CHNG 6.

KHNG VIM V KHNG HISTAMIN

1. KHI NI M QU TRNH VIM 1.1. Vim l g? Vim l m t chu i cc hi n t ng do nhi u tc nhn nh nhi m trng, cc ph n ng mi n d ch, t n thng do nhi t ho c v t l...gy ra cc d u hi u lm sng c trng : sng, nng, , au. 1.2. Cc giai o n c a qu trnh vim 1.2.1. Giai o n c p : M t n thng ti t ra cc ch t trung gian n i sinh gy xo tr n ch c nng c quan b vim
Ch t trung gian Histamin Serotonin Brandykinin Ngu n g c T bo Mast Ti u c u Dn m ch Tng tnh th m m ch Ho h ng ++ +/ ++ + +++ ng Gy au +++ +

Huy t tng + + + +++ -

Prostaglandin E2 M Leukotrien M

1.2.2. Giai o n p ng mi n d ch Cc i th c bo, b ch c u trung tnh, lympho t p trung vo vim tiu di t tc nhn gy vim b ng cch th c bo ho c trung ha c t k n l giai o n d n s ch cc m nh v n m, ch t ho t t v thay th b ng nh ng t bo m i. 1.2.3. Giai o n vim mn M ti t ra interleukin 123 v cc ch t khc lm s n xu t protaglandin ho t ha cc t bo b ch c u lm phng thch cc g c t do nh H2O2 (hydrogen peroxid), g c hydroxyl lm t n thng xng, s n d n n th p kh p. Ni chung vim l ph n ng c l i cho c th nhng n u v t qu m c (vim mn) s gy t n h i mo, lm di t n b ch c u, t o cc m s i khng c l i cho c th n a 1.3. Cc ch t khng vim Cc ch t khng vim khng o ng c c qu trnh ny m ch gi i h n ho c lm ch m qu trnh vim b ng cch c ch vi c s n xu t cc ch t trung gian gy vim 2. C CH TC NG C A THU C KHNG VIM

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Tc nhn gy vim Phospholipid Corticosteroid Cyclooxygenase Endoperoxid vng NSAIDs, Acetaminiphen Prostaglandin VIM Thromboxan K T T P TI U C U Acid Arachidonic mng t bo Phospholipase A2 Lypooxygenase Leucotrien NSAIDs m i VIM

3. PHN LO I 3.1. Thu c khng vim glucocorticoid 3.1.1. Glucocorticoid t nhin Hydrocortison (cortisol) v cortison l cc glucocorticoid t nhin u c ti t ra t v th ng th n theo co ch ph n h i m tnh. Tuy nhin do ho t tnh khng vim th p v c tnh (gi mu i) cn cao nn cc glucocorticoid t ng h p ra i. 3.1.2. Glucocorticoid t ng h p - Tc ng : Hai c ch khng vim chnh c a nhm ny l Gi m l ng b ch c u v i th c bo vim, ngn nh ng t bo ny ti t ra cc ch t trung gian ha h c lm tng tnh th m thnh m ch, dn m ch gy nng , sng, au. c ch enzym phospholipase A2, ngn t o thnh cc y u t gy vim nh prostaglandin, leucotrien, thromboxan - Tc d ng ph : Tc d ng c a mineralcorticoid nn c khuynh h ng gi Na, gi n c gy ph Tc d ng tn t o ng c th gy cao ng huy t Tc d ng th y gi i m , tch tr lipid d i da c , m t (moonface) Lm xo tr n chuy n ha Ca: gi m h p thu v tng bi th i qua th n, dng lu di s gy long xng Gi m ho t ng c a cc m lympho v ho t ng s n xu t khng th , suy y u h mi n d ch. - Ch nh D ng do th c n, cn trng c n t Khng vim do b t k nguyn nhn g (c h c, ha h c, nhi m trng, mi n d ch...) C p c u khi shock do c t , ch y mu, shock ph n v , tr y h h p (th ng ph i h p v i adrenalin) - Ch ng ch nh Ti u ng (do tc ng lm gi m glucose ngo i bin) Long xng, x p xng (do tng lo i th i Ca qua n c ti u) Lot gic m c (do lm ch m lnh v t thng) B nh th n, kh p, vim m t do virus, n m, lao (do tc d ng suy y u h mi n d ch) Mang thai (co nguy c gy s y thai, ch t thai, st nhau)

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M TS

THU C KHNG VIM GLUCOCORTICOID

KHNG VIM 1 0.8 4 5 25 30 GI MU I 1 0.8 0.3 0.3 0 0 TH I GIAN TC NG Ng n (T1/2=6-12h) Trung bnh (T1/2=12-24h) Di (T1/2=24-36h) LI U DNG 2 10mg/kgP (PO) 0.6-2,5 mg/kgP (PO) 0,2-2 mg/kgP (PO)

TN HO T CH T Hydrocortison (Cortisol) Cortison Prednison Prednisolon Betamethason Dexamethazon

3.2. Thu c khng vim khng steroid (non-steroidal anti-inflammatory drugs- NSAID) 3.2.1. Cc NSAID c Aspirin (acid acetyl salicylic) c tc d ng khng vim, gi m au, h s t. Tuy nhin Aspirin c nhi u tc d ng ph nh - Kch thch nim m c d dy c th gy ch y mu d dy do aspirin lm gi m t ng h p prostaglandin I2 v prostaglandin E2 (ch t c ch ti t acid d dy, tng ti t d ch nhy b o v nim m c d dy) - T n thng gan do aspirin v cc b nh do virus gy h h i ty th - Vim th n k khi dng thu c lu di - Tng th i gian ch y mu do c ch khng h i ph c cyclooxygenase ti u c u do c ch t ng h p thromboxan A2 m t y u t gy k t t p ti u c u. Do , vi c s d ng aspirin nh m t thu c khng vim ngy nay r t h n ch . Acetaminophen (paracetamol) Khng c tc ng khng vim do tc ng c ch t ng h p prostaglandin ng ai bin y u nn ch c tc d ng gi m au v h s t. ng th i gi m ng k cc c tnh c a aspirin. 3.2.2. Cc NSAID m i - C tc d ng khng vim, h st, gi m au, ngn k t t p ti u c u c h i ph c (khc v i aspirin ngn k t t p ti u c u khng h i ph c), khng vim li u th p (aspirin ch c tc d ng khng vim li u cao). - Ch nh : Vim kh pxng, vim th p kh p, vim t s ng Khng vim m t th i gian di (trong vim mn) - Ch ng ch nh: Suy gan, th n Lot d dy, mang thai Ch y mu D ng v i aspirin M T S THU C NSAID M I
TN THU C Phenylbutazon Piroxicam Ibuprofen Diclofenac T1/2 65 57 2 1,1 C I M Khng vim r t hi u qu , nhi u tc d ng ph , khng s d ng lu di Nguy c ch y mu d dy cao, ngy dng 1 l n Dung n p t t hn aspirin Hi u l c khng vim m nh hn nhi u ch t khc

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4. HISTAMIN 4.1. Ngu n g c Histamin c d tr trong cc h t c a t bo mast ( da, nim m c ph qu n, nim m c ru t) v cc t bo b ch c u i ki m (trong mu) d ng ph i h p v i polysaccharid-heparin v protein. 4.2. Phng thch Khi khng nguyn ti p xc c th , khng nguyn s g n k t v i khng th IgE c s n trn b m t t bo mast v basophil lm v cc t bo ny phng thch histamin ra ngoi. ph n ng ny i h i c nng l ng, Ca v theo c ch ph n h i m tnh. 4.3. Tc ng Histamin s g n k t v i cc receptor H1 ( tim m ch, kh qu n, ru t, tuy n n c b t, h th n kinh), H2 ( tim, d dy, th n kinh trung ng) v H3 ( h th n kihn trung ng) gy nn nh ng xo tr n : Gin cc ti u ng m ch gy mu mao m ch Tng tnh th m thnh m ch, lm huy t tng thot ra d ch k Co th t c tim Co th t c trn kh ph qu n Kch thch th n kinh c m gic T t c cc xo tr n trn s th hi n ra cc tri u ch ng : da , s n, ph, au th t tim, kh th , ng t th , au, ng a... 5. THU C KHNG HISTAMIN Cc thu c khng histamin th ng c ph i h p v i adrenalin v cc corticoid trong cc tr ng h p d ng, vim, phng ng a qu m n
Nhm Alkylamin Ethanolamin Phenothiazin Piperidin Tn thu c Chlorphenilamin Diphenylamin (BENADRYL) Promethazin (PHENERGAN) Astemizole (HISTALONG) Receptor H1 H1 H1 H1 c i m An th n nh An th n r r t An th n r r t Khng an th n Li u dng 0,2-1mg/kgP (IM, IV, PO) 2,5-10 mg/kgP (PO) gia sc nh

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