Nhp cu Dc lm sng Thng 1/2015, N1 Page 1/37

Ban c vn
GS.TS.BS. Phm Gia Khi
PGS.TS.BS. T Mnh Cng
Ths.DS.Trng Vit Thnh
Ths. DS. Nguyn Nh H
Ths.DS. L B Hi
Ths.DS. Th Hng Gm
Ths.DS. Hong H Phng
Ths.DS. Nguyn T Sn
DS. Nguyn Th Qunh Trang
DS. Nguyn Quc Ha
DS. Mai Thnh Tn
DS. Nguyn Tin c
DS. Th H (Php)

Tng bin tp
Ths.DS. V Th H
Ph tng bin tp
TS.DS. Nguyn Th Vn Anh

Bin tp vin ph trch tng mng ni dung

im tin dc trong nc: SVD2. L Quang Thng
Tng tc thuc, ADR: Ths.DS. Nguyn Duy Hng
Thuc mi: DS. V Th Vn
Cp nht v Hng dn thc hnh dc/Hng dn iu tr: TS.DS. Nguyn Th Vn Anh
Ca lm sng: Ths.DS. V Th H
im tin cc bi bo: Ths.DS. V Th H
Cng tc vin: cc thnh vin Nhm dch thut NCDLS (hn 300 thnh vin). Link:
https://www.facebook.com/groups/870005816351555/

Lin h:
Trang facebook ca Nhp cu Dc lm sng:
https://www.facebook.com/nhipcauduoclamsang?ref=hl
Group trao i email: https://groups.google.com/forum/?hl=vi#!forum/nhipcauduoclamsang

Thit k trang ba: SVD5. Phm Ngc Huy. nh ba: Khi mu ng. Ngun:
Brucelashleydpms Blog.
Kim tra li chnh t: DS. Trnh Th Hng Nhung, DS. Trn Minh Hip

Tp ch "Nhp cu Dc lm sng" l ti liu lu hnh ni b. Tp ch cha ng k tr

thnh Tp ch chnh thc. Mi thng tin trong ti liu ch c tnh cht tham kho. Vic p
dng cc thng tin t Tp ch cho tng bnh nhn c th l quyn quyt nh v trch nhim
ca tng cn b y t. Tp ch "Nhp cu Dc lm sng" khng chu trch nhim v vic p
dng thng tin cung cp trong Tp ch.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 2/37

 Li ng

Tp san Nhp cu Dc lm sng ra i vi mong mun l ni tng hp, chia s

nhng thng tin mi, thit thc h tr cho cng tc Thc hnh, o to v Nghin cu Dc
lm sng ti Vit Nam.

Tp san c thnh lp t s hp tc ca cc dc s c kinh nghim trong cc lnh

vc khc nhau (thc hnh, ging dy, nghin cu), trong v ngoi nc, cng nh cc sinh
vin dc tr y ti nng, nhit huyt vi mc ch hon ton phi li nhun. C th, s hp
tc l hon ton t nguyn v Tp san c th truy cp hon ton min ph.

D nh Tp san Nhp cu Dc lm sng s pht hnh 1 s mi qu. Mi s s c

mt ch trng tm. S u tin c ch l "Thuc chng ng ng ung". V y l
nhm thuc c ch s iu tr hp v l mt trong nhng nhm thuc gy ra nhiu ADR
nghim trng trn lm sng.

Hy vng Tp san Nhp cu Dc lm sng s l ti liu cp nht thng tin hu ch cho

mi Dc s lm sng!

Xin gi n qu ng nghip dc s v cc sinh vin mt nm mi 2015 li chc sc

khe v cng tc tt!

Thay mt Ban bin tp

V Th H
Nguyn Th Vn Anh

Nhp cu Dc lm sng Thng 1/2015, N1 Page 3/37

Mc lc
im tin thng tin dc trong v ngoi nc ......................................................................................... 5
Tin 1: Hi ngh Dc s bnh vin Thnh ph H Ch Minh.......................................................... 5
Tin 2: Sinh vin dc lm sng tiu biu nm 2014 do Nhp cu Dc lm sng bnh chn......... 8
Tin 3: Danh sch cc thuc b nh ch thng 11 v thng 12 nm 2014 ...................................... 10
Tin 4: Tm dng m ngnh Y, Dc ti cc trng H, C khng chuyn ............................... 11
Tin 5: im tin mi v thuc chng ng..................................................................................... 11
Hng dn thc hnh Dc lm sng/Hng dn iu tr mi ............................................................ 13
Xem xt s dng thuc. ................................................................................................................. 13
X l D ng thuc. ....................................................................................................................... 13
Hng dn v T vn bnh nhn bi Dc s............................................................................... 13
Hng dn v phng php cung cp thng tin thuc bi dc s. .............................................. 13
Nhng thay i v Hng dn iu tr rung nh ........................................................................... 14
Chn thuc chng ng ng ung mi (NOAC) theo c im lm sng bnh nhn thay th
warfarin cho bnh nhn rung nh khng do bnh van tim ............................................................. 15
Phn tch ca lm sng ............................................................................................................................ 18
11 ca v thuc chng ng ng ung ........................................................................................ 18
Ca qu liu morphin bnh nhn suy thn ................................................................................... 29
Ca bo co ADR: Ceftriaxone gy thng b nhim c hoi t tng t vt thng do bng ... 32
Gii thiu cc bi bo nc ngoi ......................................................................................................... 36
ADR/Pharmacovigilance ............................................................................................................... 36
Medication Evaluation /Optimization ........................................................................................... 36
Dose adaptation ............................................................................................................................. 37
Pharmacy Practice ......................................................................................................................... 37
Guideline ....................................................................................................................................... 37

Nhp cu Dc lm sng Thng 1/2015, N1 Page 4/37

im tin thng tin dc trong v ngoi nc

Tin 1: Hi ngh Dc s bnh vin Thnh ph H Ch Minh

Ngy 30/11/2014 ti khch sn Sheraton - TP. H Ch Minh din ra thnh cng Hi ngh
khoa hc Hot ng dc bnh vin TP. H Ch Minh m rng. Tp ch "Nhp cu Dc lm
sng" c cuc phng vn nhanh vi DS. CKI. Nguyn Th Sn Trng khoa dc, BV a
Khoa Si Gn, hin l thnh vin ph trch Qun l trang web, h tr phn k thut trong cc
hi ngh khoa hc v h tr cc cng vic khc ca Hi.

Hi Dc s bnh vin thnh ph H Ch Minh (DSBV TPHCM) thnh lp t khi no? C

cu t chc v s lng thnh vin?

Hi DSBV TPCM thnh lp t nm 1980 trc thuc Hi Y hc TPHCM, sau ny trc thuc
Hi Dc hc TPHCM.

Hi hin nay gm c 1 Ch Tch, 2 Ph Ch tch v 90 thnh vin trong Ban Chp hnh l
cc Trng, Ph khoa dc, Ban Gim c ca cc BV ng ti TPHCM.

Cc thnh vin hin nay bao gm tt c cc dc s hot ng trong lnh vc dc bnh vin.
Hin nay hi vin ch gii hn l cc bnh vin trn a bn TP. HCM.

Mc ch hot ng ca hi? Cc hot ng ca hi l g?

Hi Dc S Bnh vin TP. H Ch Minh vi mc tiu chung l xy dng v pht trin cng
tc dc bnh vin, ph bin cp nht kin thc v dc lm sng, qun l, ng dng Cng
ngh thng tin vo cc hot ng dc ti bnh vin, ni kt vi cc ng nghip trong v
ngoi ngnh y t trong c nc ng gp vo s pht trin chung ca ngnh y t.

HDSBV TP.HCM lun c cc hot ng thit thc h tr v chuyn mn, chia s kinh
nghim thc t cng cc ng nghip tiu biu l cc lp tp hun v dc lm sng, v cc
k nng cn thit cho dc s bnh vin c t chc thng xuyn ti S Y T TP. HCM, cc
ging vin l cc chuyn gia u ngnh v nhiu lnh vc c lin quan n hot ng dc
bnh vin nht l dc lm sng.

Hi ngh khoa hc Hot ng dc bnh vin TP. H Ch Minh m rng, xin cho hi hi
ngh thng din ra khi no?

Hi ngh khoa hc Hot ng dc bnh vin TP. H Ch Minh m rng l s kin quan
trng thng nin do Hi Dc S Bnh Vin TP. H Ch Minh c t chc t nm 2010.
Hi ngh thng c t chc vo dp cui nm thng 11 hoc 12. Ban u ch c phm vi l
cc BV ti TP. HCM, nay thu ht c s tn nhim v tham gia ca cc Cng ty dc
phm trong v ngoi nc, cc ng nghip trn c nc. Nm nay hi ngh c t chc
vo ngy 30/11/2014 ti khch sn Sheraton - TP. H Ch Minh, hi ngh l im hn ca
hng trm dc s - cn b lm cng tc dc bnh vin, ang lm vic, nghin cu t cc
vng min ca t nc. y cng l c hi qu bu cho cc dc s c dp gp g - chia s -
hc hi.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 5/37

Hot ng chnh ca hi ngh l g?

Hot ng trng tm l cc bo co chuyn mn v cc lnh vc hot ng Dc ti bnh

vin, c tuyn chn, nh gi bi mt hi ng chuyn gia c uy tn.

Cc bo co c gi tr, phn nh cc lnh vc hot ng Dc ti bnh vin c tuyn chn

i din cho cc khu vc c trnh by ti hi ngh. Hi ngh cng l dp cho cng ng
dc bnh vin gp g, giao lu cui nm m rng cc mi quan h c nhn chia s, hc hi
c nhiu iu b ch phc v cho cng tc chuyn mn.

Danh sch cc bo co ti Hi ngh?

Ton b bi bo co bng pdf c th ti min ph ti website www.hpahcmc.org .

S lng tham gia Hi ngh nm nay l bao nhiu? Thnh phn?

Nm nay c khong 600 i biu ton quc, ch yu 90% l dc s bnh vin, khng c sinh
vin, cn li l cc Ging vin i hc, nh qun l c lin quan n hot ng dc BV.

Nhng thng tin ni bt t hi ngh nm nay?

Cc bo co khoa hc nm nay kh a dng, Ni dung bo co tp trung vo nhiu vn

quan trng mang tnh thc tin v c gii php hiu qu nh l:

(1)nh gi hiu qu ca ng dng cng ngh thng tin trong qun l cc hot ng lin
quan n cng tc dc ti BV Qun 11 DS. CK II o Duy Kim Ng - BV. a khoa
Qun 11 - TP.HCM xy dng phn mm phn tch d liu s dng thuc gip cho vic
qun l thuc, gim st k n v xy dng danh mc hiu qu hn.

(2)Phng nga sai st trong s dng thuc ca TS.DS. V Th Thu Hng BV. E H Ni

(3) T vn la chn, s dng dng c kh dung trong iu tr hiu qu hen v COPD: Vai tr
ca Dc s - ThS.DS. Nguyn Th Thu Ba BV. a khoa Hon M - Nng

(4) Thng tin thuc v chng nhm ln trong cng tc Dc bnh vin ca DS.CKI Trn
Phm Thc - BV. a khoa Trung ng - Hu

V nhiu bo co c gi tr khc

Cng tc t chc nm nay cng ngy cng hon thin hn nhn c nh gi cao t cc
i biu v cc nh ti tr, kt qu c c l s ch o kp thi v st sao ca lnh o hi
cng vi n lc, phi hp ng b ca tt c cc thnh vin trong ban t chc.

Xin cm n DS. Sn tr li phng vn ca Tp san "Nhp cu Dc lm sng" v chc

Hi ngh Dc bnh vin TP HCM s ngy cng ln mnh v hot ng hiu qu, h tr
c lc cho thc hnh dc ti cc bnh vin.

Mt s hnh nh ca Hi ngh cung cp bi DS. Sn !

Nhp cu Dc lm sng Thng 1/2015, N1 Page 6/37

 Ths.DS. V Th H (phng vn)

Nhp cu Dc lm sng Thng 1/2015, N1 Page 7/37

Tin 2: Sinh vin dc lm sng tiu biu nm 2014 do Nhp cu Dc lm sng bnh
chn
Trong nm 2014, NCDLS c gng t chc cc cu hi mi ngi cng tham gia tr li.
Mi cu hi u c chm im s b. V bn Phan Quang Khi l ngi tham gia tr li
tch cc v chnh xc nht. Mt phn thng tr gi 500.000 VND s c trao tn tay cho
bn y nh mt s ghi nhn cho n lc c nhn v nim am m dc lm sng ca bn. Sau
y, NCDLS c cuc phng vn ngn vi bn Phan Quang Khi.

Xin bn gii thiu mt cht v bn thn?

Mnh tn Phan Quang Khi, hin l sinh vin nm th 5, H Y Dc HCM. Mt nm na

thi l mnh s c tt nghip nh cc anh ch kha trn mi tt nghip hm 20/12/2014.

nh hng ngh nghip tng lai ca bn l g?

Mnh mun theo ui Dc lm sng lu di. Mun vy trc tin mnh phi bi dng kin
thc tht tt . Tm c hi thc hnh v tch ly tht kinh nghim thc tin cng nhiu cng
tt.

Cm ngh ca bn v Nhm Nhp cu Dc lm sng?

NCDLS l mt trong nhng Nhm him hoi, cht lng dnh cho Dc s.

Vi i ng admin cc k nhit tnh, vn kin thc v kinh nghim rt tt, c bit l v mng
Dc lm sng. NCDLS l din n b ch dnh cho bt c ai yu thch DLS, c bit l cc
bn sinh vin.

Ni dung c chia s trong nhm rt a dng v phong ph, cc hng dn chi tit v cch
tip cn cc kha cnh ca DLS rt mi m.

V sao bn li quyt nh tham gia tr li rt tch cc cc cu hi v Dc lm sng do

NCDLS t chc? B quyt ca nhng cu tr li chnh xc ca bn l g? C iu g bn
mun chia s vi mi ngi?

Mnh xem vic tr li cc cu hi v DLS ging nh mt cch gii ta cng thng, tn dng
thi gian lc rnh ri. Cng ging nh vic hc ting Anh, mnh bin n thnh mt phn hot
ng khng th thiu hng ngy.

Mnh mun tm hiu su v mt vn no th trc ht phi c ngun ti liu tin cy, bit
nh hng tm vn u. Tra cu thng tin thuc l mt trong nhng k nng c bn
m mt Dc s lm sng cn phi c, v phi rn luyn thc hnh nhiu ngy mt thun
thc. NCDLS cng chia s rt nhiu ngun ti liu v cch thc tm kim cho mi ngi
c th tham kho.

DLS VN hin ti vn cha pht trin mnh. Tt c u trng cy vo i ng nhn lc dc

s hin c, v cc bn sinh vin Dc khoa hm nay s sm tr thnh ngi Dc s trong

Nhp cu Dc lm sng Thng 1/2015, N1 Page 8/37

tng lai. Con ng dnh cho DSLS khng n gin,i hi rt nhiu am m v n lc,
mnh ngh nu mi ngi cng nhau c gng,chia s, trao i kin thc,kinh nghim th thc
hnh DLS s pht trin mnh m hn. Vi nhng bn SV cha c tip xc,cha hiu nhiu
v DLS th Nhm NCDLS chnh l ni tuyt vi bn hc hi kinh nghim,trao i kin thc
v theo ui am m.

Cm n i ng NCDLS rt nhiu !

Xin cm n bn tr li phng vn v chc bn tt nghip vi kt qu tt nht v thnh

cng!

Trong nm 2015, NCDLS d nh s tin hnh bnh bnh chn cc gii thng chnh bao
gm "Dc s bnh vin tiu biu 2015", "Ging vin DLS tiu biu 2015", "DS c thnh
tch nghin cu tiu biu 2015", "Sinh vin DLS tiu biu 2015". Phng thc tin hnh,
tiu chun s c cng b trn page facebook NCLDS.

Ths.DS. V Th H (thc hin)

Nhp cu Dc lm sng Thng 1/2015, N1 Page 9/37

 Tin 3: Danh sch cc thuc b nh ch thng 11 v thng 12 nm 2014
Thuc Hot cht/Ch nh Thng tin sn phm L do nh ch Ngy ban hnh quyt nh
KAKAMA 10 loi tho dc HD: 16/02/2017, SK: VD-0275-06, do Cng ty Khng t yu cu cht lng v ch 04/12/2014 : S Y t Thnh ph
Vin bao /Thiu mu no, C phn Dc tho Phc Vinh tiu nh tnh Hng hoa theo Tiu H Ch Minh thng bo nh ch
ng au u, hoa mt chun c s. lu hnh ti Thnh ph H Ch
Minh
Levelamy L-ornithin L- L s 022014, SK: VD-17807-12 do Cng ty Phn ng ADR nng nh st cao, rt 3/12/2014: Tm ngng vic mua
500mg/5ml aspartat c phn Dc phm Armephaco run, tc ngc, kh th, tt huyt p... bn v s dng trn ton quc
Thuc tim
LOPERAMID Loperamide L s: LPV06, NSX: 08/02/2014, HD: Khng t tiu chun cht lng v 30/11/2014 Cc qun l Dc
E 2 mg 07/02/2016, SK: VN-13499-11, do Cng ty
hydrochloride/Tiu ch tiu khi lng trung bnh bt nh ch lu hnh c nc
Vin nang chy Eurolife Healthcare Pvt. Ltd., India thuc trong nang.
ULCEZ Omeprazole/Lot L s: ULCQ-13, NSX: 25/04/2013, HD: Khng t tiu chun cht lng v 30/11/2014 Cc qun l Dc
Vin d dy-t trng 25/04/2015, SK: VN-12333-11, do Cng ty ch tiu ha tan. nh ch lu hnh c nc
Nestor Pharmaceuticals Ltd., India
Omepraglobe Omeprazole/Lot L s: GC04790, NSX: 11/2013, HD: 10/2015, Khng t tiu chun cht lng v 04/11/2014 Cc qun l Dc
20 mg d dy-t trng SK: VN-5270-10, do Cng ty Globela Pharma ch tiu ha tan trong mi trng nh ch lu hnh c nc
Vin Pvt. Ltd., India m pH 6,8.
Nestoflox 200 Ofloxacin/iu tr L s: OXTR-02, NSX: 30/01/2014, HD: Khng t tiu chun cht lng v 04/11/2014 Cc qun l Dc
mg nhim khun 29/01/2017, SK: VN-13026-11, do Cng ty ch tiu tnh cht. nh ch lu hnh c nc
Vin nn Nestor Pharmaceuticals Limited - India
Euroseafox100 Cefpodoxime/ iu L s: 03, NSX: 09/06/2013, HD: 09/06/2016, Khng t tiu chun cht lng v 04/11/2014 Cc qun l Dc
mg tr nhim khun SK: VN-12288-11, do Cng ty Navana cc ch tiu hnh thc v ha tan. nh ch lu hnh c nc
Vin nang Pharmaceuticals Ltd., Bangladesh
Prednisolon 5 L s: 020213, HD: 23/02/2016, SK: VD- Khng t tiu chun cht lng v 04/11/2014 Cc qun l Dc
mg 10596-10, do Cng ty C phn dc vt t y t ch tiu ha tan. nh ch lu hnh c nc
Vin nn bao Thi Bnh

Danh sch ny khng y . Thng tin chi tit truy cp ti trang web ca B y t:
http://www.dav.gov.vn/Default.aspx?action=news&menuid=107&type=3. L Quang Thng, SVD2, H Y Dc HCM (im tin)

Nhp cu Dc lm sng Thng 1/2015, N1 Page 10/37

Tin 4: Tm dng m ngnh Y, Dc ti cc trng H, C khng chuyn

Ngy 3-12-2014, B GD-T c cng vn gi cc c s gio dc i hc, thng bo chnh

thc tm dng vic xem xt m ngnh o to trnh H cc ngnh y a khoa, rng hm
mt, y hc c truyn v c trnh H ln C vi ngnh dc hc ti tt c cc trng a
ngnh khng thuc khi chuyn ngnh y dc; nhm thc hin ch trng i mi cn bn v
ton din gio dc H lnh vc khoa hc sc khe, nng cao cht lng i ng thy thuc
phc v sc khe nhn dn. B GD-T v B Y t cng s tin hnh r sot v nh gi h
thng c s o to nhn lc y t trn ton quc v i ng cn b ging dy v c s vt cht
phc v cho cng tc o to nhn lc y t. Trong trng hp cn thit, p ng nhu cu
nhn lc cho mt s a phng, vng min, B GD- T phi hp B Y t xem xt nhu cu
nhn lc thc t, thm nh cc iu kin cn thit bo m cht lng o to trc khi
quyt nh cho m ngnh ti cc c s o to H khng chuyn ngnh y dc. B GD-T
cng yu cu cc trng H, C phi xc nh ch tiu o to nhn lc y t theo s ging
vin c hu quy i ca tng ngnh (ch khng phi da trn i ng ton trng quy i
chung vi cc ngnh khc) v cc iu kin c quy nh bo m cht lng.

L Quang Thng, SVD2, H Y Dc HCM (im tin)

Ngun tin: Bo Tui Tr (http://tuyensinh.tuoitre.vn/tin/20141203/tam-dung-mo-mot-

loat-nganh-y-duoc-o-dai-hoc-da-nganh/679767.html)

Tin 5: im tin mi v thuc chng ng

1. Thng 8/2014, FDA thay i cnh bo trn nhn thuc ca Eliquis (apixaban) :
Vic dng sm bt k thuc chng ng no, bao gm c Eliquis, m khng c liu
php chng ng thay th hp l lm tng nguy c gp cc bin c tc mch. Trong
mt nghin cu trn nhng bnh nhn b rung nh ngi ta thy tng t l t qu khi
bnh nhn chuyn t Eliquis sang warfarin. Do vy, Eliquis b dng li v bt c l do
no ngoi vic xut hin chy mu hoc l kt thc qu trnh iu tr, cn xem xt s
dng mt liu php chng ng khc thay th.

2. Thng 5/2014 : FDA gn y mi hon thnh mt nghin cu mi trn cc bnh nhn

trong c s d liu Medicare so snh gia Pradaxa (dabigatran) v warfarin. Theo
nghin cu ny, nguy c gp t qu do cc mu ng, xut huyt no v t vong
dabigatran thp hn so vi warfarin, tuy nhin bnh nhn dng dabigatran c nguy c
b xut huyt tiu ha nghim trng cao hn.

3. Thng 11/2014, FDA ang nh gi nhng d liu u tin ca mt th nghim lm

sng so snh phc s dng 2 thuc chng kt tp tiu cu (aspirin vi clopidogrel
hoc prasugrel) trong vng 30 thng v trong vng 12 thng. Nhng kt qu ban u
ch ra rng vic iu tr trong vng 30 thng lm gim nguy c nhi mu c tim v
hnh thnh cc mu ng trong stent nhng t l t vong chung li cao hn so vi vic
iu tr trong vng 12 thng. Tuy nhin y cha phi l kt lun cui cng rt ra t
nghin cu ny. Vic nh gi vn ang c tin hnh. Bc s khng nn thay i
cch k n v bnh nhn khng nn dng s dng nhng thuc ny do s lm tng
Nhp cu Dc lm sng Thng 1/2015, N1 Page 11/37
 nguy c gp cc bin c tim mch. Ths.DS. Nguyn Duy Hng (im tin).
Ngun: FDA. Link: http://goo.gl/belYGg

4. CLOPIDOGREL: 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.
Chu Thanh Hng. DVD5, Trng i hc Dc H Ni (dch)
V Th H (hiu nh)
Ngun: La Revue Prescrire 2014, 34. N363, pg 26

Nhp cu Dc lm sng Thng 1/2015, N1 Page 12/37

Hng dn thc hnh Dc lm sng/Hng dn iu tr mi

Nhm Nhp cu dc lm sng s ln lt son tho cc Hng dn v dc lm sng theo

cc ch c th, thit thc nhm h tr cho cc dc s trong thc hnh dc lm sng hng
ngy. Trc mt, vic bin son ny s do cc dc s c lp bin son n gin ha qu
trnh v tit kim thi gian. Hy vng trong thi gian xa, s tin hnh bin son c theo
nhm; trong c s phn bin, b sung, tho lun gia nhiu DS khc nhau ti liu c
hon chnh v y hn.

Trong nm 2014, NCDLS son c 4 Hng dn vi cc ch sau. Link xem v ti ti

liu nh km.

Xem xt s dng thuc.

Ti liu c son tho nhm h tr vic xem xt s dng thuc mt cch c h thng v
chun ha bnh nhn c tin hnh bi dc s nh ai tin hnh, tin hnh u, qu trnh
tin hnh gm nhng bc g.

Link: http://fr.slideshare.net/VoHa1/xem-xt-s-dng-thuc-v1

X l D ng thuc.

Ti liu c bin son nhm h tr dc s trong thc hnh X l d ng thuc trn lm

sng nh c ch, qu trnh x l, phng d ng.

Link: http://fr.slideshare.net/VoHa1/d-ng-thuc-v1-ncdls

Hng dn v T vn bnh nhn bi Dc s.

Ti liu c bin son nhm h tr dc s trong qu trnh thc hin t vn bnh nhn ti
bnh vin cng nh ti quy thuc. Ti liu gii thiu cc k nng t vn, cc bc tin hnh
t vn, cc ni dung t vn v gii thiu 3 trng hp t vn ph bin (t vn theo n, t
vn nhm gii quyt vn khng tun th iu tr v t vn thuc khng cn k n).

Link: http://fr.slideshare.net/VoHa1/3-huong-dan-ve-tu-van-benh-nhan-boi-duoc-si-v1-ncdls

Hng dn v phng php cung cp thng tin thuc bi dc s.

Ti liu c bin son nhm h tr dc s p dng phng php c tnh h thng tr li

cc cu hi v thng tin thuc trong thc hnh lm sng. Ti liu trnh by chi tit 8 bc ca
phng php cng v d minh ha thc t.

Link: http://fr.slideshare.net/VoHa1/4-huong-dan-thong-tin-thuoc-v1ncdls

Nhp cu Dc lm sng Thng 1/2015, N1 Page 13/37

Nhng thay i v Hng dn iu tr rung nh
Hi Tim mch M v Hi cc Trng i hc v Tim mch M (ACC/AHA) va ban hnh
Hng dn mi nht v iu tr rung nh nm 2014. Trong c mt s thay i quan trng
l: thay i h thng im s nh gi, phn loi nguy c ca bnh nhn t h thng
CHADS2 (1 im cho suy tim, tng huyt p, ln hn hoc bng 75 tui, i tho ng, 2
im cho tin s t qu hoc t qu thiu mu no thong qua) sang h thng CHA2DS2-
VASc (1 im cho suy tim, tng huyt p, i tho ng, bnh tim mch, tui 65-74, n, v
2 im cho tin s t qu, hoc t qu thiu mu no thong qua, hoc ln hn hoc bng
75 tui) v nhiu khuyn co mi ng h vic dng cc thuc chng ng ng ung mi
(NOAC) nh apixaban, dabigatran, rivaroxaban.

Theo h thng tnh im CHA2DS2-VASc, nu s im l 0 th khng cn iu tr, s im l

1 c th khng iu tr, hoc dng aspirin hoc dng NOAC. Tt c bnh nhn c s im 2
v ln hn 2 nn dng thuc warfarin hoc NOAC. Vi s thay i v h s tnh im ny,
nhiu bnh nhn c th c iu tr vi ch thuc chng ng mnh hn, theo l thuyt
th n c th gip lm gim s t qu do huyt khi t tim, tuy nhin n cng tim n nguy
c lm tng ADR chy mu.

Khuyn co cng khuyn dng NOAC cho nhng bnh nhn khng th duy tr INR trong
mc bnh thng khi dng warfarin. iu ny khng n gin c ngha l NOAC l gii php
thay th trong cc trng hp phc tp. Khi INR khng nm trong mc bnh thng khi dng
warfarin, cn xc nh l do v sao. Nu bnh nhn tun th iu tr vi AVK m vn khng
t c INR mong mun th c th chuyn sang dng NOAC. Nhng nu bnh nhn km
tun th iu tr vi warfarin th bnh nhn c th khng nn thay th bng NOAC bi v thi
gian bn thi ca NOAC ngn hn warfarin, nn vic qun vi liu warfarin vn c th c
INR mong mun, nhng nu qun vi liu NOAC c th dn n liu thp hn ngng iu
tr. Hn na, vic khng t INR mong mun c th do bnh nhn khng mun hoc khng
th o INR thng xuyn. Tuy nhin, vic dng AVK v ti khm hng thng o INR bi
bc s l c hi quan trng bc s nh gi li tnh trng ca bnh nhn, gio dc bnh nhn
v s tun th iu tr. Nu nhng bnh nhn ny c chuyn sang dng NOAC (NOAC
khng cn theo di INR hng thng) th bnh nhn s khng ti khm nh k vi bc s na.
Mt s bnh nhn khng thch hp cho vic ch nh NOAC nh bnh thn giai cui, bnh
nhn mang van tim nhn to c hc.

Tm li, trong khi ch i c thm nhiu bng chng v kinh nghim dng NOAC, liu php
dng AVK nn l la chn cho nhiu bnh nhn v tnh an ton v hiu qu ca n c th theo
di qua ch s INR.

Tc gi: Lisa Charneski and James M. Hollands. Recent changes in practice guidelines for
atrial fibrillation management. Pharmacotherapy 2014; 34(11):1118-1120.
Ths.DS. V Th H (lc dch)
PGS.TS.BS. T Mnh Cng (hiu nh)
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation.
Link: http://content.onlinejacc.org/article.aspx?articleid=1854231

Nhp cu Dc lm sng Thng 1/2015, N1 Page 14/37

Chn thuc chng ng ng ung mi (NOAC) theo c im lm sng bnh nhn
thay th warfarin cho bnh nhn rung nh khng do bnh van tim
Gii thiu : Thut ng rung nh khng do bnh van tim ("nonvalvular atrial fibrillation" -
NVAF) nhm cp n nhng ca rung nh m khng c hp van hai l do thp hoc van tim
nhn to. Bnh nhn b NVAF c nguy c b t qu v huyt khi, tc mch h thng (stroke
and systematic embolism- SSE), v nhng nguy c ny c th gim khi dng warfarin. Tuy
nhin, iu tr bng warfarin l phc tp v i hi theo di INR t nht hng thng. iu tr
bng ba thuc chng ng ng ung mi (new oral anticoagulant-NOAC) t phc tp hn
v c chng minh l la chn thay th cho warfarin phng SSE bnh nhn NVAF.
Tuy nhin chn NOAC no trong 3 loi trn i vi tng bnh nhn c th l quyt nh kh
khn ca cc nh thc hnh lm sng v dc s. Bi tng quan ny trnh by chi tit cc c
im lm sng cn xem xt khi chn mt thuc NOAC thay th cho warfarin i vi mt
bnh nhn c th v tm tt nhng thng tin ny trong mt bng so snh (Bng 1).

Phng php: Dng bng chng lm sng t cc th nghim quan trng, thng tin k n
c cng nhn ti Canada v M v thng tin theo di hu mi, bi tng quan ny cung cp
mt tng hp cc thng s lm sng quan trng m cn b thc hnh lm sng cn cn nhc
khi chn mt NOAC thay th cho warfarin i vi mt bnh nhn b NVAF phng SSE.

Kt qu v tho lun: Dabigatran, rivaroxaban v apixaban c cng nhn l la chn thay

th cho warfarin phng s cp v th cp SSE bnh nhn NVAF. Thm vo , apixaban
cng c so snh vi aspirin bnh nhn NVAF v cho thy khng l la chn thay th
thch hp cho liu php khng vitamin K (AVK). Cn nhc cc c tnh lm sng quan trng
ca bnh nhn gm tui, cn nng, chc nng gan, chc nng thn v tng tc thuc khi la
chn mt NOAC thay th cho warfarin.

Kt lun: Mt vi NOAC hin nay l la chn thay th cho warfarin cho phng SSE bnh
nhn NVAF tc cn b thc hnh lm sng thay v iu chnh liu warfarin t thng s INR
nay i hi k nng mi l chn NOAC da theo cc c im lm sng ca bnh nhn nh
tui, cn nng, chc nng gan, chc nng thn v tng tc thuc. Cc c im lm sng ca
bnh nhn ny c tm tt trong mt bng n gin sau:

Nhp cu Dc lm sng Thng 1/2015, N1 Page 15/37

 Bng 1: Tm tt cc bin s lm sng quan trng la chn thay th cho vic iu chnh liu warfarin nga SSE trong NVAF.

Liu cho Dabigatran Rivaroxaban Apixaban

ngi 150 mg * 2 ln/ngy 20 mg/ngy 5 mg * 2 ln/ngy
trng
thnh
Tui Theo thng tin k n ti M khng c khuyn co Theo thng tin k n ti M, cc bnh nhn Da vo th nghim ARISTOTLE, gim liu
cn iu chnh liu dng n thun theo tui. >65 tui c th c nng thuc cao hn cn 2.5 mg * 2 ln/ngy c khuyn co cho
BN 75 tui c xu hng c nguy c xut huyt trong mu. C nguy c huyt khi v xut cc bnh nhn c t nht hai yu t sau: 80
nng huyt u cao hn trong nhm BN ny c l tui; creatinine huyt tng SCr 1.5 mg/dL;
Cc trng hp chy mu c ghi nhn khi v chc nng thn b thay i do tui. cn nng 60 kg.
theo di hu mi (post-marketing) BN 80 tui Tuy nhin, t l li ch/nguy c ca thuc vn
Cc tc gi khuyn co trnh s dng thuc cho chp nhn c cho tt c nhm tui.
nhng bnh nhn ny. Cc tc gi khuyn co cn dng thn trng
thuc ny cho BN 65 tui.
Xem xt chc nng thn gim liu.
Cn nng Theo thng tin k n ti M khng c khuyn co Theo thng tin k n ti M khng c Da trn th nghim ARISOTLE, gim liu
iu chnh liu dng theo cn nng. khuyn co v iu chnh liu dng theo cn cn 2.5 mg * 2 ln/ngy c khuyn co cho
Cn nng <60 kg l mt trong bn yu t lm sng nng. cc bnh nhn c cn nng 60 kg V (80
c lin quan n xut huyt nng trong nhng tui HOC lng creatinine huyt tng SCr
nghin cu quan st. 1.5 mg/dL
Bnh gan Thng tin k n ti M khuyn co trnh s dng Thng tin k n ti M khuyn co trnh s Theo thng tin k n ti M,khng cn chnh
hot cho suy gan trung bnh n nng (Child-Pugh mc dng cho suy gan trung bnh n nng (Child- liu cho bnh nhn suy gan nh.
ng B v C) Pugh mc B hoc C) v cc bnh nhn vi Theo thng tin k n ti M, vi nhng bnh
bnh gan bt k c lin quan n s ng nhn suy gan trung bnh (Child-Pugh mc B):
mu. dng thn trng do t kinh nghim lm sng vi
nhng bnh nhn ny
Khng dng cho nhng bnh nhn vi suy gan
nng (Child-Pugh mc C)
Chc Liu dng cho thng tin k n ti M: Liu dng cho thng tin k n ti M8 Liu dng cho thng tin k n ti M
nng Clcr > 50 mL/pht: 150 mg * 2 ln/ngy. Clcr > 50: 20 mg * 1 ln/ngy. SCr 1.5 mg/dL v (80 tui hoc cn nng
thn Clcr 3050 mL/pht: Khng cn chnh liu tr khi Clcr 1550: 15 mg * 1 ln/ngy vo bui n 60 kg): 2.5 mg * 2 ln/ngy.
bnh nhn ang dng km dronedarone hoc ti. Bnh thn giai on cui (ESRD) ang chy

Nhp cu Dc lm sng Thng 1/2015, N1 Page 16/37

 ketoconazole ng ung, khi xem xt gim liu Clcr < 15: Trnh dng. thn: 5 mg * 2 ln/ngy; gim cn
cn 75 mg * 2 ln/ngy. Bnh thn giai on cui (ESRD) ang chy 2.5 mg * 2 ln/ngy nu 80 tui hoc cn
Clcr 1530 mL/pht: 75 mg * 2 ln/ngy v bnh thn: Trnh dng. nng 60 kg.
nhn khng dng km thuc c ch P-gp (bao gm Ch : Ch :
dronedarone hoc ketoconazole ng ung). AHA/ASA khuyn co trnh dng khi Clcr < Vi bnh nhn c bnh thn nng hoc giai
Trnh dng ng thi thuc c ch P-gp v 15 mL/pht on cui, warfarin vn l la chn chng ng
dabigatran. mu.
Cc tc gi khuyn co cn cc k thn trng khi s Cc tc gi khuyn co cn cc k thn trng
dng dabigatran bnh nhn c Clcr 1530 mL/ph. khi s dng apixaban vi ngi c ESRD/ chy
Bnh thn giai on cui (ESRD) ang chy thn: thn nhn to.
ngh khng s dng. Ch :
Ch : Khi c dng phng t qu bnh nhn
ACCP khuyn co trnh s dng khi Clcr < 30 NVAF, AHA/ASA khuyn co trnh s dng
mL/ph do khng c d liu lm sng. khi Clcr 25 mL/pht.
AHA/ASA khuyn co trnh dng khi Clcr < 15
mL/ph.
Tng Tng tc thuc theo thng tin k n ti M.9 Tng tc thuc theo thng tin k n ti M. Tng tc thuc theo thng tin k n ti M.
tc thuc Thuc c ch P-gp: Thuc c ch CYP3A4 v P-gp: Thuc c ch CYP3A4 v P-gp:
Xem xt gim liu khi dng vi verapamil, Trnh dng vi ketoconazole, itraconazole, Gim liu khi dng vi ketoconazole,
amiodarone, dronedarone, ketoconazole, voriconazole v posaconazole, itraconazole, voriconazole v posaconazole.
itraconazole, voriconazole v posaconazole. lopinavir/ritonavir, ritonavir, Thuc cm ng CYP3A4 v P-gp:
Thuc cm ng P-gp: Trnh dng vi rifampin, indinavir/ritonavir v conivaptan. Trnh dng chung vi rifampin, St Johns wort,
Hypericum perforatum (St Johns wort), Thuc cm ng CYP3A4 and P-gp: carbamazepine, phenytoin, phenobarbital
carbamazepine, phenytoin, phenobarbital Trnh dng vi rifampin, St Johns wort,
carbamazepine, phenytoin, phenobarbital
ClCr (Clairance of Creatinine): thanh thi creatinin. ACCP (Americain College of Clinical Pharmacy) : Hi cc trng v Dc lm sng ti
M. ESRD (end-stage renal disease): bnh thn giai on cui. AHA (Americain Heart Association): Hi Tim M. ASA (American Stroke
Asociation): Hi t qu M. P-gp: protein vn chuyn thuc qua mng. Ni dung in m th hin cc liu c khuyn co cho ngi trng
thnh v cc iu chnh liu cho nhng bin s lm sng c bit. Ngun: Consideration of clinical variables for choosing new anticoagulant
alternatives to warfarin for the management of non-valvular atrial fibrillation. Lu Y1, Branstad R, Karim RM, Asinger RW. J Clin Pharm
Ther. 2014 Dec;39(6):628-36. DS. Nguyn Ph Lc. Ths.DS. V Th H (dch).PGS.TS.BS. T Mnh Cng.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 17/37

Phn tch ca lm sng

11 ca v thuc chng ng ng ung

Ca 1: Tc dng khng mong mun - MT MI

B P, 49 tui, iu tr bng Presvican (fluindione) vi liu 1 vin nn/ngy phng nga

tc mch do rung nh c 1 nm. B P c kh tun th iu tr v qu trnh iu tr kh n
nh. Hm nay, b n hiu thuc v b cm thy rt mt v trng rt xanh xao. B va c
mt khong thi gian lm vic vi cng cao v b ngh dc s bn cho b vitamin C
phc hi.

Vic dng vitamin C c thch hp trong trng hp ca b P.?

Khng. u tin l do vitamin C khng c tc dng trong vic iu tr mt mi. Mt khc, cn

phi ch n s mt mi v xanh xao quan st thy mt bnh nhn iu tr bng mt thuc
khng vitamin K (AVK) c th l do du hiu lm sng lin quan n chy mu ng tiu
ha.

Cn nh: nhng bnh nhn s dng AVK, khng c trng hp chy mu no nn xem l
bnh thng. Mt mi t ngt thng km theo xanh xao nng c th l du hiu ca chy
mu trong (tc dng c hi ca dng AVK).

Phn tch ca

Cc trng hp chy mu khi s dng AVK c th nh v nhn thy c (nh chy mu

cam, chy mu chn rng, t mu), hoc l nghim trng v nhn thy c (nh chy mu
trc trng, ho ra mu, chy mu ngoi nghim trng), hoc l nghim trng v khng thy
c (nh xut huyt tiu ha khng km theo nn ma, xut huyt no, xut huyt trong
khp). Mt mi t ngt km theo xanh xao c th l du hiu ca xut huyt tiu ha m
thm khng biu hin ra bn ngoi.

Thi x tr

iu quan trng l khng lm bnh nhn lo lng, l do mt mi ca bnh nhn c th gy ra

bi mt yu t khc ngoi thuc (nh cng vic, thay i ma, p lc, stress ). Tuy vy,
cn phi gip cho bnh nhn hiu y l mt tnh trng khn cp. Dc s cn xut vi
bnh nhn thng bo cho bc s v tnh hnh. ngh vi bc s tip b P trong thi gian gn
nht v tin hnh xc nh cng thc mu ca bnh nhn cng nh xt nghim INR c th
iu chnh liu AVK cho bnh nhn. Theo nguyn tc, mi triu chng mi gp khi s dng
AVK cn phi c x tr nh l mt tc dng c hi ca thuc.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 18/37

THIT B O LNG T NG
T nm 2008, Php c 2 thit b t ng xt nghim INR. Vic xc nh ch s INR c
xt nghim ch bng mt git mu ly ra t cnh ca mt u ngn tay.
Hai thit b hin ti ang c mt trn th trng u c bo him chi tr vi gi 1.136 euro.
Chng c bo hnh 2 nm v c bn ti cc hiu thuc.
My Coaguchek XS (Roche Diagnostics) v phin bn Coaguchek XS Plus System
dng cho bnh vin: Xc nh INR t 10L mu. Cn phi chn gia 3 n v o :
INR, giy (thi gian Quick) v % theo t l prothrombin. My c km theo bt chch
t ng Coaguchek Softclix, cc u kim chch v bng giy xt nghim Coaguchek
XS. Khi m mt hp bng giy mi, cn phi nht vo mt con chip m s c trong
mi hp bng giy v xc nhn m mi ln cho bng giy vo my c.
My INRatio2 (AAZ-LMB) c thit k dng cho c cc nhn vin y t hoc cho
bnh nhn: xc nh INR t 10L mu. Cn phi chn gia 2 n v o: INR hoc
giy (thi gian Quick) cng vi t t khong INR mc tiu cho tng bnh nhn bi
bc s. My c km theo bt chch t ng Autolet, cc u kim chch (hoc u kim
chch kh trng dng 1 ln Unilet) v bng giy INRatio. Khi s dng mt bng giy
mi, cn phi nhp m s tng ng vi s l in trn hp ng bng giy.
Khuyn co
Sau khi nh gi cc thit b o lng t ng, Hi ng ti cao v sc khe (HAS) khuyn
co ch nn s dng cc thit b ny i vi i tng l tr em di 18 tui iu tr bng
AVK trong thi gian di. l nhm i tng m vic ly mu xt nghim c th kh tin
hnh.
Thc t
Vic o INR cn mt lng mu nhiu hn so vi vic o ng huyt, nn cc loi
bt chch km theo cc thit b ny cng ring bit
Khi ly mu, cc li khuyn cng ging nh i vi vic t o ng huyt:
o Ra tay bng x phng vi nc m v sy kh
o Ch xt trn lng bn tay gip t mu v pha cc u ngn tay
o Chch vo cnh ca t cui cng ca ngn gia, ngn p t hoc ngn t
Cn phi thm nh li kt qu ca phng php t o bng cc phng php chun
ti phng xt nghim theo protocol ca HAS.
Vic k toa dng my t o INR, gio dc v theo di bnh nhn v s dng my cn
c tin hnh khoa tim mch nhi. Cha m v tr em cn c gio dc v vic iu
tr bng AVK v phng php t o INR.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 19/37

Ca 2: Tc dng khng mong mun - N KM

K t khi ngh hu, ng V., 70 tui mt cm gic ngon ming. Hm nay, C. con gi ng
va mua cho b mt chai nc sc ming v mt bn chi nh rng mm. C y gii thch
rng k t hm kia, ng V b chy mu khi ang nh rng. C dc s hi C. rng b
c c dng thuc g khng. C. tr li rng b c ang dng thuc iu tr lon nhp, nhng c
khng bit tn, nhng c c gi h s lu v s dng thuc ca b c. Dc s pht hin bnh
nhn ang dng nhng thuc sau: Cordarone (amiodaron), Prviscan (fluindion), Hmigoxine
(digoxin) v Aldactazine (spironolacton + altazide). C dc s t hi liu chy mu li c
phi l du hiu ca qu liu AVK? Thi x tr th no?

Phn tch ca

Trn thc t, ngi gi, c bit l nhng ngi thiu dinh dng, c nguy cao b qu
liu AVK. Do nhng thuc ny c c tnh dc ng hc c bit l gn mnh vi
albumin, chng tn ti nhiu hn dng t do trong trng hp thiu protid v do
tng tc dng chng ng mu.

Nh vy, do s trm trng v thng xuyn xy ra cc bin c xut huyt nhng

ngi gi, vic s dng AVK nhng bnh nhn ny l ch ca nhng khuyn co
c bit ca ANSM (Hi quc gia an ton thuc ca Php): nh gi chc nng nhn
thc ca bnh nhn, bi cnh tm l v x hi, gim liu ban u mt na hoc so
vi ngi trng thnh, nhng nh gi v mi tng quan nguy c li ch sut qu
trnh iu tr, gim st INR t nht 1 ln/thng v chnh liu trong trng hp: c bnh
mc km, thay i v iu tr v ch n ung, c bit trong trng hp thiu
protid.

2-4% ngi gi t 60 n 80 tui sng nh b thiu dinh dng do s thay i trong

chuyn ha v thi quen n ung. S ng ha protein gim trong khi s d ha
protein vn gi nguyn. Do tiu hao nng lng ngi gi tng. Hin tng ny
cn trm trng hn nu c cng thng v th cht hoc tinh thn.

Thi x tr

Sau khi chc chn vi C. rng ng V khng t s dng NSAID hay aspirin, c dc s gii
thch rng khng nn b qua tnh trng trng thi tinh thn khng tt ca ng V v thc t
rng ng y n t hn trc do c th l nguyn nhn gy qu liu thuc chng ng mu,
gy ra chy mu li. C y cho rng nn tin hnh xt nghim INR cng sm cng tt trc
khi n tham kho kin ca bc s iu chnh liu Previscan v nh gi tnh trng tm
l v dinh dng ca ng V.

Cn nh: AVK c nguy c cao gy tc dng khng mong mun, c bit l ngi trn 65
tui. Cn phi tng cng theo di iu tr nhng i tng ny do c nguy c cao b qu
liu, c bit l khi c nhng thay i ln trong ch n ung.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 20/37

MT CUN S THEO DI S DNG AVK KHNG THCH HP CHO NGI GI
Theo mt nghin cu ng trn bo Presse Mdicale thng 9/2011, nhng ngi gi
thng gp kh khn khi c v s dng cun s gip theo di s dng AVK. Cun
s ny c bin son bi ANSM, Cespharm v hi tim mch Php nhm ti u vic
theo di v gio dc bnh nhn s dng AVK. N nhc li nhng nguyn tc s dng
thuc, a ra nhng li khuyn thc t v cho php ghi li liu, ngy o v gi tr
INR.
Hoc l, ch trong s kh c vi nhng ngi trn 75 tui (font ch qu mnh,
tng phn khng thch hp : ch trng trn nn tm). Tuy nhin, tui trung bnh
ca bnh nhn s dng AVK l 72,5. Do , ch c khong 70% trong s 47 bnh
nhn tham gia nghin cu (bnh nhn ni tr, t nht 75 tui, khng c vn v tm
l) c c 8 dng c ch to trch dn t cun s.
Do nhng hn ch ca ngi gi trong vic s dng ng cun s, r rng dc s l
ngi ng hnh vi nhng ngi gi dng AVK ngn chn nhng tc dng ph
gy ra do thuc.

Ca 3: Tng tc thuc- BNH NM MING

ng A, 67 tui, c thay van tim nhn to c hc. ng phi dng Sintrom

(acenocoumarol) ngn nga huyt khi ti van. Vi ngy gn y, do cm thy c v l
trong ming, ng dng nc sc ming khng khun. V khng c hiu qu, ng n
khm bc s, bc s k cho ng dng kem bi ming Daktarin 8 tha/ngy do ngh rng ng
b nhim nm ming. ng A bt u iu tr c 2 ngy. ng y tr li quy thuc
vo hm nay mua nc sc ming v ng b chy mu li.

Vic chy mu li c phi l mt du hiu cnh bo qu liu AVK khng? V sao? Thi
x l th no?

C, tt c cc trng hp chy mu ngi ang dng AVK u l du hiu ng bo ng.

Trong trng hp ng A, c th l do tng tc gia Daktarin/Sintrom gy ra qu liu AVK.

Phn tch ca

i vi ngi mang van tim nhn to, nht l van tim c hc, vic s dng thuc chng ng
l cn thit phng nga huyt khi ti van nhn to. Mt khc, ng A b nhim nm
ming. Bc s cho rng cn thit phi iu tr nm ming v chn miconazol dng ti
ch, l mt la chn tt trong trng hp ny. Miconazol l mt cht c ch enzym
CYP450. Cc AVK t nhy cm vi enzyme ny. Tuy nhin, tc dng c ch ny ca
miconazol li mnh lm thay i s thi tr ca cc AVK. Mt khi trong vng tun
hon chung, miconazol lm tng nng ca acenocoumarol trong mu v do lm tng tc
dng chng ng (nh hnh minh ha di). iu c th gii thch tnh trng chy mu
bnh nhn ny. Dng dng ti ch ca kem miconazol c th lm ta qun mt kh nng tng
tc ca thuc ny. Tuy vy, s hp thu vo h tun hon chung ca kem miconazonl khi dng

Nhp cu Dc lm sng Thng 1/2015, N1 Page 21/37

ti ch vn ng k. Dng thuc sc ming (sau bnh nhn c th nut) c sinh kh
dng tng ng khi dng thuc dng vin nn ng ung.

Thi x tr

Cn phi dng Daktarin ngay lp tc v kim sot nguy c chy mu. Ngi dc s cn phi
bo cho bc s k n v gii thch cho bc s tnh hnh. Vic kim sot nguy c chy mu bao
gm nh gi li 1 ln liu AVK v o nhanh INR hiu r hn nguy c hin ti. Khi m s
xut huyt r rng, vic iu chnh liu AVK cn phi lm ngay, thm ch trc c khi c
kt qu INR. Khi bc s khm li cho bnh nhn, nn xut mt phng n iu tr thay th
nh l Fungizone (Amphoterecin B). Thuc ny khng gy ra tng tc vi AVK.

Cn nh:Vic phi hp miconazol vi mt AVK c th lm tng tc dng ca AVK. iu ny

lm tng nguy c chy mu. Vic dng ng thi 2 thuc ny l chng ch nh.

S tng tc thuc

c ch Cytochrome

Tng hot ng
ca acenocoumarol

Ca 4: Tng tc thuc- DNG KHNG SINH

ng G. b huyt khi tnh mch su. ng dng Presvican (fluindion) hng ngy (3/4
vin/ngy) v vic iu tr kh cn bng trong vng 6 thng qua, INR trong khong gii hn
2-3. ng G gh hiu thuc my hm trc tm mua thuc iu tr au hng: Clamoxyl
1g (amoxicillin), ung sng v ti trong vng 6 ngy. Hm nay ng y quay tr li v INR
tng vt qu 3,8. ng y t hi liu c phi khng sinh gy ra tnh trng ny khng? Thi
x l ca dc s th no?

C phi amoxicillin l nguyn nhn?

Phi, tt c khng sinh u c kh nng gy tng IRN mt bnh nhn ang dng AVK.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 22/37

Phn tch ca

Chng ta bit t lu rng cc khng sinh, do lm gim h vi sinh vt ng rut (ngun sn

sinh vitamin K), c th lm tng tc dng ca cc thuc khng vitamin K v do , lm tng
INR. Tuy vy, khng phi l nguyn nhn chnh gy ra tng INR khi dng ng thi AVK
v khng sinh trn bnh nhn ny. Trn thc t, c ch chnh l s gim chuyn ha ca cc
AVK bi khng sinh amoxicillin, c th l amoxicillin lm gim chuyn ha AVK qua
CYP2C9.

Thi x tr

ng G c INR nm ngoi khong iu tr (2-3) nhng vn thp hn 4. Trc ht, cn phi u

tin tm kim cc du hiu xut huyt ngoi hoc trong (kh th, au u, mt mi ). Nu
khng c nhng du hiu trn, khng c c s iu chnh liu AVK. Nguyn nhn gy qu
liu r rng: l do vic s dng khng sinh, vic ny s kt thc vo ngy hm sau (khi
ht dng khng sinh). Cn khuyn ng G theo di INR vo ngy hm sau.

Cn nh : Khi vic qu liu khng c biu hin g, km theo INR < 4, khng cn phi dng
thuc chng ng AVK. Cn phi o li INR vo ngy hm sau. Nu INR >= 4(nhng <6)
cn phi thng bo ngay vi bc s. Trong trng hp ny, HAS cng khuyn co rng cn
b qua 1 liu thuc AVK. Nu INR > 6, cn phi dng AVK li ngay v cn phi ung
vitamin K.

Ca 5: Tng tc thuc- DNG NHM THUC

ng S., 77 tui, iu tr bng Presvican c 5 nm. Hm nay, ng y vi v n gp dc

s k t khi m ca ni rng ng y dng Biprofenid (ketoprofen) ca v ng t 1 tun
nay thay th cho Bitildiem (diltiazem) ca ng y. ng y nhn ra s nhm ln t ti qua v
cn lo lng hn na khi sng nay ng y nn ra mu. Tuy nhin, ng S. o INR hm
qua v kt qu c cao nhng vn nm trong gii hn iu tr 2-3. Trng hp ny bnh nhn
c nguy c no khng? Thi x tr?

Trng hp ny c nguy c no khng?

C, vic nn ra mu lun l mt trng hp khn cp v c nguy c cao. Vic INR vn

trong gii hn cho php l khng m bo an ton cho bnh nhn ny.

Phn tch ca

ng S. v dng 2 loi thuc (Biprofenid v Presvican) m vic dng chung 2 thuc ny

khng c khuyn khch. Dng nhm ln ny thng xy ra vi nhng bit dc m tn gn
ging nhau (v d nh Biprofenid v Bitildiem trong trng hp ny). Rt nhiu c ch khc
nhau c th gii thch cho tng tc ny. u tin, cc NSAID gy c trn ng tiu ha,
c kh nng dn n xut huyt tiu ha, iu ny li cng trm trng hn khi dng AVK.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 23/37

Hn na, cc AVK c cho l c kh nng kin kt vi protein huyt tng mnh (khong
97%). Hu ht cc NSAID c kh nng chim ch ca cc AVK phn lin kt vi cc
protein v do lm tng lng AVK t do trong mu. iu ny dn n tng nguy c xut
huyt, thng l km theo tng INR. Cui cng, cc NSAID c tc dng ngn kt tp tiu
cu, vic ny cng lm tng tc dng ca AVK.

Thi x tr

Nn ra mu l mt trng hp cp cu. Bnh nhn cn phi n khoa cp cu ngay. Dc s

cn gi in thng bo vi bc s iu tr cho ng S.

Cn nh: Vic dng chung mt AVK v mt NSAID khng c khuyn khch do chng lm
tng nguy c xut huyt.

Ca 6: Tng tc thuc-TO BN TM THI

ng C. 74 tui, b vim khp nhiu nm nay, c xu hng t vn ng v hn ch di chuyn.

ng b tc mch phi cch y 1 nm v t c iu tr bng Presvican (fluindion),
vin nn/ngy. Vic iu tr kh cn bng. Hm nay ng n hiu thuc do b to bn t 2
ngy nay v thy au u. ng mun mua mt hp Doliprane v mt hp Lansoyl (thuc
nhun trng).

C nn bn thuc cho ng C. khng?

Khng c vn g nu dng Doliprane (paracetamol) ng lc. Vic dng Lansoyl khng

c khuyn khch vi ngi dng AVK.

Phn tch ca

Trong trng hp ng C, vic dng paracetamol khng c vn g. l thuc gim au

u tay cho nhng ngi dng AVK. Tuy nhin, mt vi ca mt cn bng trung bnh INR
c bo co khi dng paracetamol lp i lp li vi liu trn 2g/ngy. S tng tc ny c
th l do s c ch nhiu enzyme ch ca cc AVK gy ra bi s chuyn ha paracetamol,
do lm tng tc dng chng ng ca cc thuc ny. Tuy nhin, iu ny ch lin quan n
mt vi trng hp c bit (dng liu thuc ti a trong thi gian di, cn kit glutathion,
ngi gi .) Vic can thip bng thuc l khng cn thit i vi nhng bnh nhn dng
thuc gim au hp l.

Parafin c trong Lansoyl c th tng tc vi AVK. N hn ch vic hp thu ca cc vitamin

tan trong du (c bit l vitamin K), iu c th lm tng tc dng chng ng. Bn cnh
, cc AVK cng tan trong du nn vic hp thu ca chng cng c th b hn ch. Mt
khc, ging nh cc cht nhun trng khc, parafin lm tng nhu ng rut c th lm ri lon
s hp thu AVK.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 24/37

Cui cng, vic dng thuc ny c th gy hu qu khng on trc c ln s cn bng
ca qu trnh iu tr.

Thi x tr

V vic to bn, dc s c th a ra nhng li khuyn v v sinh n ung.

Dc s c th ngh i sang mt thuc nhun trng thm thu m t c nguy c tng tc

vi AVK hn.

Cn nh: Tt c cc cht nhun trng, c bit l parafin, c th lm mt cn bng vic iu

tr chng ng bng AVK.

Ca 7: Tng tc thuc- DNG THO DC

B H., 70 tui, c thay van tim nhn to c hc. B iu tr bng Coumadin (warfarin)
6mg/ngy t 3 nm nay ngn cc bin c huyt khi. B n hiu thuc hm nay mua
Midlac 600mg m b mua thng trc ti mt hiu thuc ni b i ngh mt.

C nn bn thuc cho b H. khng?

Khng, bi Midlac c cha St. Johns Wort (Hypericum perforatum) l mt loi tho dc
chng ch nh khi dng cng vi AVK.

Phn tch ca

St.Johns Wort l mt loi cy c tc dng cm ng enzyme mnh. Cm ng enzyme l mt

hin tng km chn lc, n tc dng ln hu ht cc enzyme gan CYP450. Nh vy, cc
AVK, do chuyn ha mt phn qua CYP2C9, s b tng thi tr khi dng cng vi mt cht
cm ng. Do vy c th gy hu qu l tc mch. Cm ng enzyme l mt hin tng chm
c th ko di t 2-3 tun.

Thi x tr

Cn phi tin hnh o INR ngay trong ngy. Dc s cn gi cho bc s k n. Tc dng cm

ng c th ko di 2-3 tun, do cn phi tin hnh theo di INR nghim ngt trong thi
gian ny. Bc s s xut mt thuc chng trm cm tng thch hn vi vic iu tr AVK.
Cn nh rng, tng tc gia AVK v cc cht c ch ti hp thu serotonin c chn lc
(SSRIs) chim a s trong cc trng hp tai bin do thuc c lin quan n AVK (v mt s
lng)

Cn nh: Cc cht cm ng enzyme mnh nh l St.Johns Wort c th lm gim tc dng

ca cc AVK v lm tng nguy c hnh thnh cc mu ng. Tt c cc trng hp k n
St.Johns Wort cn phi xc nhn rng bnh nhn ang khng ang dng song song mt
thuc khc.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 25/37

Ca 8: Ca c bit - I NC NGOI

ng B, 69 tui, dng Presvican (fluindion) c 10 nm nay do b rung nh. Vic iu tr kh

cn bng. ng nh n n vo nm sau v bc s ca ng k cho ng vaccin chng virus
vim gan A t by gi. Do ng n nh thuc mua Harvix.

ng B c th dng Harvix khng?

C th, tuy nhin, tt c cc hnh ng gy tn thng trong qu trnh tim vaccin u c th

gy chy mu nng nhng bnh nhn dng AVK.

Phn tch ca

Vaccin chng virus vim gan A c dng theo phc 2 mi cch nhau 6 n 12 thng. Cc
dng c khuyn co l tim bp c delta, tuy nhin vic ny khng c khuyn khch
nhng bnh nhn ang dng AVK do nguy c chy mu. Do khng c bin php thay th no
khc, cn nh gi li s cn bng nguy c/li ch ca vic iu tr.

Thi x tr

Dc s cn phi gii thch vi ng B rng vic tim bp c nguy c gy chy mu do ng

ang dng AVK. Vic tim do cn phi thay th bng ng tim di da khi m ng
dng thng thng b cm ch nh, ging nh trong t tm tt c tnh sn phm ca Harvix.
Nu khng th ng B cn phi m bo rng ng c th tin hnh o INR khi cn thit trong
khi i ngh n .

Cn nh: Tim bp khng c khuyn khch vi nhng bnh nhn ang iu tr bng AVK.
Cn phi thay th bng ng dng khc khi cn thit.

Ca 9: Ca c bit - INR THP

B G., 75 tui, iu tr bng Sintrom (acenocoumarol) t nhiu nm nay phng nga bin
chng huyt khi do b c thay van tim nhn to. Vic iu tr rt cn bng. Hm nay,
b n gp bn, c v rt lo lng, do INR o ln cui cng ca b rt thp ( 1,9 thay v 3,5).
iu ny cha tng xy ra nhiu nm nay. Sau khi hi b v tnh hnh bnh l, dc s bit
rng gn y b G bt u mt ch n ung nghim ngt nhm gim cn.

iu g lm INR ca b G thp?

Vic thay i hon ton ch n ung ca mt bnh nhn ang dng AVK c th lm mt
cn bng vic iu tr chng ng mu.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 26/37

Phn tch ca

Cc thuc khng vitamin K c ch cc qu trnh tng hp cc yu t ng mu ph thuc

vitamin K (yu t II, VII, IX, X, protein C v S) gan. Protein C v S thng c chuyn
ha gan bi phn ng carboxyl ha m cn c s c mt ca vitamin K. Thc t, vic b
sung vitamin K lm gim hiu qu iu tr. Mt trong nhng ngun cung cp vitamin K ch
yu l t thc n, c bit l trong mt vi loi rau xanh v du thc vt. Trong trng hp
bnh nhn ny, s mt cn bng c v nh gy ra bi vic dng mt lng rau xanh ln m
thng th bnh nhn khng n. l mt ngun cung cp vitamin K ln, v do lm gim
tc dng ca cc AVK v gim INR.

Thi x tr

Mt mt, dc s cn giai thch vi b G nguyn nhn ca vn , l do vic dng khng

theo thi quen mt lng ln thc phm giu vitamin K. Vic ny khng b cm, nhng cn
phi c tin hnh thng xuyn v khng nn dng mt lng ln ngay lp tc. Vic iu
tr bng AVK cn bng vi ch n ung quen thuc ca bnh nhn. B G khng nn thay
i t ngt thi quen n ung.

Mt khc, dc s cn phi kim sot nguy c ng mu khi INR thp. Cn phi gi cho bc
s k n iu chnh liu AVK. Vic iu chnh liu s tin hnh ngay lp tc hay khng
ph thuc vo vic liu v G c mun tip tc ch n ung nghim ngt hay khng. B G
s phi theo di nghim ngt INR trong mt vi ngy nu mun tip tc ch n ny.

Cn nh: Trong mt vi trng hp n ung khng theo thi quen, thc n c th lm gim
hiu qu ca AVK, c bit l acenocoumarol (thi gian bn thi ngn).

Ca 10: Tng tc thuc v th thut chn on - Phu thut ni soi

B T., 45 tui, iu tr Prviscan (fluindion) t nhiu nm nay v b thay van tim nhn to c
hc. B tun th iu tr. Ngoi ra, B thng xuyn c nhng cn au do 1 khi u nang lnh
tnh. Cuc phu thut ni soi d kin t 3 thng trc v ngy mai s tin hnh.

Hm nay b T. n nh thuc bi v bc s yu cu b ngng s dng thuc AVK

(chng ng mu) 5 ngy trc phu thut, v iu tr bng Fragmin (dalteparine) thay th.

Nhng b qun, vn tip tc iu tr bng AVK m khng s dng heparine thay th. V
sao phi thay th AVK bng heparine 5 ngy trc phu thut? Nu b T. vn tin hnh phu
thut vo ngy mai, th vic khuyn b dng dng AVK ngy hm nay nh th c
phng bin chng chy mu? Thi x l?

Thi hn trn c ?

Khng. Trong trng hp phu thut trn, vic ngng s dng AVK l hon ton cn thit, v
thi hn 24h khng bnh nhn khng gp phi nguy c chy mu.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 27/37

Phn tch trng hp

B T. phi ngng iu tr bng thuc chng ng trc 1 cuc can thip phu thut. l s
phng cn thit cho tt c tnh hung c kh nng gy ra chy mu kh cm. Trong trng
hp ngng s dng thuc chng ng trc phu thut, c 2 kh nng c xem xt. Nu
bnh nhn gim nguy c kt tp tiu cu, th khng cn s dng thm heparine. Nu bnh
nhn tng nguy c kt tp tiu cu, th cn thit phi s dng thm heparine tim 2 ln/ngy
liu iu tr. B T. mang van nhn to, nn s la chn dng thm heparine l ph hp. Liu
AVK cui cng s dng cn thit phi vo 5 ngy trc phu thut, iu tr HBPM (hparine
trng lng phn t thp) phi bt u vo ngy th 3 trc phu thut (1 ln tim vo bui
sng), sau vo ngy th 2 trc phu thut (1 ln tim vo bui sng, 1 vo bui ti), v
vo ngy trc phu thut 1 ln tim bui sng hn ch nguy c chy mu trong phu
thut.

Thi x l

Dc s phi thng bo vi bnh nhn v nguy c chy mu nghim trng nu h phu thut
trong trng hp trn. V cn bo vi bc s phu thut.

Cn nh: Khi c can thip phu thut, phi m bo ngng s dng AVK trc 5 ngy.

Ca 11: AVK v s khng tun th iu tr

ng R. iu tr Prviscan (fluindione) 3 thng nay. Bnh nhn ti nh thuc sng nay bi

ng b chy mu li. Dc s bit c rng ng R. qun ung thuc trong 2 ngy i cng
tc cui tun, v ng ung b liu qun. Bnh nhn c l khi ung li liu qun? Thi
x l?

Bnh nhn c l khi ung li liu qun?

Khng c l, qun ung 1 liu AVK t hn 8 ting khng c ung b li.

Phn tch trng hp

ng R. l bnh nhn mi iu tr thuc chng ng mu. ng ung b li 2 liu qun

trnh nguy c kt tp tiu cu. iu dn n hin tng qu liu chng ng mu v l
nguyn nhn ca chy mu nu. Bnh nhn khng c cn b y t hng dn cn lm g
khi qun s dng thuc AVK. Do , trng hp ny l 1 v d v tm quan trng cn cung
cp thng tin ny khi dng AVK cho bnh nhn.

Thi x l

Cn lin lc vi bc s iu tr ca bnh nhn kim sot tnh hnh xut huyt ngay lp tc.
Khn cp tin hnh xt nghim INR. Tip , cn nhc li nhng nguyn tc khi s dng

Nhp cu Dc lm sng Thng 1/2015, N1 Page 28/37

AVK cho bnh nhn, hoc pht cho bnh nhn s theo di iu tr AVK (c th ti link
www.cespharm.fr).

Cn nh: Trong trng hp qun ung AVK hn 8h, khng nn ung b bt c liu no.
Trong trng hp nghi ng, khng xc nh, tt hn ht l b 1 liu qun, v ung liu
tip theo vo gi nh.

Ca 1 n 9 do: DS.Ths. Nguyn Duy Hng (dch)

Ca 10 v 11 do:Trn Phng Trinh, SVD4, H Y Dc HCM (dch)
Ths.DS. V Th H (hiu nh)
PGS.TS. T Mnh Cng (hiu nh)
GS. Phm Gia Khi (hiu nh)
Ngun: Link gc: Ngun: Les Formateur des Pharmacies - Formation N143. Cahier 2 du n
2913/2914 du 7 janvier 2012.

Ca 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

Nhp cu Dc lm sng Thng 1/2015, N1 Page 29/37

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.

Nhp cu Dc lm sng Thng 1/2015, N1 Page 30/37

 Morphine

10% thi qua thn v 90% thi qua chuyn ha ti gan

thi qua lc mu

M3G M6G

Thi qua thn&

khng thi qua lc mu

Hnh 1: Qu trnh o thi ca morphine v cc cht chuyn ha chnh ca n.

Nhn xt:

- Vi bnh nhn suy gan: nng morphine trong mu s tng ln, tng tc dng v c tnh
gy ra do morphine.

- Vi bnh nhn suy thn: nng cht chuyn ha ca morphine l M3G v M6G s tng ln
trong mu, gy tng c tnh ca morphine gy ra do cc cht chuyn ha ny b tch ly, d
bnh nhn c lc mu hay khng. (Hnh v v Phn nhn xt ny c b sung bi ngi
hiu nh).

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.

Tc gi: Eddie Chen, D.O., R.Ph.

Hiu nh: V. Dimov, M.D.
DS. V Th Vn (dch)
TS.DS. Nguyn Vn Anh, Ging vin Trng H Khoa hc v Cng ngh H Ni (hiu nh)
Ths.DS. V Th H, Ging vin Trng i hc Y Dc Hu(hiu nh)
Link gc: http://clinicalcases.org/2003/10/morphine-overdose-in-renal-failure.html

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Ca bo co ADR: Ceftriaxone gy thng b nhim c hoi t tng t vt thng do
bng

Tm tt

Gii thiu: Thng b nhim c hoi t l mt ri lon bong trc da him thy c t l t
vong cao.

Khi qut ca lm sng: Mt ph n gc Iran 70 tui biu hin thng b nhim c hoi t
c chn on ban u l bng nng. Tm hiu su hn v bnh s cho thy bnh nhn c
biu hin tn thng lan rng trong thi k nm vin v c s dng ceftriaxone trong
vi ngy. Theo nh kin thc ca chng ti th y l ca lm sng u tin m ceftriaxone gy
bnh thng b nhim c hoi t trong ti liu ting Anh.

Kt lun: Thng b nhim c hoi t l mt ri lon bong trc da cp tnh, e da tnh

mng vi t l t vong cao. Nghi ng lm sng cao, nhanh chng ghi nhn v chm sc h tr
ban u l bt buc. iu tra trit c ch gy bnh l nguyn tc c bn, vn cha c cc
hng dn iu tr ti u.

Gii thiu

Thng b nhim c hoi t l mt bnh him thy c c im l da hoi t lan rng v c

th e da tnh mng [1,2]. Phn ln cc lm sng c bo co l do phn ng c ng? ca
thuc [3]. Mc nghim trng ca hi chng, cc bo co khng chnh thng v hng lot
khng c kim sot c trnh by trong cc ti liu ting Anh gy kh khn cho vic m
t chnh xc c tnh ca hi chng, c ch gy bnh c bn v cc la chn iu tr y .
Chng ti trnh by 1 ca TEN c chn on ban u nh l bng nng. Biu hin trn da
ban u ging nhau ca nhng bnh ny c th gy nhm ln cho bc s lm sng, c bit l
khi bnh nhn khng tnh to v kh khai thc ng tin s bnh. Vi ca lm sng ny,
thng b nhim c hoi t gy ra bi ceftriaxon. Theo nh kin thc ca chng ti th y
l ca TEN u tin ceftriaxon gy TEN trong ti liu ting Anh.

Ni dung ca lm sng

Mt ph n gc Iran c chuyn n n v cha thng ca chng ti do vt thng bng

ln. Nguyn nhn vt thng cha r. Bnh nhn c tiu s mc bnh i tho ng type 2,
bnh tim thiu mu cc b, tng huyt p, cng gip, tng lipid huyt, vim ph qun mn
tnh, glaucom, v ri lon trm cm nh. Bnh nhn c iu tr mt cch thng xuyn vi
cc thuc sau: amitriptyline, enalapril, glyburide, verapamil, omeprazole, aspirin, simvastatin,
theophylline, furosemide, metformin, citropram, thuc nh mt dorzolamide hydrochloride,
v latanoprost

Khi nhp vin, bnh nhn mt phng hng. Huyt p 90/60 mmHg. Kim tra da thy vt
bng 2 b mt c 2 v, mt ngoi ca hai sn, mt trong ca cnh tay, mt trong bp

Nhp cu Dc lm sng Thng 1/2015, N1 Page 32/37

i, v khu vc xng b vai bn phi. Cc ban lan ta c lu , c bit l ca chi trn
v pha trc thn mnh (Hnh 1,2).

Mt chn on c th ng l bng b mt mc 2 nh hng n 26% tng b mt c th

c a ra. B dch l iu tr ban u theo nh cng thc Parkland. Mt ng truyn
tnh mch c thit lp. Vt thng c x l bng gc tm nc mui. Kt qu kim tra
cc ch bng ca bc s sau 12 gi nhp vin lu n cc vt rp da mng cc v tr m
khi nhp vin khng c nh: lng, nch, vng bn, v hai u gi (hnh 1,2), cui cng th
nh hng ti 35% tng b mt c th. Bong trc da tr nn nng n hn km vi du hiu
Nikolsky r rng. Da trn vic hi su hn v bnh s, chn on bng c loi tr. Bnh
nhn k li 2 ngy trc khi nhp vin, bnh nhn c chn on nhim pneumonia, c
iu tr ceftriaxone trong bn ngy mt bnh vin khc v cho xut vin sau . Kt lun
cui cng l bnh thng b nhim c hoi t do dng ceftriaxone. Cc nim mc khng b
nh hng. Bt u iu tr vi hydrocortisone 500mg tim tnh mch. H ng huyt (mc
glucose 45mg/dl) c iu tr thnh cng vi truyn tnh mch dextrose 5%, v ngng ung
thuc h ng huyt. Phng xt nghim nhn thy h magie huyt (1,32 mg/dl), v vy ch
nh tim tnh mch MgS04. iu tr ti ch bi gc tm vaselin c thay mt ln mt ngy.
Ngay th hai sau kkhi nhp vin, thn nhit bnh nhn bt u tng. Cng thc mu cho thy
bch cu gim cn 2.300 mg/dl. m sinh thit da chng minh y dy da hoi t (hnh
3). Lp h b khng c cc t bo b vim. Kt qu m bnh hc ph hp vi chn on bnh
TEN. Bnh nhn c chuyn n khoa hi sc tch cc - chng c (ICU) ca chng ti v
bt u iu tr vi globulin min dch (0,5 g/kg/ngy trong 4 ngy, tng liu 40g/ngy).
Huyt p ng mch khng n nh c iu tr thnh cng vi cc tc nhn co mch v
th my. Kt qu cy mu thu c trong khi bnh nhn nm ti khoa ICU, dng tnh vi
Klebsiella pneumoniae, Proteus mirabilis, Enterobacter, Enterococcus v Pseudomonas
aeruginosai. Khng sinh iu tr bao gm:vancomycin, levofloxacin, ciprofloxacin, ampicillin
- sulbactam, piperacillin tazobactam, and amikacin sulfate. Din bin lm sng kh phc tp
vi hi chng suy ng h hp ngi ln, gim tiu cu, v h ng huyt. Sau khi lc
mu bng oxy ko di, m kh qun c thc hin. Sau 42 ngy iu tr ti khoa hi sc tch
cc, huyt p ca bnh nhn n nh, bnh nhn ht st v c xut vin. Nghin cu nhng
tn thng da chng minh ti to biu m cha vt thng thnh cng. S thay i sc t nh
vn c nhng khng li so. Mc d din bin TEN hi phc thun li trong trng hp
ny, bnh nhn qua i v xut huyt ni s 4 thng sau . Kt qu ny l hon ton khng
lin quan n TEN.

Tho lun

TEN l mt ri lon da trc vy him thy vi t l c tnh hng nm l 1-2 trng hp/mt
triu ngi [2]. Bo co t l t vong bin ng t 20-60% [3]. Nguyn nhn ph bin nht
ca TEN l phn ng c ng ca thuc, mc d nhim virus, vi khun, v nm, cng nh
tim chng, c m t [3]. Cc loi thuc thng gp nht l cc thuc khng vim
khng steroid, cc cht ha tr, thuc khng sinh, thuc chng co git v [3,5]. Trong s cc
cephalosporin th ceftazidime [6], cefuroxim [7], cephalexin [7-10], v cephem [11] l cn

Nhp cu Dc lm sng Thng 1/2015, N1 Page 33/37

ch . Vi tt c s hiu bit ca chng ti th y l bo co u tin ca trng hp TEN
gy ra bi ceftriaxone.

Sinh l bnh ca TEN vn khng hon ton r rng. S lan rng thng b hoi t c coi l
mt h qu ca t bo keratin hoi t hng lot [12]. Mt vai tr quan trng ca lympho T c
t bo c xut [3]. Nhng nghin cu gn y ch ra rng TEN c th l mt MHC
lp 1- gii hn chuyn bit nhy ca thuc dn n vic nhn ln v tnh t bo lympho
CD8 + c t bo c tim nng ly gii t bo. Cc c t bo dng nh c trung gian bi
granzymes (serine proteinases l nhng thnh phn ca cc t bo gy c t bo v git t
nhin ht t bo [13].

Din bin lm sng ca TEN c c trng bi mt giai on bo trc vi cc triu chng

ging cm, tip theo l ban , cc mng my ay dy c v bng nc ko di mt hoc hai
ngy n khi cc mng biu b kh trc ph bin [3]. B mt nim mc c th b nh hng
nghim trng. V mt chc nng, nim mc b nh hng c th dn n vic gim s nui
dng v tn thng cao hn dn n nhim trng, nn tin lng bt li. Nh vy, vic nim
mc khng b nh hng trong trng hp bnh nhn trn c th gp phn kt qu iu
tr kh quan. Tin trnh gim bch cu v gim tiu cu c th pht trin trong mt vi ngy
v, cng vi cc bin chng nhim trng, c th dn n suy a ph tng v t vong. Ngoi
vic nhanh chng ngng thuc gy bnh v bt u chm sc h tr, hng dn iu tr chun
xc vn cn thiu. Li ch ca vic la chn iu tr c nhn l mt vn ca cuc tranh
lun, c gi c th tham kho thm cc nh gi ton din bi Chave v cng s [1].

Mc d hiu qu ca tim tnh mch globulin v corticosteroids vn cn tranh ci, bnh nhn
ca chng ti c iu tr vi c hai loi ny. Tuy nhin din bin lm sng ca bnh nhn
c ci thin v chng ti khng bit l do tc ng ca loi thuc no.

Kt lun

Thng b nhim c hoi t l mt ri lon bong trc da cp tnh, e da tnh mng vi t l

t vong cao. Nghi ng lm sng cao, nhanh chng ghi nhn v chm sc h tr ban u l bt
buc. iu tra trit c ch gy bnh l nguyn tc c bn, vn cha c cc hng dn iu
tr ti u. N lc hp tc a t chc pht trin chin lc iu tr tt hn c chng nhn.

T vit tt

TEN: toxic epidermal necrolysis (thng b nhim c hoi t)

MHC: major histocompatibility complex (phc hp tng thch m chnh)

Ngun tham kho

1. Chave TA, Mortimer NJ, Sladden MJ, Hall AP, Hutchinson PE: Toxicepidermal
necrolysis: current evidence, practical management and future directions. Br J Dermatol
2005, 153:241-253.

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2. Ducic I, Shalom A, Rising W, Nagamoto K, Munster AM: Outcomeof patients with toxic
epidermal necrolysis syndrome. PlastReconstr Surg 2002, 110(3):768-773.
3. Avakian R, Flowers FP, Araujo OE, Ramos-Caro FA: Toxic epider
mal necrolysis: A review. J Am Acad Dermatol 1991, 25(1 part1):69-79.
4. Scheulen JJ, Munster AM: The Parkland formula in patients withburns and inhalation
injury. J Trauma 1982, 22(10):869-871.
5. Baroni A, Ruocco E: Lyell syndrome. Skin Med 2005, 4(4):221-225.
6. Thestrup-Pedersen K, Hainau B, Al'Eisa A, Al'Fadley A, Hamadah I: Fatal toxic epidermal
necrolysis associated with ceftazidime
and vancomycin therapy: a report of two cases. Acta DermVenereol 2000, 80(4):316-317.
7. Yossepowitch O, Amir G, Safadi R, Lossos I: Ischemic hepatitisassociated with toxic
epidermal necrolysis in a cirrhotic
patient treated with cefuroxime. Eur J Med Res 1997, 2(4):182-184.
8. Dave J, Heathcock R, Fenelon L, Bihari DJ, Simmons NA: Cephalexininduced toxic
epidermal necrolysis. J Antimicrob Chemother 1999, 28(3):477-478.
9. Hogan DJ, Rooney ME: Toxic epidermal necrolysis due tocephalexin. J Am Acad Dermatol
1987, 17(5 pt 1):852-853.
10. Jick H, Derby LE: A large population based follow-up study oftrimethoprim-
sulfamethoxazole, trimethoprim, andcephalexin for uncommon serious drug toxicity.
Pharmacotherapy 1995, 15(4):428-432.
11. Okana M, Kitano O, Ohzono K: Toxic epidermal necrolysis dueto cephem. Int J Dermatol
1988, 27(3):183-184.
12. Paul C, Wolkenstein P, Adle H, Wechsler J, Garchon HJ, Revuz J, Roujeau JC: Apoptosis
as a mechanism of keratinocyte death intoxic epidermal necrolysis. Br J Dermatol 1996,
134:710-714.
13. Miyauchi H, Hosokawa H, Akaeda T, Iba H, Asada Y: T cells subsetsin drug-induced
toxic epidermal necrolysis. Possible pathogenic mechanism induced by CD8-positive T cell.
Arch Dermatol 1991, 127:851-855.

Tc gi: Sarit Cohen*, Allan Billig and Dean Ad-El

DS. Nguyn Th Nguyt, Khoa Dc -Bnh vin 2 Lm ng (dch)
DS. Nguyn Quc Ha, GV DLS, i hc Y Dc HCM (hiu nh)
PGS.TS.BS. T Mnh Cng
Ngun: Journal of Medical Case Reports 2009, 3:9323 doi:10.1186/1752-1947-3-9323
Link: http://www.jmedicalcasereports.com/content/3/1/9323

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Gii thiu cc bi bo nc ngoi

ADR/Pharmacovigilance
1. Warfarin-induced deep vein thrombosis. Binymin KA1, Nasher M2, Patel D2. Int Med Case
Rep J. 2014 Sep 9;7:123-5.

2. Warfarin-induced skin necrosis. Kakagia DD1, Papanas N2, Karadimas E3, Polychronidis A1.
Ann Dermatol. 2014 Feb;26(1):96-8.

3. Risk of hemorrhage in patients with chronic liver disease and coagulopathy receiving
pharmacologic venous thromboembolism prophylaxis. Reichert JA1, Hlavinka PF, Stolzfus JC.
Pharmacotherapy. 2014 Oct;34(10):1043-9.

Medication Evaluation /Optimization

1. Strategies to reduce bleeding risk in acute coronary syndromes and percutaneous coronary
intervention: new and emerging pharmacotherapeutic considerations. Coons JC1, Miller T.
Pharmacotherapy. 2014 Sep;34(9):973-90.

2. Influence of regular physical activity on warfarin dose and risk of hemorrhagic complications.
Shendre A, Beasley TM, Brown TM, Hill CE, Arnett DK, Limdi NA. Pharmacotherapy. 2014
Jun;34(6):545-54.

3. Anticoagulation management by community pharmacists in New Zealand: an evaluation of a

collaborative model in primary care. Harrison J, Shaw JP, Harrison JE. Int J Pharm Pract. 2014
Sep 23.

4. An audit of anticoagulant management to assess anticoagulant control using decision support

software. Harper P, Harper J, Hill C. BMJ Open. 2014 Sep 2;4(9):e005864.

5. Self-testing and self-management of warfarin anticoagulation therapy in geriatric patients.

Pugh AN, Murphy BL. Consult Pharm. 2013 May;28(5):319-21.

6. Pharmacist-managed oral anticoagulation therapy in the community setting. Bouwmeester C,

Chim C. Consult Pharm. 2013 May;28(5):280-94. doi: 10.4140/TCP.n.2013.280.

7. Assessing anticoagulation knowledge in patients new to warfarin therapy. Winans AR, Rudd
KM, Triller D. Ann Pharmacother. 2010 Jul-Aug;44(7-8):1152-7. doi: 10.1345/aph.1P092. Epub
2010 Jun 22.

8. Selecting an anticoagulant for recurrent venous thromboembolism in cancer. Goodin S. Am J

Health Syst Pharm. 2005 Nov 15;62(22 Suppl 5):S10-3.

9. Pharmacy-managed anticoagulation: assessment of in-hospital efficacy and evaluation of

financial impact and community acceptance. Donovan JL1, Drake JA, Whittaker P, Tran MT. J
Thromb Thrombolysis. 2006 Aug;22(1):23-30.

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Dose adaptation
1. Evaluation of warfarin dose requirements in patients with chronic kidney disease and end-
stage renal disease. Sakaan SA1, Hudson JQ, Oliphant CS, Tolley EA, Cummings C, Alabdan
NA, Self TH. Pharmacotherapy. 2014 Jul;34(7):695-702.

Pharmacy Practice
1. ACCP Guidelines. Standards of Practice for Clinical Pharmacists. Pharmacotherapy. The
Journal of Human Pharmacology and Drug Therapy. Volume 34, Issue 8, pages 794797,
August 2014.

2. Validation of a patient-level medication regimen complexity index as a possible tool to identify

patients for medication therapy management intervention. Hirsch JD1, Metz KR, Hosokawa PW,
Libby AM. Pharmacotherapy. 2014 Aug;34(8):826-35.

Guideline
1. Guidelines on oral anticoagulation with warfarin - fourth edition. Keeling D, Baglin T, Tait
C, Watson H, Perry D, Baglin C, Kitchen S, Makris M, British Committee for Standards in
Haematology. Br J Haematol. 2011 Aug;154(3):311-24.

2. Risk-adapted management of acute pulmonary embolism: recent evidence, new guidelines.

Kberich A1, Wrntges S1, Konstantinides S2. Rambam Maimonides Med J. 2014 Oct
29;5(4):e0040. (Free article)

3. Recent guidelines and recommendations for laboratory assessment of the direct oral
anticoagulants (DOACs): is there consensus?Lippi G, Favaloro EJ. Clin Chem Lab Med. 2014
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4. European Heart and Rhythm Association guidelines on new oral anticoagulants: A bold step
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5. European Heart Rhythm Association launches a practical guide on new oral anticoagulants in
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DS. Ths. V Th H (lc tin)

Nu ng nghip cn ti bo ton vn c th lin h NCLDS nh ti.

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