2% of participants taking
edoxaban had a symptomatic recurrent VTE, compared with 3.5% of those taking warfarin.
The most common adverse effects observed in trial participants were bleeding and anemia. As
with other FDA-approved anticlotting drugs, bleeding, including life-threatening bleeding, is the
most serious risk with edoxaban. No treatment has been proven to reverse
edoxaban's anticoagulant effect.
Edoxaban has a boxed warning that provides important dosing and safety information for health
professionals about specific patient groups, including a warning that edoxaban is less effective in
atrial fibrillation patients with a creatinine clearance greater than 95 mL per minute. This should
be assessed before initiating therapy with edoxaban. Patients with creatinine clearance greater
than 95 mL per minute have an increased risk of stroke compared with similar patients given
warfarin. Edoxaban should not be used in nonvalvular atrial fibrillation patients with a higher
creatinine clearance. Another anticoagulant should be used instead.
As with other anticoagulants, the boxed warning counsels that premature discontinuation of
edoxaban increases the risk of stroke and notes that spinal or epidural hematomas may occur in
patients treated with edoxaban who are receiving anesthesia injected around the spine or
undergoing spinal puncture.
B F, 54 tui, 60kg b ung th v c iu tr taxotere (docetaxel) truyn tnh mch ba tun mt

ln ti khoa ung th ca mt bnh vin. Trong ba ngy ti, b s c truyn t th ba. t
trc b b gim bch cu trung tnh 3 do thuc gy nn, phi vo nm vin. (bch cu a
nhn trung tnh 700/mm3). Hm lng ny sau tr v bnh thng.
Ni dung bi
Thy thuc k n thuc sau y trnh t gim bch cu trung tnh mi v hng dn cho
bnh nhn c th t tim v dn trc l thuc c th gy au xng. Nu trng hp ny xy ra
th c th ung paracetamol, ti 2 vin 500mg mi ln, ngy 4 ln.
n thuc: (bnh nhn sp dng ho cht t 3 trong vng 3 ngy ti).
- Granocyte 34 (lenograstim): mt ln tim di da /ngy trong 6 ngy, bt u vo ngy th 3.
- Cortancyl 20mg (prednisolon): 5 vin ung vo bui sng trong 3 ngy, bt u ngay trc hm
chy ho cht.
- Dafalgan 500mg (paracetamol) 2 vin, c th 4 ln mi ngy, nu cn thit.
Bnh nhn hi dc s nn dng g v b au ming t hm trc lm b kh an ung.
V cc thuc k trong n:
Granocyte 34 (lenograstim) tim di da (33,6 triu n v quc t trong 1ml). L cytokin
G_CSF (granulocyte colony sti mulating factor) hoc yu t tng trng t bo ht. c ch
nh rt ngn thi gian gim bch cu trung tnh v gim bt t l mc gim bch cu trung
tnh c st bnh nhn iu tr ho cht c t bo. Liu dng: 150 microgam/m 3/ngy, tng
ng vi 5 microgam/kg/ngy. iu tr bt u t nht 24 gi sau khi xong ho liu php.
Cortancyl 20mg (prednison): glucocorticoid, ngoi cc ch nh khc cn c dng trong iu

tr bun nn, nn v nhng t ph v vim khi iu tr chng ung th. Liu dng: 0,35 _ 1,2
mg/kg/ngy. Cng c th dng liu cao hn.
Dafalgan 500mg (paracetamol)
Thuc gim au, h st dng iu tr triu chng au v/hoc trng thi st. Liu lng:
3_4 g/ngy. Cc ln ung phi cch nhau t nht 4 gi.
Pht hin tng tc thuc:
Khng c tng tc no trong n ny.
Phn tch liu dng:
Cc liu u ph hp. Nn dng mt corticoid ung, th d dexamethason 16 mg/ngy trong 3
ngy trc hm tim truyn docetaxel Nh vy tng ng vi 100mg prednison trong n.
Gp v thuc:
Granocyte l mt bit dc cn phi c k n ban u ti bnh vin tng 3 thng mt. n
ny l hp l.
Cch la chn ca thy thuc k n:
- Mc tiu ca n thuc ny l phng nga v chm sc mt s tc dng khng mong mun ca
docetaxel. Thuc chng ung th ny c th gy c tnh huyt hc, rng tc, tng mn cm, tc
dng thn kinh, tim, hoc nc.
- Lenograstim (granocyte) gip rt ngn thi gian gim bch cu trung tnh v nguy c xut hin
gim bch cu trung tnh c st. ngui bnh ny, tng b mt t ln iu tr trc: yu t
tng trng t bo ht ny (G_CSF) kch thch c hiu s pht trin dng bch cu a nhn
trung tnh. Thuc c tim nhm bao chm thi gian m t bo mu h sung thp nht (nadir).
Thng xut hin khong 7 ngy sau khi iu tr ho cht. Chng gim bch cu trung tnh l tc
dng ph hay gp nht i vi docetaxel. N c th l nguyn nhn ca cc t nhim khun.
Prednison lm gim nguy c gi nc lin quan n thuc chng ung th v c tc dng chng
nn, d phng bun nn v nn do ho cht gy nn (i vi nhng iu tr gy nn nh).
Corticoid cng hn ch nguy c phn ng da (ban, nga) sau khi tim truyn thuc chng ung
th.
Paracetamol gip chm sc cc chng au c, au khp do docetaxol gy nn, v au xng do
lenograstim gy ra.
B tr iu tr:
Lenograstim khng c dng ng thi vi ho tr liu c t bo. Mi tim u tin ca

lenograstim c thc hin sm nht l 24 gi sau khi xong t dng ho cht. trng hp b
F, lenograstim c tim vo thi im 3 ngy sau khi truyn docetaxel.
- Vic iu tr docetaxel ch c lp li khi lng bch cu a nhn trung tnh cao hn hoc
bng 1500/mm3.
Can thip bng thuc
- Qua li k ca bnh nhn, ngi dc s nghi vn l chng vim nim mc ming, thng
hay xy ra v c to thun li do kh ming sau khi iu tr thuc chng ung th hoc x tr
- Vim nim mc ming cn c iu tr ngay v c th l ca ng ca mt nhim khun ton
thn. Ngoi ra cn dn n kh chu nh hng n cht lng cuc sng ca ngi bnh ( kh
nut, gy st). Sau khi c bnh nhn ch r ni nim mc ming b au v mc kh chu
(kh nut, au), ngi dc s lin h qua in thoi vi thy thuc k n. ng ny mun gp
li bnh nhn trc ln tim truyn taxotere sau nu cn s li li, tu theo mc ca vim
nim mc ming. ng chuyn bng fax mt n thuc n hiu thuc. Trong c thuc chng
nm fluconazol (Trifucan), liu 100mg/ngy, dng trong hai tun, v sc ming bn ln/ ngy
(500ml dung dch bicarbonatnatri 1,4% trn vi 100ml Hextril). Ch phm ny trong t lnh.
Bicarbonat lm kim ho hc ming. Hexetidin c tc dng st khun. Lng dung dch trn cho
php bnh nhn dng trong nhiu ngy (sc khong 20ml x 4 ln mi ngy). Ht th li mua
thm.
Theo di iu tr
Kim tra: mt khi bt u tim Granocyte (lenograstim). Cn thng xuyn lm cng thc
mu nh gi hiu qu ca cch iu tr bng G-CSF. Phi tim hng ngy cho ti khi vt
qu thi hn (theo d kin) m bch cu tt xung thp nht (nadir) v lng bch cu a nhn
trung tnh tr v bnh thng. C th b F khng phi dng ht s 6 ng tim k n.
- Kim tra u n nhit cng rt quan trng pht hin kh nng xut hin nhim khun.
- Theo ri tnh trng dinh dng v nh gi mc au ca bnh nhn cng cn thit trong tnh
trng vim nim mc ming do ho liu php gy nn.
Tc dng khng mong mun
Lenograstim: Ri lon tiu ho, au xng, khp, ri lon enzym gan, lch to, l nhng tc dng
ph c th gp. Phi theo di lm sng th tch lch. Fluconazol c k n iu tr vim
nim mc ming cng c th gy tn thng gan.
Docetaxel: Thuc chng ung th ny thng dn n h hi mng chn, tay. Ngi bnh cn bi
mt vecni c silic tng sc chu ng ca mng v trnh rng mng.
Li khuyn cho bnh nhn
- phng nhim khun:

Nguy c nhim khun l ln khi b gim bch cu trung tnh. Bnh nhn phi ch n nhng
du hiu gi n nhim khun. Run rt, xanh xao, nht nht, kh . Tuy nhin, st c th b
che lp bi paracetamol. Trng hp st, bnh nhn phi bo cho thy thuc v vic phn tch
mu l cn thit. Trnh tip xc vi ngi cm, cm.
- V tim:
Granocyte bo qun nhit phng. Thuc c ng gi bao gm mt l cha bt
lenograstim, mt bm tim cha dung mi v hai kim. Lau nt l thuc bng alcol, thng
ng ri chc thng nt bng chic kim c ui mu be (19G). Bm lng cha trong bm trn
ri lc nh cho tan hon ton (khong 15 giy) ln l thuc ri ht dung dch ra. Rt kim tim
mu be ra ri thay bng kim tim c ui mu ht d (26G). Loi bt khng kh bng cch p
nh vo thn bm tim v y nh nhng pt tng, kim tim ln trn. Bm di da vng bng,
i hoc cnh tay. Thay i v tr tim sau mi ln tim thuc: Vt b cc th dng vo ni
ph hp.
- V vim nim mc ming
- Sc dung dch thuc trong ming v gi khong 30 giy trc khi nh ra. Khng n hoc ung
g ngay sau thuc c thi gian tc dng.
- Phng kh ming trnh mt s bnh (lot ming, vim nim mc ming, nm). Lnh c tc
dng gim au v kch thch tit nc bt, do nn bo qun thuc sc ming trong t lnh.
Mt mt vin nc lnh trong thi gian tim truyn ho cht c kh nng lm gim nguy c
vim nim mc ming (tc dng co mch)
- Gi v sinh rng ming.
- Nn u tin dng ung v thc n lnh, khng acid. Trnh ru, gia v. Thc n cng rn c
th lm tn thng nim mc.
V au:
Lenograstim c th dn n au xng v vng tht lng. Gii thch cho ngi bnh l au ch
nht thi. Dng paracetamol (Dafalgan) ti hai vin mi ln x 4 ln mi ngy lm gim bt au.
Hng dn cho ngi bnh l c th dng paracetamol gim bt au do vim nim mc
ming.
K hoch dng thuc:
7 gi
12 gi
18 gi
22 gi
Granocyte 34
Cortancyl 20 mg
+ (5 vin)
Dafalgan 500 mg
+ (2 vin)
++
++
++
Xc ming
Trifucan 100 mg
- Granocyte 34: tim ngay sau khi pha thuc.

- Cortancyl: ung 5 vin trong ba n.
- Dafalgan: ung 2 vin mi ln x 4 ln mi ngy, khi au. Cc ln ung cch nhau t nht 4 gi.
Sc ming: nn thc hin sau ba n.
Trifucan: c th ung trong hoc ngoi ba n.
Tm tt
Mt phc m bnh nhn s dng quen thuc vn c th gy ra cc tc dng khng mong
mun. Ngi dc s nh thuc cn phi bit cch phn tch vn v khc phc trong qu
trnh cp pht thuc.
T kha:
Ni dung bi
Mt bnh nhn n mua thuc vi n thuc c glibenclamid v metoprolol. n thuc ny ng
dng trong thi gian trc nhng ng vn than phin v mt vi tc dng khng mong
mun khi dng thuc.
Bc s A
N THUC
Bc s a khoa
Daonil 5 mg: 3 vin/ngy

Lopressor 100mg: 2vin/ngy
ng B, 72 tui, 85
kg
Stilnox: 2 vin bui ti (Bc s ghi r liu dng l 2 vin)

n thuc s dng trong vng 1 thng
c im ca bnh nhn
Bnh nhn l nam gii, 72 tui, cao 1,65m, nng 85kg. ng sng vi v v tng l cu th bng
. ng mc i tho ng (T) typ 2 v tng huyt p t 15 nm nay.
Tin s bnh
Tin s bnh ca ng gm:
- T typ 2 iu tr bng Daonil 5 mg,3 vin/ngy
- Tng huyt p iu tr bng Lopressor 100mg, 2 vin/ngy
- Mt ng v hay gp c mng trong lc ng t 15 nm nay, iu tr bng Stilnox
Phc ny c duy tr lin tc, khng thay i trong sut 15 nm qua.
Tnh hiu lc ca n thuc
y l n thuc ca mt bc s a khoa, ch c k trong vng 1 thng v ch pht thuc 1 ln.
Theo quy nh, trong mi trng hp, Stilnox ch c pht vi s lng dng trong vng 1
thng. Da vo ngy thng, ch k ca bc s, n thuc ny hon ton hp l. Trn th trng,
c dng thuc generic ca Daonil l glibenclamid, ca Lopressor 100mg l
metoprolol v Stilnox l zolpidem nhng ngay t u, bnh nhn quyt nh s dng bit dc
Stilnox nn dc s ti hiu thuc ch c th thay th hai loi thuc u tin bng thuc
generic.
Nhng cu hi u tin cn t ra:
Dc s ti nh thuc hi cc thng tin sau y :
Dc s: ng c ung thm thuc no khc khng, k c cc thuc mua khng cn n?
ng B: C, ti ung vi vin thuc ng y phng bnh thp khp.
Dc s: n thuc ca ng c thay i g khng?

ng B: n thuc ca ti khng thay i g trong sut my nm nay. Nhng thc s l, mi ln
ti qun ung metoprolol vo bui ti, ti thy ng ngon hn nhiu.
Dc s: Trong vi tun ti, ng c phi vo vin phu thut g hay khng?
ng B: Khng
Dc s phi hi nh vy v trong cc trng hp phu thut nht thit phi thng bo vi bc s
gy m v vic dng metoprolol.
Phn tch n thuc
- Glibenclamid 5mg (Daonil): l thuc h ng huyt nhm sulfamid.
- Metoprolol 100mg (Lopressor): thuc chn th th beta-1 chn lc trn tim, c tc dng
chng lon nhp tim, khng c tc dng cng giao cm ni ti.
- Stilnox: hot cht chnh l zolpidem, mt n cht imidazopyridin gy ng c c tnh tng
t nhm benzodiazepin. Tc dng gy ng th hin liu thp hn so vi liu dng cn thit
gii lo u, gin c hay chng co git. Trn thc t, thuc c tc dng ch vn c hiu trn th
th trung tm BZ1, mt phn trong phc hp th th GABAA c tc dng iu ha vic ng
m ca knh Cl-. Trn ngi, zolpidem c tc dng sau:
+ Gip i vo gic ng nhanh
+ Gim s ln thc gic vo ban m
+ Tng tng thi gian ng
+ Ci thin cht lng gic ng
Tc dng khng mong mun
Khi c mt n thuc nh trn, cn ch ngay n loi thuc h ng huyt no c nguy c
gy h ng huyt qu mc trn bnh nhn. y, glibenclamid l mt thuc d gy h ng
huyt. Tc dng khng mong mun c th gp phi ca cc thuc nh sau:
- Glibenclamid 5mg: h ng huyt, tc dng ph trn ng tiu ha (nn, bun nn, tiu
chy, au bng, mt cm gic n ngon), ri lon chc nng gan, d ng da, ri lon cc ch s
huyt hc v khng dung np alcol.
- Metoprolol 100mg: mt mi, chng mt, lm gim nhp tim, kch ng ng tiu ha, nn v
bun nn. Ung thuc bui ti c th gy kh ng, c mng hoc tnh trng h huyt p vo ban
m.
- Stilnox: bun ng, l m, yu c, kh tp trung vo cng vic, c th xy ra phn ng bt li

(kch ng, b kch ng, mt ng), hay qun, ng ming, gim ham mun tnh dc, d ng
ngoi da, vim gan, nhn i. Khi s dng thuc ko di, tnh trng ph thuc thuc tng dn v
hiu qu iu tr gim dn. Cn dng thuc t t (khng phi trong trng hp ca ng B), nht
l sau mt qu trnh iu tr ko di. Trn thc t cc triu chng cai thuc nh lo lng, mt ng,
au u, l ln, o gic, co git c th xut hin.
Du hiu bo trc
Cc du hiu sau y c th cnh bo trc cc bin c bt li:
- H huyt p th ng (do metoprolol) vi triu chng chng mt, nht l khi ng dy vo bui
sng hoc mi ln ng ln c cm gic hoa mt, tim p nhanh, sa sm mt my.
- Mt mi, kh chu, c th ngt xu.
Cc du hiu qu liu hoc h ng huyt do glibenclamid: biu hin bt thng v hnh vi,
li ni, da xanh, run, v m hi, i, chng mt, mt mi, ng l m, cm gic kim chm mi,
hoa mt. Nu bnh nhn bt tnh hoc xut hin co git, cn a ngay vo bnh vin.
Khi s dng glibenclamid, c th nhn thy cc triu chng chng iu ha giao cm: v m
hi, lo lng, tim p nhanh, tng huyt p, au tht ngc v ri lon nhp tim.
Nhng
im
cn
ch
khi
b
h
ng
huyt:
Bnh nhn cn n ngay mt dng ng n hp thu nhanh vi s lng khong 1 vin ng
hoc mt tha mt/ 20kg cn nng, sau n cc loi ng phc hp nh bnh m, bnh quy.
Ch
Cn lu , tnh trng h ng huyt nng cng nghim trng nh trng hp tai bin mch mu
no
Theo di iu tr
- Bnh nhn cn t theo di nng ng huyt nhiu ln trong ngy.
- Theo di chiu cao, cn nng, ch s BMI v huyt p (cc ch s cn theo di trong T v
tng huyt p).
- Theo di nng ng huyt, HbA1c, nng ng trong nc tiu.
- Theo di cng thc mu (hng cu, bch cu, tiu cu) v cc yu t min dch trong mu (d
phng tc dng ph ca glibenclamid).
- Theo di protein niu (do bnh nhn tng huyt p km theo i tho ng).
- Kim tra bn chn v ngn chn 3-4 thng mt ln (d phng bin chng T).
- Soi y mt v kim tra th lc hng nm.
- Kim tra thng xuyn chc nng gan, thn v ty (d phng tc dng khng mong mun ca
glibenclamid).
- Nng kali, natri, calci trong mu (do tng huyt p).
Tng tc thuc
Trn bnh nhn i tho ng, cn ch cc t dc trong thuc c cha ng nh
lactose trong Stilnox hoc mt s dng thuc gc ca metoprolol v glibenclamid cng c cha
t dc lactose.
Trong trng hp ny, nn nh gi li phc iu tr cho ng B, xem xt n triu chng mt
ng v c mng m ng thng gp phi trong lc dng metoprolol. Chnh ng cng nhn l
mnh ng ngon hn nu qun ung thuc.
Cc thuc bn khng cn n (OTC) cn trnh trong trng hp ny
- Cc loi tinh du liu cao, thuc cha cao bch qu Ginkgo biloba, thuc bi ngoi da c cha
methyl salicylat (Salonpas) c th lm long mu v gy h ng huyt
(tc dng khng mong mun hip ng vi glibenclamid).
- Cc thuc khng acid H2 bn t do khng cn n: cimetidin, famotidin c th gy tng ng
huyt.
- Cc loi thuc trong thnh phn c cha ng hoc alcol: cn trnh s dng d c cha cc
thnh phn ny di dng no do cc thuc ny c th gy tc dng ph hip ng vi
glibenclamid.
- Mt s dng thuc siro ho, thuc gim au cha codein v khng d ng c th lm tng tc
dng trn thn kinh ca zolpidem.
- n thuc c cha thuc gy cm ng enzym, do c th lm gim hiu qu ca phc iu tr
sau khong 10 ngy s dng.
Liu trnh iu tr
- Glibenclamid 5 mg, 3 vin/ngy, ung 1 ln trc ba sng (vi thnh phn ba sng gm
nhiu cht c cha phn t ng hp thu nhanh). Ch nut ton b vin thuc cng vi nc.
Nu qun ung thuc, cn ung liu tip theo vi liu bnh thng, khng c ung gp i
liu.
- Metoprolol 100mg: ung 1 vin 100mg vo bui sng, cng vi cc thc n giu cht bo (do
metoprolol c bn cht thn du), ti u nht nn ung thuc vo lc 7 n 8 gi sng, thuc
pht huy tc dng c ngy. Ch , nu ung vo bui ti th nn ung trc 18 gi. Do ung vo
bui ti, metoprolol c th gy kh ng, c mng ban m hoc h huyt p trong m. Cc tc
dng khng mong mun ny xut hin trong trng hp ca ng B. Vai tr ca dc s l phi
thng bo cho bc s cn nhc iu chnh n thuc. Trong trng hp qun ung thuc, cn
ung ln tip theo vi liu thng thng, khng ung gp i liu thuc.
- Stilnox: 2 vin trc khi i ng. Liu thng thng l 10mg/ngy, nhng trong trng hp
ny, bc s nhn mnh r 2 vin v ghi bng ch khng nh liu dng.
Nhng im cn nhn mnh vi bnh nhn
- Trnh ung ru: do ru c th gy tng ng huyt v tng triglycerid (khng dung np
glibenclamid).
- Khi la chn ung glibenclamid trc ba n th ba n cn n vi khu phn nhiu ng,
tinh bt, trnh h ng huyt qu mc.
- Khi thy hoa mt, chng mt, khng nn li tu xe v vn hnh my mc.
T vn cho bnh nhn
- iu chnh li sng ci thin huyt p:
Ngi bnh tng huyt p cn trnh: ung ru, n nhiu mui (khng vt qu 5g/ngy),
cc loi mui cha kali, nc c ga v cc dng vin si (do c cha lng natri). Cn khuyn
bnh nhn tp luyn t nht 30 pht mi ngy, v d i b vi tc nhanh, ch ch n
nhiu
rau
v
hoa
qu.
c p ng iu tr tt, cn kim tra huyt p thng xuyn, c th kim tra ti cc c s y t
hoc t o huyt p ti nh bng my o t ng.
- iu chnh li sng ci thin ng huyt:
Bnh nhn i tho ng cn n t nht 3 n 4 ln/ngy v ung nhiu nc (1,5 L/ngy)
ngoi ba n. Bnh nhn c th tm hiu thng tin v hc cch phn loi cc loi thc n, tng
ng vi cc dng ng hp thu nhanh, ng hp thu chm, phn phi ba n cho ph hp.
Trnh ung nhiu ru (ti a 2 chn ru/ngy), thuc l, cc loi lipid bo ha, qu by
l nhng cht lm cn tr qu trnh tit insulin.
Cn kim tra bn chn, ngn chn v mt thng xuyn ngn nga bin chng. Lin quan
n ngn chn, mt t vn khng th thiu l: lau ra hng ngy, lau kh v c th bi kem
dng m, ct mng chn thng xuyn, i giy v tt loi va, d chu v kn. ct mng
chn, c th s dng loi ko c bit.
Cn ch rng, cng thng, st, nhim trng, chn thng, phu thut c th lm thay i
ng huyt.
- iu chnh li sng khc phc tnh trng mt ng:
Ngi b mt ng thng xuyn nn hot ng th cht nh nhng, thng xuyn vo ban ngy,
th gin, ht th su v tun th gi ng u n . Cn chn loi ging, m d chu, trong mt
phng thong, yn tnh v ung metoprolol trc 18h hng ngy.
Case 1: Fungal Infection JM is a 67-year-old male complaining of painful white lesions in his
mouth and on his tongue that occasionally bleed when he pokes or scrapes them with his
toothbrush. He first noticed symptoms several days after starting a new inhaler medication to
control his chronic obstructive pulmonary disease (COPD). He has never experienced symptoms
like this in the past and would like a recommendation for an OTC product to get rid of them. He
has a history of diabetes, hypertension, chronic kidney disease, and COPD, for which he takes
aspirin 81 mg, atorvastatin 20 mg, lisinopril 20 mg daily, amlodipine 5 mg daily, glipizide XL 10
mg once daily, tiotropium 18 mcg once daily, fluticasone/salmeterol 250/50 mcg twice a day, and
albuterol 2 puffs every 4 hours as needed for shortness of breath; he has no known medication
allergies. Is JM a candidate for self-care? What treatment options can you recommend? Answer:
JMs symptoms are consistent with the presentation of oral thrush, which is characterized by
overgrowth of Candida albicans fungal species in the mouth. This condition is likely to affect
individuals who are immunocompromised, wear dentures, or use inhaled
corticosteroids.1 Symptoms of thrush can include cottage cheeselike, white discolorations or
plaques on the mouth structures, oral pain, minimal bleeding with irritation, taste disturbances, or
difficulty swallowing if the lesions have spread and have affected the esophagus.1 JMs risk
factors for developing thrush may include recently starting a combination inhaled
corticosteroid/long-acting beta2-agonist for the treatment of COPD and having diabetes, poor
control of which may result in this infection. Counsel JM to avoid self-care at this time and to
follow up with his primary care provider, as JM will likely need a topical oral antifungal agent,
such as clotrimazole troches, available by prescription only, to cure this condition. Salt water
gargles are the safest remedy for providing some symptomatic relief while waiting to see his
physician. Take this opportunity to reinforce proper inhaler technique, including the importance
of rinsing the mouth after each use. Case 2: Omega-3 Fatty Acid Supplementation TJ is a 45year-old male who is seeking information on omega-3 fatty acids. Hes heard and seen a lot of
news extolling the benefits of the omega-3s for heart health is and wondering if supplementation
is a natural way for him to lower his cholesterol without medications. TJ has a sulfa allergy and
is currently taking atorvastatin 40 mg once daily for dyslipidemia, lisinopril 40 mg daily and
chlorthalidone 50 mg daily for hypertension, and escitalopram 10 mg daily for depression. What
can you recommend for TJ? What information can you give him about the benefits of dietary
intake and supplementation with omega-3 fatty acids? Answer: Omega-3 fatty acids have
received much attention in the press and been the subject of several large-scale clinical research
studies on heart health and cholesterol reduction in recent years. The major dietary forms of this
type of fatty acid include docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and alphalinolenic acid (ALA). DHA and EPA are primarily found in animal products, particularly from
dietary seafood sources (oily fish and shellfish) and from fish oil capsules. ALA is more often
derived from vegetable oils and dietary sources such as flax seeds, walnuts, and dairy products.
Omega-3 fatty acids may reduce triglycerides and blood pressure and improve immune function,
among many other potential health benefits. Consuming 1 or 2 servings of fish per week may
additionally reduce the risk of heart disease, particularly sudden cardiac death. Much like the
use of vitamin and mineral supplements for promoting health and wellness, it is generally
recognized that dietary intake of the omega-3 fatty acids has been shown to have a benefit in
promoting cardiac wellness, while the benefits of omega-3 supplements to the diet remain less
certain. The Dietary Guidelines for Americans, 2010, has been updated to include a
recommendation that most American adults should consume 8 or more ounces of seafood per
week to ensure adequate intake of these heart-healthy nutrients; pregnant women and children
usually require less than this amount.2 A recent study published in 2012 found that
supplementing EPA and DHA may not have the same protective effect on heart function as food
sources of these nutrients.3 For TJ, counsel him on the importance of dietary consumption and
on foods rich in omega-3s for heart health promotion. Case 3: Pain Management for Arthritis UR
is an 83-year-old female looking for a recommendation regarding OTC pain medication. Upon
questioning, she states that the arthritis pain in her hand joints is noticeably worse in cold
weather and that she is looking for something stronger than the acetaminophen she has been
taking for pain relief. She currently takes aspirin 81 mg, clopidogrel 75 mg, atorvastatin 40 mg,
ramipril 2.5 mg daily, and metoprolol 12.5 mg twice daily; she has no known medication
allergies. What therapeutic alternatives for pain relief can UR consider? Answer: Osteoarthritis is
characterized by destruction of cartilage between joint spaces, usually affecting the hip, knee,
lower back, and hands, resulting in alterations in the architecture of these spaces.4 The pain
associated with osteoarthritis is usually dull, localized to the affected joints, and accompanied by
joint stiffness, and is estimated to affect more than 27 million Americans.5 Pain management
approaches aimed at alleviating the pain and stiffness associated with this condition involve
nonpharmacologic and pharmacologic therapies. Nonpharmacologic strategies to provide relief
of osteoarthritis pain include exercising the affected joints to increase lubrication and to help
strengthen the affected muscle and ligament groups surrounding the affected area. Topical
counterirritants, which exert their analgesic effect by stimulating a local inflammatory reaction,
represent reasonable alternatives to consider in patients unable to tolerate other pharmacologic
treatment options. OTC agents in this class include ingredients such as methyl salicylate,
camphor, menthol, and capsicum, all of which may provide temporary localized pain relief and
need to be reapplied 3 or 4 times daily. Systemic analgesics, including acetaminophen and
nonsteroidal anti-inflammatory drugs (NSAIDs), represent the next step in pharmacologic
treatment of pain. Scheduled, rather than as needed, use of these products may provide more
adequate relief of pain for individuals with chronic symptoms.4 Based on her antiplatelet agent
use and presumed underlying cardiac condition, UR is not a candidate for OTC NSAID use at
this time. She can consider use of topical OTC analgesic creams or should be referred to her
primary care provider for a prescription-only alternative (eg, tramadol, opioid) for pain relief.
Case 4: Anxiety GM is a 38-year-old female who comes to the pharmacy looking for something
natural to control her anxiety. She says she becomes anxious from time to time and feels like she
wants to take something to control her anxiety. She says her anxiety is mild according to her
doctor. Typically, her anxiety occurs when she is in social situations. GM usually starts sweating
and gets tachycardia when she is around people she doesnt know. She is very embarrassed
because most people can tell that she is acting oddly. Her doctor recommended that she try
relaxation techniques. GM says that her next-door neighbor takes kava for anxiety. The neighbor
said that kava is the natural solution to anxiety and that GM should try it. The neighbor said that
kava doesnt have the scary side effects that prescription medications have. GM has no other
medical conditions and takes no other medication. She has no other complaints. What are your
recommendations for GM regarding her anxiety? Answer: It appears that GM suffers from social
anxiety disorder. The evidence supporting the use of kava is conflicting. Some studies have
shown improvement of mild anxiety in patients who took kava; however, there have not been
studies in patients with social anxiety. It is important to educate GM that although kava may help
her neighbor, it may not necessarily help GMs type of anxiety. GM should be made aware that
kava could increase her risk for liver toxicity. On August 20, 2013, the FDA issued a statement
that included the following: Kava-containing products have been associated with liver-related
injuries, including hepatitis, cirrhosis, and liver failure.6 Most natural supplements have not
been shown to help with social anxiety. For social anxiety disorder, GM should be referred to her
physician for a prescription of a selective serotonin reuptake inhibitor or venlafaxine. Both are
considered first-line treatments for social anxiety disorder. She could also try relaxation
techniques and behavior modification. Case 5: Self-Treatment of Acne DD is a 16-year-old
female who stops by the pharmacy with her mother while out shopping. DDs mother wants to
know which OTC face wash would be best for helping DD treat and prevent blackheads on her
forehead, nose, and cheeks. DDs mother reports that her daughter suffers from occasional acne
flares that seem to worsen with the onset of menses; however, her blackheads are a constant
problem that seem to make DD anxious and self-conscious about her appearance. DD has not yet
seen a dermatologist for evaluation of her condition, but her mother is hoping to improve DDs
condition with self-care. What products and self-care recommendations can you share with DD?
Answer: DDs acne vulgaris is a common problem in adolescents and in some adults. This
bothersome skin condition is thought to result from genetic, hormonal, and environmental
influences, although the exact cause remains unknown.7 DDs self-identified blackheads
represent a type of noninflammatory lesion; papules, pustules, and nodules are inflammatory
lesions associated with this condition. The goals of self-care for this often self-limiting condition
include reducing the appearance of lesions and minimizing scarring.7 Topical retinoids are
considered the gold standard treatment for moderate to severe acne, although their availability is
limited by their prescription-only status.7 In the case of DD, consider recommending that she use
an OTC face wash containing benzoyl peroxide in a concentration of 2.5% to 10%. The
concentration does not seem to affect product efficacy; higher-strength formulations have similar
antimicrobial effects and greater potential for causing adverse effects compared with their lowerstrength counterparts.7,8 Counsel DD that topical application of benzoyl peroxide may result in
redness and scaling of the skin that should subside within 1 to 2 weeks with continued use. If
severe redness or suspected allergic reaction occurs, recommend discontinuation of the product
and prompt physician follow-up for further evaluation. Case 6: Perennial Allergies and Asthma
NN is a 24-year-old female who comes to the pharmacy complaining of runny nose, congestion,
watery eyes, and shortness of breath. She says she has been having difficulty breathing the past
few days because her allergies have gotten so bad. She says she is allergic to dust and has not
needed to take anything for it in the past. She was first diagnosed with her dust allergy when she
was diagnosed with asthma as a child. She is usually careful not to expose herself to dusty areas,
but the past few weeks, she has been cleaning houses and her allergies have gotten worse. She is
currently taking Advair (fluticasone/salmeterol) and using an albuterol inhaler as needed. She
denies taking anything for her allergies and has not tried anything. She claims she has used her
albuterol around the clock for the past few days but feels her shortness of breath is not
improving. She is looking for something to treat her dust allergy. What recommendations would
you have for NN? Answer: NN appears to be suffering from allergies and asthma. Her asthma
may not be controlled because her allergies have worsened. Therefore, NN should be referred to
a physician for evaluation of her asthma and shortness of breath. Many patients suffer from both
allergies and asthma. It is important to remember that when patients have shortness of breath or
wheezing, they should be instructed to get medical care immediately. NN should also be
educated on allergy avoidance. If possible, she should avoid cleaning houses because it
predisposes her to more dust exposure. She should be educated to seek immediate medical care if
her shortness of breath does not improve after she uses albuterol. Other patients who would not
be candidates for self-treatment of allergies include children younger than 12 years, pregnant or
lactating patients, patients who appear to have an infection, or patients who use an OTC
medication that is not effective or causes side effects.
Cc yu t v dc ng/dc lc qun l vancomycin khi truyn tnh mch lin tc
cc nc chu u, Vancomycin thng c s dng theo ng truyn tnh mch lin tc
(continuous infusion CI), trong khi ti Hoa K truyn tnh mch gin on (intermittent
infusion II) li ph bin hn. Mt bo co c thc hin nhm xem xt cc bng chng hin
c v u im v nhc im ca CI vancomycin khi so vi II, da trn cc kha cnh dc
ng v dc lc ca liu dng v phng php theo di, ng thi cng xc nh liu lng s
dng Vancomycin khi truyn tnh mch lin tc cc liu php hin c. Bo co ny phn tch
43 bi bo khoa hc c lin quan Vancomycin c thu thp trn Medline, Cochrane v c s d
liu GoogleScholar. Phn kt qu v tho lun gm nhng im chnh sau: Cc nh gi da trn
cc bng chng lm sng cho thy khng bng chng kt lun truyn tnh mch lin tc
hay truyn tnh mch gin on Vancomycin hiu qu hn trn lm sng. Khi truyn tnh mch
gin on Vancomycin, o nng y l phng php chun nh gi hiu qu cng nh
xem xt vic chnh liu. Nng y nn c o 30 pht trc khi s dng liu tip theo, khi
nng n nh t c (thng l trc khi s dng liu th 4). Thi gian o nng y
l yu t quan trng nh gi ng nng trong huyt thanh v iu chnh liu cho ph
hp.Trong khi nu truyn tnh mch lin tc, ch cn o nng thuc n nh trong mu
(steady-state serum concentrations Css), c th o vo bt k thi gian no, khi nng n
nh t c. Xt v c tnh trn thn khi truyn Vacomycin lin tc hoc gin on: s
khc bit cha xc nh c, do vn cn thiu d liu v cc bo co mu thun. Kt qu phn
tch gp su nghin cu kt lun rng truyn lin tc Vancomycin c lin quan vi nguy c tn
thng thn thp hn so vi truyn gin on Vancomycin, mc d cc nghin cu khc cho kt
qu khng r rng. Nhng im mi v kt lun Cha c bng chng chng minh truyn gin
on c hiu qu lm sng tt hn truyn lin tc, nhng nghin cu ny a ra bng chng ng
h dng phng php truyn lin tc v liu dng v theo di tr liu n gin hn truyn gin
on. S dng Vancomcin truyn tnh mch lin tc c li im l ch cn o nng thuc
trong mu, n gin hn phi o nng y khi truyn tnh mch gin on. Tuy nhin mt bt
li khi truyn lin tc l khi cn truyn tnh mch ng thi vi mt thuc khc c th khng
tng thch vi Vancomycin. Khi truyn lin tc, liu Vancomycin hin hnh: liu tn cng 1520 mg/kg, sau 10-40mg/kg/ngy da trn chc nng thn ca bnh nhn, vi Css mc tiu
khong 20-30mg/L. Bo co cng ch ra phng php tnh liu thay th cho tnh liu theo cn
nng, l tnh liu da vo thanh thi Vancomycin c tnh ca bnh nhn (L/24h) v
Css/AUC mc tiu. thanh thi Vancomycin c tnh theo cng thc (CrCl*0.041 )+0.22
Mc d c d liu ng h vic dng Vancomycin truyn tnh mch lin tc thay th truyn
gin on, vn cn thm nhng nghin cu su hn v phng php ny. Trong khi ch i,
phng php truyn tnh mch trc tip Vancomycin c th c xem xt thay th cho truyn
tnh mch gin on. Cc im chnh v Vancomycin Vancomycin l khng sinh thuc nhm
glycopeptid, c ph tc dng ch yu trn cc chng vi khun gram dng (S. aureus, S.
epidermidis, Bacillus spp., Corynebacterium spp); phn ln cc chng Actinomyces v
Clostridium nhy cm vi thuc. Trn lm sng, Vancomycin ch yu c s dng trong iu
tr t cu vng khngmethicillin (MRSA). Liu dng trn bnh nhn c chc nng thn bnh
thng: 1520 mg/kg mi 8-12 gi. t c hiu qu iu tr, nng y ca Vancomycin
nn dc duy tr mc 10 mg/L; mc 15-20 mg/L c khuyn co cho cc trng hp nhim
trng nng do MRSA. ng thi t l AUC24/MIC 400cng l mc tiu t hiu qu iu
tr. Tc dng ph khng mong mun (ADR) hay gp nht ca Vancomycin l vim tnh mch v
phn ng gi d ng. Tc dng ph khc cng cn lu vi vancomycin l c tnh trn tai v
trn thn,thng lin quan vi s tng qu mc nng thuc trong mu. Ngoi ra thuc c th
gy tc dng ph l cc biu hin ca qu mn nh phn ng phn v, st, rt run, chng mt
B trai b suy gip v u ni m mch mu
M T
Mt b trai thng c tin hnh siu m bng lc 6 tun tui theo di nc thn tri
c chn on t trc khi sinh. Mc d khng thy thn nc, siu m bng cho thy hnh
nh gan ln vi nhiu tn thng gim m ng knh o c ti 25 mm. B c nhp vin
tip tc nh gi cc tn thng gan.
Kt qu kim tra cho thy nhiu u mu nh trn da u, hai c tay v nch. Bng ca b b cng
phng do gan to 6-7 cm di b sn. Khm tim mch khng thy c du hiu suy tim. Kt qu
in gii, creatinine, cht chuyn ha ca catecholamine trong nc tiu, -fetoprotein, v men
gan u nm trong gii hn cho php, ngoi tr tng transferase -glutamyl 257 IU / L (gi tr
bnh thng 7-64 IU / L). Xt nghim chc nng tuyn gip (TFT) thy nng hormone kch
thch tuyn gip (TSH) tng 37,7 mU / L (gi tr bnh thng theo tui ca b 0,30-5,00 mU / L),
thyroxine t do (fT4) 17,9 pmol / L trong gii hn cho php (gi tr bnh thng theo tui 12,030,0 pmol / L), v triiodotyronine t do thp (fT3) 3,3 pmol / L (gi tr bnh thng theo tui
3,8-6,0 pmol / L) (Beckman DXi, Beckman Coulter) . Xt nghim khng th Thyroid peroxidase
v khng th thyroglobulin u m tnh. Cc kt qu xt nghim sng lc s sinh TSH u nm
trong khong gii hn cho php. Kt qu chp MRI bng cho thy nhiu tn thng gan ging
vi u mu ni m.
CU HI NH GI
1. Nhng nguyn nhn no c th dn ti s mu thun gia kt qu TSH v fT4?
2. Cn lm thm cc xt nghim y sinh no h tr cho vic gii thch s mu thun gia
TSH v fT4?
3.
Chn on c kh nng nht l g?
THO LUN
S MU THUN TRONG CC KT QU XT NGHIM CHC NNG TUYN GIP
V NHNG NGHIN CU SU HN
Sai lch (nhiu) trong phn tch TSH hoc FT4, suy gip bm sinh th pht do ri lon tng hp
hormone do di truyn, v suy gip tiu hao do u mu ni m l nhng nguyn nhn c th dn
ti s chnh lch gia TSH v FT4 qu bnh nhn ny.
Chng ti loi tr kh nng xt nghim chc nng gip b nhiu bng cch phn tch li chc
nng gip sau khi s dng phng php khng th heterophile (Scantibodies Laboratories) v
kim tra li kt qu chc nng gip vi nhiu my phn tch khc nhau (Siemens Centaur v
Roche E602).
Kim tra chc nng hp thu Technetium-99m ca tuyn gip thy v tr, kch thc, v kh nng
hp thu ca tuyn gip u bnh thng. Nng T3 o (RT3) l 20,95 nmol / L (gii hn
tham chiu ca ngi ln l 0,17-0,45 nmol / L). RT3 c o bng RIA (Radim). Nng RT3
cao nht ngay sau khi sinh trong mu cung rn (0,3-5,51 nmol / L); Tuy nhin, nng ny s
gim dn trong giai on s sinh v th u (1).
CHN ON HP L V THEO DI
Suy gip tiu hao lin quan n u mu ni m gan (HHE) c xem l li gii thch hp l
nht cho tnh trng chc nng gip bt thng bnh nhi ny.
Liu php thay th l-T4 bt u vi liu 25 mg / ngy (4,2 mg/kg/ngy) (liu chun 2,5-5
mg/kg/ngy). Liu ny c tng ln n 100 mg/ngy (16 mg/kg mi ngy) trong vng 4 tun.
U mu ni m c iu tr bng prednisolone v propranolol.
Kt qu siu m bng lp li sau 6 thng iu tr cho thy tnh trng u mu ni m gim so vi
trc y. Do nhu cu T4 cng gim. Xt nghim li chc nng tuyn gip thy nng TSH
2.59 mIU / L (gi tr bnh thng 0,5-4,0 mIU/L), fT4 26,2 pmol /L (gi tr bnh thng 10,019,0 pmol / L), v fT3 3,9 pmol/L (gi tr bnh thng 3,5-6,5 pmol / L). Liu l-T4 c gim
xung mc 50 g/ngy v kt qu xt nghim chc nng gip c duy tr trong gii hn cho
php. Bnh nhn tip tc c gim liu T4, kt qu nh gi gn y nht (9 thng sau khi bt
u iu tr), bnh nhn c iu tr liu 50 g trong 5 ngy v 25 g trong 2 ngy, tng
ng vi 43 g/ngy, hay 4,4 g/kg/ngy.
CHUYN HA NGOI BIN CA HORMONE TUYN GIP

Hormone tuyn gip c ngun gc t axit amin tyrosine. Qu trnh gn Iod vo tyrosin trong
thyroglobulin
cui
cng
to
ra
T4
v
T3.
T4 cha 4 nguyn t Iod (v tr 3, 5 vng trong v v tr 3 ', 5' trn vng ngoi ca cc phn t
thyronine). Hu ht tt c T4 c tng hp bi tuyn gip. T3 c hot tnh sinh hc cha 3
nguyn t Iod v tr 3, 5, v 3 '. Ch c 20% T3 c tng hp bi tuyn gip, 80% cn li l
sn phm ca qu trnh kh iod v tr (5 ') ca T4 cc m ngoi vi. T3 o (rT3) khng c
hot tnh sinh hc, c 2 nguyn t Iod vng ngoi nhng ch c 1 nguyn t Iod vng trong (3,
3 ', 5' T3). Hu ht tt c cc rT3 c hnh thnh bng cch chuyn i T4 ngoi vi (2).
Qu trnh chuyn ha ngoi vi ca hormone tuyn gip c xc tc bi enzyme deiodinase. C
3 loi deiodinase chnh: loi 1, loi 2, v loi 3. Loi 1 iodothyronine deiodinase (D1) c hot
tnh kh Iod vng trong v vng ngoi, ch yu c gan, thn, v tuyn gip. Loi 2
iodothyronine deiodinase (D2) hin din ch yu trong h thng thn kinh trung ng (CNS),
thy trc tuyn yn, cht bo nu, tim v c xng, nhau thai, v tuyn gip. D2 c hot tnh
kh Iod vng ngoi v c i lc vi T4 cao hn D1. T3 (to ra t D2) cn thit cho qu trnh
iu ha ngc s bi tit TSH (2). Loi 3 iodothyronine deiodinase (D3), c hot tnh kh iod
vng trong, lm bt hot cc hormone gip bng cch chuyn i T4 thnh rT3 v T3 thnh
diiodothyronine (T2). D3 ch yu c tm thy nhau thai, t cung, thn kinh trung ng, da
v l ngun quan trng nht ca rT3 (2) (Hnh. 1).
Hnh 1. Chuyn ha ngoi bin ca hormone gip

Kh nng biu hin hot tnh D3 ca khi u trong u mu ni m c xem l nguyn nhn chnh
gy nn suy gip do tng tiu hao.
Trong trng thi tuyn gip hot ng bnh thng, mt phn nh ca T3 huyt thanh c to ra
t D1. Tuy nhin, trong trng hp cng gip, khong 50% T3 huyt thanh l do D1 to ra.
Trong iu tr, do propylthiouracil c tc dng c ch D1 nn c s dng iu tr cng
gip. Ngc li, D2 khng nhy vi s c ch ca propylthiouracil. Hot tnh ca D1 b gim
trong cc bnh cp tnh, lm gim T3 huyt thanh ng thi tng rT3 (do s gim chuyn ha
rT3 thnh T2 qua D1 v ti kch hot D3 trong gan v c xng) (2). S xut hin ca D3 trong
nhau thai v bo thai ang pht trin hn ch vic vn chuyn hormone tuyn gip ca m cho
thai nhi. Sau khi sinh, hot tnh D3 gim v khng th pht hin trong hu ht cc m tr thn
kinh trung ng v da. Tuy nhin, y vn l con ng chnh ca s bt hot hormone gip (2).
U MU NI M GAN TR S SINH
U mu ni m gan tr s sinh l loi u mch gan ph bin nht tr em, chim ti 12 % cc
trng hp u gan. Hu ht cc bnh nhn c chn on trong 6 thng u i, vi t l cao hn
n (3). Bnh nhn thng xut hin khi l bng, cc triu chng v du hiu khc c th
bao gm gan to, suy tim lu lng cao, u mu da, gim tiu cu, thiu mu tn huyt, v chy
mu mng bng. Mc d cc tn thng khng triu chng thng t gim trong vng mt nm,
nhng bnh nhn c triu chng tn thng cn c chm sc tch cc. La chn iu tr ni
khoa bao gm corticosteroids, interferon-, v propranolol ung (4). Phng php iu tr can
thip bao gm lm tc v tht ng mch gan, phu thut ct b, v cy ghp gan (3).
SUY GIP DO TNG TIU HAO (CONSUMPTIVE THYROIDISM)
Mi lin h gia suy gip do tng tiu hao v u mu ni m gan tr em c m t u tin
vo nm 2000 (5). Phn ln cc ca suy gip do tng tiu hao c m t tr em c u mu ni
m, tuy nhin cng c nhng ca c ghi nhn ngi trng thnh c u x v u mch ln (6
8).
Biu hin cc khi u do hot tnh enzyme D3 trong cc tn thng mch mu gan v da c
cho l nguyn nhn gy ra suy gip so tng tiu hao (5, 8, 9). Biu hin tng hot ca D3 c
m t trong mt bnh nhn c khi u c tnh ln n c v suy gip (7). D3 lm bt hot cc
hormon tuyn gip bng cch chuyn i T4 thnh rT3 v T3 thnh T2. S thoi ging qu mc
hormone tuyn gip do biu hin tng hot tnh ca D3 bi m khi u cng c chng minh bi
s tng nng rT3, cn liu php thay th hormon gip liu rt cao, v tnh trng suy gip c
ci thin sau khi ghp gan hoc s thoi trin ca tnh trng u ni m mch mu gan (HHE) (5,
6 , 8, 9).
Bnh nhn suy gip tiu hao thng c cc biu hin c bn ca khi u nhng cng c th xut
hin tnh trng suy gip nng khng p ng vi liu thng thng ca liu php thay th
hormone gip. V mt sinh ha nhng bnh nhn ny b tng TSH km theo fT4 thp hoc trong
gii hn bnh thng. Nng fT3 thng thp km theo tng nng rT3 v T2. Cn thng
xuyn theo di chc nng tuyn gip kim sot tnh trng bnh nhn do t l ging ha T4
(km theo nng TSH, fT4, v fT3) ph thuc vo khi lng ca HHE. T l ging ha T4
cao nht trong giai on tng sinh ca HHE (5). Chn on suy gip tiu hao cn da trn du
hiu lm sng v sinh thit v chng minh hot tnh D3 trong m HHE khng c thc hin
thng quy do nguy c chy mu. Nn yu cu kim tra chc nng tuyn gip i vi bnh nhn
HHE, c bit tr s sinh v suy gip c th c nhng nh hng bt li n s pht trin ca
tr.
NHNG IM CN GHI NH
Suy gip tiu hao l bnh l him gp nhng rt quan trng nhng bnh nhn c u mu
ni m gan.
Cn xem xt k cc kh nng trc khi a ra chn on suy gip tiu hao.
Suy gip khng tr c th l mt gi cho u mch mu khng triu chng.
Kim tra theo di chc nng tuyn gip thng xuyn rt quan trng trong vic iu tr
suy gip tiu hao do s thoi ha hormone gip ph thuc vo khi lng khi u
Trng hp bnh nhn ny c suy gip cn lm sng vi TSH tng v fT4 trong khong gii hn
cho php, km theo fT3 hi thp. Tuy nhin, bnh nhn cn T4 liu cao duy tr tnh trng
tuyn gip bnh thng trong giai on sm ca bnh. Vic s dng liu cao ny c chng
minh trong nhng trng hp trc y, v mt s bnh nhn i hi phi thay th kt hp T4
vi T3 hoc T3 tim tnh mch (10). Tuy nhin, nhu cu hormone tuyn gip gim theo s thu
gim ca khi u.
T vit tt:
TFT
TSH
thyroid function test;

thyroid-stimulating hormone;
fT4
free thyroxine;
fT3
free triiodothyronine;
rT3
reverse T3;
HHE
hepatic hemangioendothelioma;
D1
type 1 iodothyronine deiodinase;
CNS
central nervous system;
T2
diiodothyronine.
1/ Hu ht cc thuc h glucose mu u tim n nhiu nguy c bnh nhn suy gim chc nng
thn.
2/ Cc dng thuc tc dng ko di him khi c s dng.
3/ Metformin b chng ch nh bnh nhn suy thn nng.
4/ Cc sulfonylureas (hoc dng chuyn ha c hot tnh) nh glibenclamide hay glimepiride c

th b tch ly khi suy thn.
5/ Glipizide v gliclazide c chuyn ha gan, bi tit qua nc tiu mt lng nh dng cn
hot tnh, do vy an ton hn cc thuc khc.
6/ Linagliptin khng cn hiu chnh liu khi c bnh thn. Cc thuc c ch DPP-4 khc nn
gim liu bnh nhn CKD giai on 3.
7/ Exenatide v lixisenatide nn dng thn trng bnh nhn CKD giai on 3 v khng dng
bnh nhn CKD 4.
8/ Liraglutide khng nn dng bnh nhn CKD giai on 3.
9/ Pioglitazone c th dng bnh nhn suy thn, nhng khng c dng bnh nhn thm
tch mu.
10/ Khng khi u iu tr vi thuc c ch SGLT2 nu eGFR < 60.
11/ Insulin c thi tr qua nc tiu cn gim liu v tnh trng suy thn c th nng hn.
Ch vit tt:
DPP-4: Dipeptidyl peptidase-4
CKD: Chronic Kidney Disease (bnh thn mn tnh)
SGLT2: Sodium-Glucose Cotransporter 2 (knh ng vn chuyn glucose natri)
eGFR: estimated Glomerular Filtration Rate (Tc lc cu thn c lng)
BACK TO MY CPD
Drug interactions
Triptan interactions
Clinical Pharmacist25 SEP 2015By Harpreet Sandhu
, Claire L. Preston
, Stephanie Jones
A number of clinically relevant pharmacokinetic and

pharmacodynamic interactions involving 5HT1 receptor
agonists are known, although these are not frequently

encountered in migraine treatment.
Source: Department of Nuclear Medicine, Charing Cross Hospital / Science Photo Library
5HT1 receptor agonists (triptans) are widely used to treat acute migraine attacks, however clinically
relevant interactions are not frequently encountered
Summary
Commonly known as the triptans, 5HT1 receptor agonists are used to treat acute migraine attacks
and include almotriptan, eletriptan, frovatriptan, naratriptan, sumatriptan and
zolmitriptan. Despite their widespread use, clinically relevant interactions with 5HT1 receptor
agonists are not frequently encountered, but a number of interactions are known.
Naratriptan is unlikely to be involved in important pharmacokinetic interactions as half the dose
is excreted unchanged and the rest is metabolised by a variety of isoenzymes. CYP3A4
inhibition and induction are important interactions for eletriptan and almotriptan, which are both
metabolised by CYP3A4. CYP1A2 inhibition and induction can affect zolmitriptan and
frovatriptan. CYP1A2 inducers, such as tobacco smoke, are expected to decrease exposure to
frovatriptan and zolmitriptan. Monomamine oxidase A inhibition can affect almotriptan,
rizatriptan, sumatriptan and zolmatriptan.
5HT1 receptor agonists are generally contraindicated in patients taking ergot derivatives because
of a theoretical risk of additive vasoconstriction. Drug interations between selective serotoninreuptake inhibitors and 5HT1 receptor agonists causing adverse reactions are possible, although
these and interactions causing serotonin syndrome are extremely rare. Serotonin syndrome may
also occur with concurrent use of monoamine oxidase A inhibitors and 5HT1 receptor
antagonists.
5HT1 receptor agonists, commonly known as the triptans, are used to treat
acute migraine attacks. The 5HT1 receptor agonists currently available are
almotriptan, eletriptan, frovatriptan, naratriptan, sumatriptan and
zolmitriptan. If patients do not respond to one 5HT1 receptor agonist, another
can be used. Sumatriptan and zolmitriptan can also be used to treat cluster
headache.
Despite their widespread use, clinically relevant interactions with
5HT1receptor agonists are not frequently encountered. One reason for this
could be because migraines most commonly occur in younger patients, who
are unlikely to be taking multiple drugs for other conditions[1]. This article
discusses some of the known interactions involving 5HT1 receptor agonists.
Pharmacokinetic interactions
5HT1 receptor agonists are metabolised via various different metabolic

pathways and therefore do not all necessarily share the same pharmacokinetic
interactions. Naratriptan is unlikely to be involved in important
pharmacokinetic interactions because half the dose is excreted unchanged and
the rest is metabolised by a variety of isoenzymes.
CYP3A4 inhibition and induction are important mechanisms for potential
interactions for eletriptan and almotriptan, which are both metabolised by
CYP3A4. A randomised, crossover study in 16 healthy subjects has shown
that ketoconazole, a potent CYP3A4 inhibitor, increased the area under the
curve (AUC) of almotriptan by 57%[2] and a pharmacokinetic study

conducted by the manufacturer of eletriptan found that ketoconazole
increased the AUC of eletriptan 5.9-fold[3]. CYP3A4 is not the only route of
metabolism for almotriptan, so inhibition of this isoenzyme by ketoconazole
has a less dramatic effect on its exposure than with eletriptan. Other potent
inhibitors of CYP3A4 would be expected to interact similarly (see Stockleys
Drug Interactions for a full list).
It is not necessary to adjust the dose in patients taking almotriptan with
ketoconazole or other potent CYP3A4 inhibitors. However the US
manufacturer (Ortho-McNeil Pharmaceutical) recommends an initial dose of
6.25mg for patients starting almotriptan who are taking potent CYP3A4
inhibitors[4].
On account of the marked increase in exposure to eletriptan, concurrent use
with ketoconazole or other potent CYP3A4 inhibitors should be
avoided[3], and the US manufacturer (Pfizer) additionally recommends that
eletriptan should not be given within 72 hours of potent CYP3A4 inhibitors[5].
Erythromycin, which is a moderate inhibitor of CYP3A4, has been shown to
increase eletriptan exposure by 3.6 fold[3]. Concurrent use should therefore be
avoided. Verapamil, another moderate CYP3A4 inhibitor, had a negligible
effect on the exposure to almotriptan[6], therefore no dose adjustments would
seem necessary on concurrent use. Other moderate CYP3A4 inhibitors
(seeStockleys Drug Interactions for a list) would be expected to have a
similar effect.
Despite a lack of clinical reports, inducers of CYP3A4 are predicted to
decrease the exposure to both eletriptan and almotriptan, potentially leading
to a decrease in their efficacy. However, further study is needed.
Other 5HT1 receptor agonists are expected to have little or no interaction with
inhibitors or inducers of CYP3A4, as they are not predominantly metabolised
by this route.
CYP1A2 inhibition and induction can affect zolmitriptan and frovatriptan.

In a crossover study in 16 healthy subjects, cimetidine, a weak non-specific
inhibitor of several cytochrome P450 isoenzymes including CYP1A2,
increased the AUC of zolmitriptan by 48% and increased the AUC of its
active metabolite by 100%[7]. Based on the effect of cimetidine on
zolmitriptan exposure, fluvoxamine (a potent CYP1A2 inhibitor) is expected
to increase the plasma concentration of zolmitriptan. The UK manufacturer of
zolmitriptan (AstraZeneca UK) consequently recommends a maximum dose
of 5mg in 24 hours for zolmitriptan in patients taking CYP1A2 inhibitors [8]
(see Stockleys Drug Interactions for a list).
Fluvoxamine has been shown to increase the plasma concentration of
frovatriptan by up to 49%[9]. While the increase is not considered clinically
important, the manufacturer of frovatriptan (A Menarini Pharma UK) does
advise caution and strict adherence to the recommended dose (2.5mg
repeated after at least two hours if necessary, with a maximum dose of 5mg in
24 hours)[10].
CYP1A2 inducers, such as tobacco smoke, are expected to decrease the
exposure to frovatriptan and zolmitriptan. A retrospective analysis of
pharmacokinetic data from phase I studies found a lower AUC and maximum
plasma concentration of frovatriptan in smokers when compared with nonsmokers[11]. As the observed change was only slight, it is thought that any
interaction between frovatriptan with tobacco smoke is unlikely to be
clinically relevant. The effect of smoking on zolmitriptan metabolism does
not appear to have been studied.
Monoamine oxidase A (MAO-A) inhibition can affect almotriptan,
rizatriptan, sumatriptan and zolmitriptan, which are all metabolised by the
enzyme.
Pharmacokinetic studies have shown that moclobemide, a reversible inhibitor
of MAO-A, can affect exposure. The AUC of almotriptan increased by
37%[12], the AUC of rizatriptan was increased 2.2-fold[13], the AUC of
sumatriptan increased 2.3-fold[14] and the AUC of zolmitriptan increased by
26% (and that of its active metabolite increased three-fold)[8].
The interactions of moclobemide with rizatriptan and sumatriptan are

established and clinically relevant. There seems to be no direct evidence of an
interaction between rizatriptan or sumatriptan and non-selective MAO
inhibitors (e.g. phenelzine), nevertheless, they would be expected to behave
similarly. Consequently, rizatriptan[15],[16] and sumatriptan[17],[18] are
contraindicated in patients taking, and for two weeks after the use of,
selective or non-selective MAO inhibitors.
Although the increase in zolmitriptan exposure is slight, the UK manufacturer
(AstraZeneca UK) advises that, if used in patients taking moclobemide or
other MAO-A inhibitors, the dose of zolmitriptan should not exceed 5mg in
24 hours[8]. The US manufacturer (AstraZeneca Pharmaceuticals LP) states
that zolmitriptan should be avoided in patients who have taken a MAO-A
inhibitor within the last two weeks[19].
Moclobemide does not affect the pharmacokinetics of frovatriptan[20] and
would not be expected to affect eletriptan and naratriptan pharmacokinetics
as they, like frovatriptan, are not metabolised by MAO-A.
Propranolol, a drug also used in the prevention of migraine, has been shown
to affect the pharmacokinetics of rizatriptan, possibly through inhibition of
MAO-A. In a series of double-blind, placebo-controlled studies conducted in
51 healthy subjects, the AUC of rizatriptan increased by 67%, and a four-fold
increase in AUC was observed in one patient[21]. The manufacturers of
rizatriptan (Merck) therefore recommend a dose of 5mg is used in patients
taking propranolol, with a maximum of two (UK advice) or three (US advice)
doses in 24 hours[15],[16].
Other beta-blockers used for the prevention of migraine (e.g., atenolol,
nadolol, metoprolol and timolol) have all been shown in vitro to have no
effect on the metabolism of rizatriptan[21] and are therefore unlikely to have
an effect in clinical practice. No clinically important interactions appear to
occur between other 5HT1 receptor agonists and beta-blockers.
Pharmacodynamic interactions
5HT1 receptor agonists are generally contraindicated in patients taking ergot

derivatives (e.g. ergotamine, dihydroergotamine and methysergide) because
there is a theoretical risk of additive vasoconstriction. The UK manufacturers
of sumatriptan[18] (GlaxoSmithKline), almotriptan[22] (Almirall),
rizatriptan[15] (Merck Sharp & Dohme) and zolmitriptan[8] (AstraZeneca UK)
state that ergotamine should not be given less than six hours after taking a
5HT1 receptor agonist, and that a 5HT1 receptor agonist should not be taken
for at least 24 hours after ergotamine. The UK manufacturers of
eletriptan[3] (Pfizer), frovatriptan[10] (A Menarini Pharma UK) and
naritriptan[23] (GlaxoSmithKline) recommend that 5HT1 receptor agonists
should not be taken less than 24 hours after taking ergotamine or other ergot
derivatives.
Selective serotonin reuptake inhibitors (SSRIs) increase the amount of 5-HT
(serotonin) at post-synaptic receptors. In theory, 5HT1 receptor agonists may
add to the effects of these increased amounts of serotonin. SSRIs have
frequently been prescribed with 5HT1 receptor agonists and, while adverse
reactions such as dyskinesia, weakness and incoordination have occasionally
occurred[24],[25] a drug interaction causing serotonin syndrome appears to be
extremely rare[26],[27]. Some reports, including from the American Headache
Society, conclude that while concurrent use should not necessarily be
avoided, patients should be monitored closely[28],[29],[30]. The US Food and
Drug Administration (FDA) recommends that patients given a 5HT1 receptor
agonist with an SSRI or a serotonin and norepinephrine reuptake inhibitor
(e.g. venlafaxine) should be informed of the possibility of serotonin
syndrome and be monitored closely[31]. Serotonin syndrome may also occur
with concurrent use of MAO inhibitors and 5HT1 receptor antagonists[10],[16],
[17],[22]
.

Case LS

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case LS

Uploaded by

Copyright:

Available Formats

D LIU CA LM SNG

1. Ca lm sng tng huyt p dng thuc gim au NSAID

Ti sao bnh tng huyt p ca b B. li nng thm?

Phn tch ca:

Cn lu : Trnh t s dng NSAIDs cc bnh nhn tng huyt p. Trong trng hp

3. Ca h glucose mu v m ti pht bnh nhn i tho ng typ 1

Copied and edited by Trng Cng Bng from Nhp cu DLS

H glucose mu bnh nhn T thng thng nht l c gy ra bi liu php insulin qu

Copied and edited by Trng Cng Bng from Nhp cu DLS

Copied and edited by Trng Cng Bng from Nhp cu DLS

Chng ti i n quyt nh rng bnh nhn ny mc chng h glucose mu gi to (factitious

Copied and edited by Trng Cng Bng from Nhp cu DLS

Copied and edited by Trng Cng Bng from Nhp cu DLS

C nn khuyn b B s dng mui n king cho chng ?

in thoi v tho lun v vn ri lon v gic v mt v gic ca ng B. vi bc s k n v

Gim lng mui s dng n di 6g/ngy (ch n khng mui l bt buc cc

Hn ch s dng cc cht cha cn (ung di 2 cc/ngy n gii v 3 cc/ngy vi

Vn ng th cht mt cch thng xuyn, v d i b (l tng nht l 30 pht mi

Nhn mnh tm quan trng ca vic b thuc l

Cn trnh s dng cc thuc gim au nhm NSAID (c bit l t dng thuc) cc

6. Ca lm sng bnh nhn i tho ng c nng cholesterol thp

Copied and edited by Trng Cng Bng from Nhp cu DLS

Loi lipid no thay i bt thng bnh nhn T typ 2 ?

truyn: abetalipoproteinemia (ABL), bnh tch ly chylomicron (chylomicron retention disease

Copied and edited by Trng Cng Bng from Nhp cu DLS

Phn tch su hn v nng thp Apo B v LDL-C

i codon arginine v tr 2495 thnh mt codon kt thc (p.R2495X), dn n s hnh thnh

H betalipoprotein mu (HBL) c xc nh bng cc nng TC, LDL-C hay apo B

7. Ca lm sng ho dai dng nghi ng do thuc c ch men chuyn bnh

Copied and edited by Trng Cng Bng from Nhp cu DLS

Bc s iu tr ca bnh nhn c lin h xut thay th thuc Coversyl bng mt thuc

8. Ca lm sng gp c mng khi ng khi dng thuc chn beta giao cm

Thuc tr ri lon tng ng gim ch : methylphenidate, lisdexamfetamine, amphetamine + dextroam

Thuc an thn: duloxetine, venlafaxine

Khng sinh: ciprofloxacine

Thuc tr trm cm: nhm ba vng; c ch ti thu hi serotonine; c ch MAO

Thuc tr ng kinh: phenobarbital, clonazepam

Thuc tr l ln (Alzheimer): donepezil, risperidone, rivastigmine

Thuc gim au: naproxen, ketamine, morphine

Thuc tr Parkinson: amantadine, ropinirole

Thuc tr tm thn phn lit : clozapine, risperidone, olanzapine

Thuc gy ng: temazepam, triazolam, zolpidem, eszopiclone

Thuc gip cai thuc l: varenicline, ming dn cha nicotine, bupropion

Thuc nhm statin: atorvastatin, simvastatine, rosuvastatine

9. Ca lm sng lin quan n ADR ca furosemid bnh nhn tng huyt p

Copied and edited by Trng Cng Bng from Nhp cu DLS

Copied and edited by Trng Cng Bng from Nhp cu DLS

10. Ca lm sng trm cm nghi ng do dng thuc chn beta giao cm

Copied and edited by Trng Cng Bng from Nhp cu DLS

11. Ca lm sng qu liu morphin bnh nhn suy thn

Duragesic (ming dn fentanyl) 75 mcg/gi, 3 ngy/ln.

Copied and edited by Trng Cng Bng from Nhp cu DLS

Nhng cu hi t ra l, cc sn phm lin hp gluccuronide c b thi tr trong qu trnh

Copied and edited by Trng Cng Bng from Nhp cu DLS

trong iu tr bnh au na u, nhng cng l ngun gc ca tc dng ph gy ra nhng cn c

- ca ny, b H. ang c iu tr tng huyt p bng indapamide, mt thuc li tiu nhm

15. CLS Tng tc thuc bnh nhn tng huyt p v b hng cm nh

Dc s quyt nh gi cho bc s iu tr ca bnh nhn S. thng bo vi bc s l hin ti

16. CLS Hen ph qun v tng huyt p

Copied and edited by Trng Cng Bng from Nhp cu DLS

Copied and edited by Trng Cng Bng from Nhp cu DLS

Clopidogrel v bnh a chy mu mc phi

Mi lin h gia metoclopramide v tc dng ph v thn kinh (cc ri lon