IEU TR AI THAO NG

ThS. BS. Trng Quang Hoanh MUC TIEU: 1. Nam c cac nguyen tac va muc tieu ieu tr ai thao ng. 2. Neu c cac bien phap khong dung thuoc. 3. Liet ke c cac nhom thuoc ieu tr. 4. Nam vng ch nh va cac tac dung phu. 5. Biet cach la chon bien phap va phoi hp thuoc. 6. Biet cach tam soat va hng x tr cac bien chng man tnh do ai thao ng. I. NHAC LAI BENH HOC: ai thao ng (T) la mot nhom benh chuyen hoa, ac trng bi tang ng huyet do s khiem khuyet tiet Insulin va/hoac s suy giam hoat tnh Insulin. Chan oan xac nh T va cac trang thai tien T da vao tieu chuan chan oan cua ADA-1997 va WHO-1999, cap nhat ADA-2010. Chan oan the benh (nguyen nhan) va cac bien chng; anh gia c a benh nhan va cac yeu to nguy c khac la can thiet do la chon ieu tr va tien lng.

II. CAC BIEN PHAP CHUNG: 1. Che o an: - Che o an uong can bang dinh dng la mot yeu to c ban cua ieu tr. Tr lieu dinh dng vi che o an kieng can bang, thch hp nham duy tr can nang ly tng c khuyen cao ap dung cho moi benh nhan. - nhng benh nhan tha can, che o han che calo mc 10001500Kcal/ngay (n) va 1200-1800Kcal/ngay (nam), tuy thuoc vao hoat ong the lc va can nang ban au. - Phan bo thanh phan dinh dng gom 45-65% carbohydrate, 10-30% protein, va di 30% chat beo (trong o chat beo bao hoa <7%, Cholesterol <300mg/ngay). benh nhan co LDL-C >100mg/dL, nen tieu thu chat beo <25% va Cholesterol <200mg/ngay. - benh nhan co benh than tien trien, can han che protein <0.8mg/kg/ngay. Khi co benh than man nang, can han che thc an co Kali va Phosphor. 2. Cac chat tao v ngot: - Co the s dung ho tr che o an kieng ng. Aspartame la mot chat tao ngot manh 180 lan hn Sucrose, nhng khong on nh vi nhiet nen khong the dung trong nau an. Saccharin, Sucralose, Acesulfame va Rebiana s dung trong nau an. - Fructose la mot chat ng t nhien, co ty le thap trong trai cay nhng c s dung nhieu trong thc pham che bien cong nghiep di dang HFCS.
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Fructose ch gay tang nhe ng huyet, va khong can Insulin cho chuyen hoa. Tuy nhien, dung lng nhieu fructose se gay tang Cholesterol TP, Triglyceride va LDL-C. Do o khong c s dung nhieu. - Cac polyol hoac polyalcohol nh Sorbitol, Xylitol, Mannitol, Lactitol, Isomalt, Maltitol thng c s dung nh chat lam ngot trong thc pham che bien dan nhan sugar free. Chung c hap thu kem qua ruot nen t gay tang ng huyet. Tuy nhien, neu benh nhan dung vi so lng ln, ng huyet se tang cao va co the b chng bung va tieu chay. 3. Van ong: - La can thiet cho tat ca benh nhan T. - Giup cai thien nhay cam Insulin, giam ng huyet va nhieu li ch ve tam ly, tim mach va chuyen hoa. - Che o tap luyen can c hng dan thch hp tuy benh nhan. 4. Hng dan benh nhan: - T theo doi ng huyet c khuyen cao cho tat ca benh nhan T ang ieu tr nham cung cap thong tin e kiem soat ng huyet toi u. Tien hanh 3-4 lan/ngay oi vi benh nhan s dung che o Insulin nhieu lan trong ngay hoac s dung bm Insulin va t hn oi vi benh nhan s dung thuoc uong. Nen th tai cac thi iem trc an, sau an 1-2h, trc khi i ngu va khi nghi ng ha ng huyet. - Cham soc ban chan. - S dung Insulin neu co ch nh. - Cac tnh trang can nhap vien: khi co cac bien chng cap do tang ng huyet, ha ng huyet, T type 1 va T thai ky mi chan oan, T type 2 co ng huyet cao kem cac roi loan tam than va thc the khac. 5. Muc tieu ieu tr: - ng huyet mao mach trc ba an: 70-130mg/dL. - ng huyet mao mach sau an <180mg/dL. - HbA1c <7% hoac cang gan mc bnh thng cang tot neu tranh c nguy c ha ng huyet. Nen nh lng HbA1c moi 3 thang neu cha at muc tieu, thay oi ieu tr hoac tnh trang lam sang; hoac 2 lan/nam neu ng huyet kiem soat tot. Can chu y cac phng phap nh lng tin cay va cac tnh trang giam gia (xuat huyet, tan huyet, truyen mau, benh huyet sac to). - Huyet ap <130/80mmHg. u tien dung nhom c che men chuyen hoac nhom c che thu the Angiotensin. Neu cha at huyet ap muc tieu, nen phoi hp li tieu quai (neu GFR <30ml/min/1.73m2). - Lipid mau: Cholesterol toan phan <150mg/dL, LDL-C <100mg/dL, HDL-C >40mg/dL nam va >50mg/dL n. - The trong:
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 oi vi benh nhan T type 2 khong co beo ph hoac benh nhan T type 1: khong can chu trong vao giam can, nhng tap the duc van la mot bien phap quan trong cua ieu tr. oi vi benh nhan T type 2 co beo ph: viec giam can la muc tieu quan trong, mac du thng kho thc hien. Can khuyen cao benh nhan no lc thay oi hanh vi e tuan thu che o an kieng, gia tang hoac ong the lc. Co the s dung cac thuoc ieu tr (Sibutramine, Orlistat) hoac phau thuat giam beo. III. CAC THUOC IEU TR: Ngoai tr cac che pham Insulin, Exenatide, Liraglutide, Pramlintide co dang thuoc tiem, tat ca cac thuoc con lai eu s dung ng uong. Ngoai Insulin, cac thuoc co 3 c che tac dung chnh: (1) Kch thch tang tiet Insulin te bao tuy; (2) Gia tang s nhay cam Insulin cua cac c quan ch; va (3) Giam s hap thu Glucose t da day-ruot. 1. Insulin: a. C che tac dung: - Tren chuyen hoa carbohydrate va protein: Tang van chuyen Glucose vao te bao va d tr thanh Glycogen Tang s dung Glucose c va mo m c che phan huy Glycogen gan va tan tao Glucose c che phan huy protein va tan tao ng t acid amin. - Tren chuyen hoa lipid: Kch thch tong hp va ngan thoai hoa Triglyceride. b. Che pham Insulin: CAC CHE PHAM INSULIN Thi gian tac dung (gi) Dang tac dung Khi phat nh Keo dai Tac dung ngan, dang tiem Lispro (Humalog) <0.25 0.5-1.5 3-4 Aspart (Novolog) <0.25 0.5-1.5 3-4 Glulisine (Apidra) <0.25 0.5-1.5 3-4 Regular (Humulin R) 0.5-1.0 2-3 4-6 Tac dung ngan, dang ht Regular insulin(Exubera) <0.25 0.5-1.5 4-6 Tac dung trung bnh NPH (Isophane) (Insulatard) 1-4 6-10 10-16 Tac dung dai Detemir (Levemir) 1-4 12-20
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Glargine (Lantus) 1-4 24 Insulin tron san 75% Protamine Lispro, 25% Lispro <0.25 1.5 en 10-16 70% Protamine Aspart, 30% Aspart <0.25 1.5 en 10-16 70% NPH, 30% Regular (Mixtard) 0.5-1 2 nh 10-16 50% NPH, 50% Regular insulin 0.5-1 2 nh 10-16 c. Tac dung phu: Ha ng huyet, gi muoi nc, teo mo m v tr tiem, d ng. d. Cach dung va v tr tiem: Tiem tnh mach: ch s dung cho Insulin nhanh. Tiem di da: la cach s dung pho bien cho tat ca cac dang Insulin. V tr thng dung la bung, ui, mong, canh tay. V tr tiem nen c thay oi e tranh teo mo m va hap thu thuoc khong on nh. Co the ho tr hap thu thuoc bang tap the duc hoac massage v tr tiem. Bm tiem lien tuc Insulin di da c s dung chon loc mot so benh nhan vi dung cu bm Insulin a c lap trnh. Co the s dung benh nhan ngoai tru neu trang thai tam than bnh thng. Cac dang s dung khac nh dang uong, dang ht, tiem xuyen da, dang xt mui hien ang nghien cu hoac a rut khoi th trng. Can lu y bao quan lanh theo hng dan va s dung ung cach bm tiem hoac but tiem. 2. Cac thuoc ieu tr ai thao ng type 2: a. Nhom Sulfonylureas (SU): SU the he I: Tolbutamide, Tolazamide, Acetohexamide, Chorpropanmide: ha ng huyet manh va keo dai, hien nay t c s dung. SU the he II: Glyburide (Glibenclamide), Glipizide, Gliclazide, Glimepiride. C che tac dung: kch thch te bao tuy tiet Insulin, c che nhe tiet Glucagon. Tac dung phu: ha ng huyet (nhat la ngi gia va/hoac co suy than), tang can, d ng, vang da, thieu mau. Chong ch nh: suy chc nang than, gan nang, phu n mang thai cho con bu. b. Nhom kch thch tiet Insulin non-SU (Meglitinide, Glinides): Gom: Repaglinide va Nateglinide. C che tac dung: kch thch te bao tuy tiet insulin nhng tac dung ngan hn nen chu yeu ch nh e kiem soat ng huyet sau an. S dung thuoc ngay trong ba an, khong dung neu bo ba va khong uong sau an neu quen uong trc an. Tac dung phu: tang can, ha ng huyet.
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c. Nhom Biguanides: Gom Metformin (a co tac dung dai) va Phenformin (a cam s dung). C che tac dung tang nhay cam Insulin gan, c va mo m; giam tan sinh ng gan. Metformin khong gay ha ng huyet khi dung n tr va khong gay tang can. Can khi tr vi lieu thap va tang dan lieu. Tac dung phu: thng gap snh bung, chan an, tieu chay, buon non, mieng v kim loai Co the khac phuc vi s dung lieu nho va uong ngay sau khi an no. Nhiem toan acid lactic la benh canh nang, hiem gap. Chong ch nh: Creatinine huyet thanh >1.5mg nam, >1.4mg n hoac GFR <70ml/min; Suy tim xung huyet can ieu tr; Suy gan nang, tnh trang shock, giam O2 mau. Phai ngng Metformin trc khi s dung chat can quang va sau o 48h. d. Nhom c che -Glucosidase: Gom: Acarbose, Miglitol va Voglibose. C che tac dung: c che cac men -Glucosidase ruot nen lam cham thuy phan Sucrose va cac carbohydrate phc tap. Ket qua lam giam hap thu ng nen chu yeu giam ng huyet sau an. Thuoc t c hap thu va ch co tac dung khi ba an co carbohydrate. Khi tr vi lieu thap va tang dan lieu. Uong hay nhai vien thuoc ngay trc ba an. Tac dung phu: thng gap tieu chay, ay hi, au bung co the phai ngng ieu tr. Acarbose lieu cao co the gay tang men gan. e. Nhom Thiazolidinediones (TZD, Glitazones): Gom: Rosiglitazone va Pioglitazone (Troliglitazone a ngng s dung). C che tac dung: TZD gan vao receptor PPRA- (Peroxisome proliferator activated receptor ) gan, c va mo m nen gia tang nhay cam Insulin va s dung Glucose. Thuoc khong gay ha ng huyet neu s dung n tr. Tac dung phu: phu do gi muoi nc, tang can, tang nguy c loang xng phu n, nhiem oc gan, tai rung trng phu n tien man kinh. Chong ch nh: suy tim xung huyet NYHA III-IV, roi loan chc nang gan (benh gan hoat ong, men gan tang >2.5 lan gii han tren bnh thng), phu n cho con bu. f. Nhom c che DPP-4 (Gliptins): Gom: Sitagliptin, Saxagliptin va Vildagliptin. C che tac dung: Hai hormone incretin GLP-1 (Glucagon like peptid-1) va GIP (Glucose dependent insulinotropic polypeptide) c te bao L ruot tiet ra lien tuc trong ngay, va tang len sau ba an. Hai chat nay la mot phan cua he thong ieu hoa Glucose cua c the. Khi nong o Glucose mau bnh thng hoac tang cao, GLIP-1 va GIP se tang tong hp va giai
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phong Insulin t te bao tuy bang cach kch hoat cAMP trong te bao. GLIP-1 con lam giam tiet Glucagon t te bao , dan en lam giam san xuat Glucose gan. Tuy nhien, hai hormone nay nhanh chong b bat hoat bi enzyme Dipeptidyl peptidase 4 (DPP-4). Cac Gliptins c che enzyme nay, se lam tang nong o va keo dai thi gian hoat ong cua hai hormone tren, dan en tang giai phong Insulin va lam giam Glucagon trong tuan hoan. Tac dung phu: t gap. Ha ng huyet gap khi phoi hp vi thuoc khac. Lu y: giam lieu trong suy than theo GFR. g. Nhom ong van GLP-1/chat chong Incretin: Gom: Exenatide va Liraglutide C che tac dung: cac peptide nay co cau truc giong GLP-1 nhng t chu tac ong cua enzyme DPP. Do o, chung keo dai thi gian tac dung hn la GLP-1 noi sinh nen gay tac dung tang tiet Insulin keo dai. Thuoc co dang tiem e ieu tr T type 2. Tac dung phu: buon non, non, chong mat, nhc au. Hiem gap hn la viem tuy, tang Calcitonin mau va gay bu giap. Chong ch nh: khong dung Exenatide neu eGFR <30ml/min. h. Thuoc khac: Colesevelam hydrochloride: ay la thuoc gan acid mat ruot nhng co tac dung lam giam ng huyet va co the lam giam HbA1c t 0.4-0.8% khi s dung n tr hoac phoi hp cac thuoc khac. No cung co tac dung lam giam LDL-C. Thuoc khong c hap thu nen s dung c trong trng hp suy gan, suy than. Tac dung phu: bon, co the lam tang Triglyceride, giam hap thu cac thuoc khac neu uong chung. Lieu 3 vien 625mg x 2 lan/ngay; uong luc bung oi. 3. Chat giong Amylin (Pramlintide): - C che tac dung: Amylin la hormone tuyen tuy c te bao tuy tiet cung vi Insulin sau ba an. Pramlintide la dan xuat tong hp cua Amylin, co tac dung lam cham s lam rong cua da day va giam bai tiet Glucagon sau ba an. ay la dang thuoc tiem di da ngay trc ba an ieu tr T type 1 va 2. - Tac dung phu: non. - Cach dung: Benh nhan T type 2 ang ieu tr Insulin: khi tr 6g, 3 lan/ngay, tang lieu en 120g, 3 lan/ngay neu benh nhan khong non sau 3-7 ngay. Benh nhan T type 1: khi tr bang 15g, 3 lan/ngay, tang dan moi 15g cho en khi at lieu ieu tr 60g, 3 lan/ngay. e tranh ha ng huyet, can giam 50% lieu Insulin luc khi tr.
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4. Cac che pham thuoc phoi hp: - Hien nay co nhieu che pham thuoc phoi hp thuoc uong vi cac ham lng khac nhau nham tang kha nang tuan thu ieu tr cua benh nhan. Tuy nhien, cac phoi hp co nh nay han che kha nang hieu chnh toi u lieu dung cho moi thuoc. V the, khong nen khuyen cao s dung pho bien. - Mot so che pham: Glyburide va Metformin (Glucovance, Hasanbest); Glipizide va Metformin (Metaglip); Repaglide va Metformin (Prandi-Met); Rosiglitazone va Metformin (Avandamet); Pioglitazone va Metformin (ACTOplus Met); Rosiglitazone va Glimepiride (Avandaryl); Pioglitazone va Glimepiride (Duetact); Sitagliptin va Metformin (Janumet, Velmetia) IV. CHON LA BIEN PHAP IEU TR: Nhn chung, khong co thuoc nao thch hp cho tat ca benh nhan. Viec la chon va phoi hp thuoc thay oi tuy thuoc vao thuoc san co, mc ng huyet, benh nhan (c a, s tuan thu ieu tr, tam ly), benh ly i kem (benh ly than, gan, mach vanh, suy tim), kha nang dung nap thuoc va chi ph. 1. ai thao ng type 1: - ieu tr thay the Insulin suot i. - Lieu Insulin e kiem soat toi u ng huyet la 0.5-0.8IUkg/ngay cho benh nhan khong beo ph. Khi tr benh nhan mi chan oan, nen dung lieu 0.4UI/kg/ngay roi ieu chnh theo ng huyet. - Che o dung Insulin nhieu lan gom Insulin nen va Insulin trc cac ba an. Insulin nen co the dung NPH (2 lan/ngay), Insulin Detemir (1-2 lan/ngay), hoac Glargin (1 lan/ngay) vi lieu 0.2UI/kg/ngay (tng ng 40-50% tong lieu hang ngay) va ieu chnh dan 5-10% moi ngay en khi at c ng huyet trc an <130mg/dL. - Insulin trc ba an: dung cac loai tac dung ngan, tong lieu tng ng vi Insulin nen chi lam 3 lan trc cac ba an chnh. 2. ai thao ng type 2 va cac the khac: - S la chon thuoc khi tr phu thuoc vao nhieu yeu to: cac phng tien san co, phan ng phu cua thuoc, c a benh nhan va cac benh kem theo va kha nang cua benh nhan, s thch cua benh nhan va thay thuoc. - Theo cac khuyen cao hien nay, khi tr vi Merformin tai thi iem chan oan, khong can phai ch xem benh nhan co at c muc tieu kiem soat ng huyet vi giam can va tap the duc. Li iem cua Metformin la giam ng huyet ma khong gay ra ha ng huyet, giam Triglyceride mau va ho tr giam can. Tuy nhien, khoang 20% benh nhan khong dung nap c thuo do tac dung phu ng tieu hoa hoac suy than.

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- Cac TZD cai thien e khang Insulin ngoai vi va khong gay ha ng huyet neu dung n tr, nhng thng gay tang can, gi muoi nc va tang nguy c gay xng phu n. - Sulfonylureas c s dung pho bien t lau, tac dung phu thng gap la ha ng huyet va gay tang can. Co the ch nh cho benh nhan gay. - Khi ng huyet khong c kiem soat tot vi n tr ban au (thng la Metformin), nen phoi hp thuoc uong th hai. Neu benh nhan co xu hng tang ng huyet sau an, nen la chon thuoc kch thch tiet Insulin non-SU hoac thuoc c che -Glucosidase, dung ngay trc ba an. Neu benh nhan co bieu hien e khang Insulin nang, nen chon TZD. Neu benh nhan co xu hng tang can nhieu, nen chon 1 thuoc ong van thu the GLP-1 hoac thuoc c che DPP-4. Nhn chung nen phoi hp 1 thuoc kch thch tiet Insulin vi 1 thuoc tang nhay cam Insulin. - Neu phoi hp 2 thuoc cha u kiem soat ng huyet hieu qua, xem xet phoi hp 3 thuoc. Chang han: - TZD - c che DPP-4 - Metformin + + - SU - ong van GLP-1 - Glinide - Neu phoi hp 3 thuoc khong hieu qua, nen ieu tr ket hp Insulin khi cac thuoc uong van co the duy tr tuy la chon. Co nhieu che o dung Insulin khac nhau co hieu qua (Insulin tac dung dai ban em hoac insulin hon hp dung 2 lan/ngay trc an sang va chieu). Lu y: han che phoi hp Insulin va TZD v nguy c cao thuc ay suy tim xung huyet. - Neu van cha at hieu qua hoac benh nhan b nhng cn ha ng huyet hoac benh nhan co benh than man nang, can xem xet che o Insulin tang cng nh ieu tr T type 1. - Ch nh Insulin tam thi benh nhan T type 2 khi: co cac bien chng cap do tang ng huyet, thai ky, phau thuat, cac bien chng mach mau ln cap, cac tnh trang chong ch nh thuoc uong, benh nhan chan oan mi co tang ng huyet nang, nhiem trung nang, s dung corticoid. V. HNG IEU TR CAC BIEN CHNG MAN TNH: T lau nam gay ra nhieu bien chng man tnh mach mau, than kinh, than, mat. Kiem soat ng huyet hieu qua lam giam ty le va tien trien cac bien chng mach mau nho. D phong cac bien chng la mot trong nhng muc tieu chnh cua ieu tr T. ieu tr thch hp cac bien chng man se lam cham dien tien cua no, cai thien chat lng song, han che ty le tan phe va t vong. 1. Benh ly vong mac: Tam soat va chan oan:
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- Kham chuyen khoa mat hang nam t khi chan oan oi vi T type 2 va t 3-5 nam sau chan oan oi vi T type 1, v benh ly vong mac co the hoan toan khong co trieu chng cho en khi mat th lc ot ngot. - Khi benh nhan T co bat ky bat thng nao ve th lc, nen gi kham mat ngay. ieu tr cang sm, hieu qua cang cao vi laser quang ong hoac phau thuat. 2. Benh than ai thao ng: Tam soat va chan oan: - Microalbumin nieu xuat hien co the xuat hien trc nhieu nam trc khi tieu xuat hien am ai the va suy than. Sang loc albumin nieu la bat buoc v bien chng than thng khong co trieu chng va cac bien phap ieu tr lam cham dien tien benh trong giai oan nay. - Can lu y benh nhan T co the suy giam chc nang than ma khong co albumin nieu. Benh nhan co benh than mang thng kem nguy c cao benh mach vanh va t vong. - o albumin nc tieu 24h hoac ty so ACR trong mau nc tieu ngau nhien. Co the lap lai 2-3 lan trong 6 thang e xac nh chan oan. Xet nghiem creatinine huyet thanh, BUN, c tnh GFR. Can anh gia thieu mau, cac roi loan can bang kiem toan va ien giai neu eGFE <60ml/min/1.73m2 da. ieu tr: - Can kiem soat tang cng ca ng huyet va tang huyet ap e lam cham tien trien cua benh than man. Neu co kem benh ong mach vanh, huyet ap muc tieu nen at <125/75mmHg. - u tien chon thuoc ha ap nhom c che men chuyen hoac nhom chen thu the Angiotensin cho tat ca benh nhan T co tang huyet ap. Cac thuoc nay lam cham tien trien cua benh than man va ca benh vong mac. Co the dung thuoc cho cac benh nhan co huyet ap bnh thng hoac tien tang huyet ap. - Co the phoi hp cac nhom thuoc khac: li tieu, chen kenh calci, chen beta giao cam va alpha giao cam trung ng. - Can han che thc an am, tranh cac thuoc va cac chat gay oc than. 3. Benh than kinh do ai thao ng: - Benh than kinh ngoai bien kem au: s dung cac thuoc nhom thuoc chong tram cam ba bong (Amitriptyline, Nortriptyline), chong ong kinh (Gabapentin, Pregablin, Carbamazepine) hoac boi Cream Capsaisin. - Ha huyet ap t the: ieu tr trieu chng. Co the s dung Fludrocortisone uong kem muoi NaCl. Can loai tr cac nguyen nhan thng gap khac nh mat nc, thieu mau, thuoc - Giam nhu ong da day ruot: thng gay ra cham tieu, non va buon non:

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 ieu tr thng kho: can chia nho cac ba an thanh 6-8 lan/ngay vi thc an mem, t beo va chat x. Nuoi an ng tnh mach can thiet cho mot so benh nhan. Kiem soat ng huyet chat che giup nhanh lam rong da day. Thuoc: co the s dung Metoclopramide hoac Amitriptyline. - Tieu chay man tnh: thng do nhieu nguyen nhan phoi hp. ieu tr vi khang sinh pho rong, khang nam, Loperamide hoac Octreotide. - Roi loan chc nang bang quang: vi bieu hien nhieu roi loan trong ong tac tieu tien. ieu tr vi Bethanechol hoac sonde tieu gian oan. 4. Benh mach mau ngoai vi: 5. Benh ong mach vanh: 6. Roi loan cng: c tnh gap khoang 40-60% benh nhan nam, gia tang theo tuoi va thi gian benh, hut thuoc la, kiem soat ng huyet kem, HDL-C thap, co benh than kinh va vong mac. ieu tr vi testosterone neu co ch nh, cac thuoc c che thu the PDE-5 va cac phng tien khac. 7. Loet chan: ieu tr khang sinh, cham soc vet thng, oan chi neu ieu tr noi khoa bao ton that bai Tai lieu tham khao: 1. Harrisons Principles of Internal Medicine, 17th ed, 2008, McGraw-Hill. 2. Current Medical Diagnosis & Treatment, 50th ed, 2011, McGraw-Hill. 3. The Washington Manual of Medical Therapeutics 33rd 2010, Lippincott Williams.

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BANG CAC THUOC HA NG HUYET VA LIEU DUNG Thuoc Sulfonylureas Tolbutamide (Orinase) Tolazamide (Tolinase) Acetohexamide (Dymelor)2 Chlorpropamide (Diabinese)2 Glyburide (Glibenclamide, Daonil, Micronase) Glipizide (Glucotrol) Glipizide TD cham (Glucotrol XL) Gliclazide (Diamicron, Predian) Gliclazide TD cham (Diamicron XL) Climepiride (Amaryl) Meglitinide analogs Repaglinide (Prandin, NovoNorm) Nateglinide (Starlix) Biguanides Metformin (Glucophage) Merformin TD cham (Glucophage XR) Thiazolidinediones Rosiglitazone (Avandia) Pioglitazone (Actos) Ham lng 500mg 100, 250, 500mg 250, 500mg 100, 250mg 1.25, 2.5, 5mg 5, 10mg 2.5, 5, 10mg 80mg 30, 60mg 1, 2, 4mg 0.5, 1, 2mg 60, 120mg 500, 850, 1000mg 500mg Lieu hang ngay 0.5-2g, chia 2-3 lan/ngay 0.1-1g, chia 1-2 lan/ngay 0.25-1.5g, 1-2 lan/ngay 0.1-0.5g, 1 lan/ngay 1.25-20mg, chia 1-2 lan/ngay 0.5-2mg, 2 lan/ngay trc an 30 phut 2.5-20mg, thng la 1 lan/ngay 40-80mg, 1 lan/ngay, hoac 160-320mg chia 2 lan/ngay 30-60mg, 1 lan/ngay 1-8mg, 1 lan/ngay 0.5-4mg, 3 lan/ngay trc ba an 60-120mg, 3 lan/ngay trc an 1-2.5g; 1v trong ba an, 2-3 lan/ngay 500-2000mg 1 lan/ngay Thi gian tac dung 6-12h en 24h 8-24h 24-72h en 24h 6-12h en 24h 12h en 24h en 24h 3h 1.5h

7-12h en 24h

2, 4, 8mg 15, 30, 45mg

4-8mg moi ngay 15-45mg moi ngay

en 24h en 24h

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c che -Glucosidase Acarbose (Glucobay) Voglibose (Basen) Miglitol (Glyset) ong van thu the GLP-1 Exnatide (Byetta) But 1.22.4ml, cha 5-10g But a lieu 0.6-1.8 mg/lan 25, 50, 100mg 2.5-5mg 50mg Lo 5ml cha 0.6 mg/ml 5g TDD 2 lan/ngay, trong vong 1h au trc an sang va chieu tang len 10g, 2 lan/ngay Khi tr: TDD 0.6mg, 1 lan/ngay. Tang len 1.21.8mg, sau 1 tuan neu khong co tac dung phu 100mg, 1 lan/gay. Giam lieu trong suy than 2.5-5mg, 1 lan/ngay. Giam lieu trong suy than 50mg, 1-2 lan/ngay. CC khi GFR <60ml/min Lieu khac nhau cho T type 1 va type 2 6h 50-100mg 0.2-0.3mg 25, 50, 100mg 25-100mg, 3 lan/ngay ngay trc ba an 0.2-0.3mg, 3 lan/ngay ngay trc ba an 25-100mg, 3 lan/ngay ngay trc ba an 4h 4h 4h

Liraglutide (Victoza) DPP-4 inhibitor Sitagliptin (Januvia) Saxagliptin (Onglyza) Vildagliptin (Galvus) Chat chong Amylin Pramlintide (Symlin)

24h

24h 24h 24h

8h

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