Bnh Nhc Tuyn Gip Hypothyroidism BS. Trnh Cng, M.D.

Nhp Bnh nhc tuyn gip l kt qu cu mt trng thi lm sng cng nh sinh-ha trong ngun cung cp kch thch t tuyn gip cho cc m b thiu ht v v tc dng cu kch thch t trn c th thng a dng nn s thiu ht ca n s nh hng ti nhiu c nng. Trn phng din lm sng, nhc tuyn gip bao gm nhiu trng thi i t nhc tuyn gip nh cho ti hn m v ph nim (myxedema coma) c th gy t vong. Nguyn do Nhc tuyn gip c th do s thiu hot ng nguyn thy ca tuyn gip (primary hypothyroidism), do s thiu ni tit t kch thch tuyn gip tuyn yn (pituitary thyroid stimulating hormone hoc TSH) hoc him hn na do s thiu ht ni tit t kch tuyn gip di i (hypothalamic thyrotropin-releasing hormone hay TRH). Trn t M nguyn nhn thng thng nht l vim tuyn gip ca Hashimoto (Hashimoto s thyroiditis); bnh ny thng xy ra cho ph n trn 50 tui, ngi bnh b bu c v c khng th khng tuyn gip (anti-thyroid antibodies) trong huyt thanh. Nhc tuyn gip cn c th l kt qu cu s iu tr bnh cng tuyn gip bng quang-tuyn hoc gii phu hoc dng nhng thuc nh lithium v amiodarone. nh bnh Nhng triu-chng c in l mi mt, tc kh v d gy, ln cn, to bn, km chu lnh v gim thiu nhng phn x gn chp (tendons). Nhng bnh nhn b nhc tuyn gip nh thng khng c triu-chng g. Th nghim : Nng TSH s cao Nng T4 hoc FTI (free thyroxine index) s thp trong trng hp nhc tuyn gip nh, lng thyroxine (T4) s bnh thng v TSH s cao (di 20milliunits/L). Trong trng hp nhc tuyn gip ph thuc (secondary hypothyroidism), lng T4 hoc FTI v TSH u thp hoc vo mc thp ca di bnh thng. Nhng bnh nhn b vim tuyn gip ca Hashimoto thng c khng th khng tuyn gip (anti thyroid antibodies, antimicrosomal antibodies hoc antithyroglobulin antibodies) cao trong huyt thanh. iu tr Dc phm

1- L-thyroxine (levothyroxine-Synthroid, Levoxyl) l thuc c s dng cha tr nhc tuyn gip. Thuc ch cn ung ngy mt ln cng thc hin mc qun bnh cu T4 v T3 (triiodothyronine) v T3 c bin i t T4 ngoi bin (peripheral conversion to T3 from T4). Thuc c nhiu liu khc nhau gip Bc-s iu chnh liu mt cch chnh xc. Mc ch ca cuc iu-tr l bnh thng ha TSH v sa i cc triu-chng. Nhng boch t tuyn gip sy kh (dessicated thyroid preparation) thng cho nhng nng hay thay i v c th gy nn nhng triu-chng khng mong mun v lm cho s theo di cc th nghim tr thnh kh khn. Liu 1 grain (65mg) tuyn gip trng sy kh tng ng vi 0.1 mg L- thyroxine; tuy nhin cch thay i tt nht l cn c trn cn nng ca bnh nhn (xem di). 2- Liothyronine (L-T3 - Cytomel) khng nn s dng trong vic iu-tr kinh nin; n thng c dng iu-tr ngn hn cho nhng bnh nhn b ung th tuyn gip sau khi gii phu sa son o r bng iodine (I- scanning) v n c th hu dng trong cn ph nim hn m (myxedema coma) v nhc tuyn gip nng. Liu thuc Trc khi khi s iu tr, ta phi ch trng n tui ngi bnh v nhng bnh khc m h mc phi cng nh mc nng nh v nguyn nhn cu nhc tuyn gip. Khi s nn cho dng L-thyroxine t 50 n 75 microgram (mcg) mi ngy v tng dn mi ln 25 mcg cho ti khi thc hin c tnh trng bnh thng. Mt liu thay th hon ton l khong 1.6 mcg cho mi kilo mi ngy (tc l t 75-100 mcg cho n b v 100-150 mcg cho n ng mi ngy). Nhng bnh nhn b nhc tuyn gip sau khi c iu tr bnh Grave (Grave s disease) bng quang tuyn hoc gii phu s cn liu nh hn v tuyn gip ca h hy cn mt phn c nng. i vi bnh nhn khng c bnh g khc tt c liu L-thyroxine c th c dng ngay lc u; mt liu thp 25 mcg mi ngy nn c dng i vi nhng ngi b nhc tuyn gip v ngi gi c thng mc phi bnh tim. V thi gian bn hy trong huyt thanh (serum-half lives) ca L-thyroxine l t 6-7 ngy, tnh trng qun bnh (steady state levels) ch thc hin c 6 tun sau khi bt u iu tr. Nng TSH s bnh thng ha trong thi gian . Bnh nhn phi c cho bit l nhng triu-chng ch s chm dt nhiu thng sau khi cc th nghim c bnh thng. Nhng phn ng ngoi mun v phn ng nghch (side-effects and adverse reactions) Nhng phn ng v d ng thc s thng khng xy ra tr trng hp ngi bnh b bin ng vi cc cht khc trong vin thuc thyroxine. Nhng ph n b nhc tuyn gip v him mun phi c bo cho bit l iu tr bng thyroxine c th lm cho h d th thai. i vi bnh nhn b bnh tiu ng, liu insulin cn c gia tng v nhng ngi dng thuc khng ng mu cn phi gim liu thuc ng mu . V Lthyroxine c th gia tng s bin th ca cortisol, nhng ngi b nghi ng mc phi nhc tuyn thng thn (adrenal insufficiency) cn phi c khm nghim k cng trc khi dng thyroxine. a s cc vn gy nn bi s iu tr bnh nhc tuyn gip l do cho thuc qu liu. Cng tuyn gip do liu thyroxine qu cao gy nn nhng

triu-chng nh lo u, nhc u, run ly by v hi hp. Th nghim s cho thy nng TSH xung thp; ta c th tm ngng cho thuc v cho bnh nhn ung mt liu nh hn t vi ngy n mt tun sau. iu-tr mn tnh (Chronic therapy) Mi nm nng TSH trong huyt thanh phi c o mt ln. Thng th nng . T4 hoc FTI khng cn phi theo di khi thc hin c s qun bnh trong vic cha tr nhc tuyn gip ngoi tr trng hp ngi bnh b nhc tuyn gip trung ng (central hypothyroidism). V TSH khng th c s dng lm mc tiu i vi nhng bnh nhn trn, T4 hoc FTI cn phi c iu chnh sao cho chng vo gia khong bnh thng. i khi liu thyroxine cn c gia tng i vi bnh nhn mc chng thiu hp th (malabsorption) hoc bnh nhn no dng thuc lm gia tng s bin th cu L-thyroxine nh phenytoin (Dilantin), carbamazepine (Tegretol) v rifampicin (Rimactane, Rifadine). Nhng thuc khc nh cholestyramine (Questran), colestipol (Colestid) v sucralfate (Carafate) c th cn tr s hp th ca L-thyroxine; trong trng hp phi cho bnh nhn ung thyroxine cch xa thi gian ung cc loi thuc trn. i vi nhng bnh nhn m bnh nhc gip khng c kh quan sau khi dng thuc y v s thiu hp th cng nh s tng phn thuc c loi ra ta phi ngh ti trng hp bnh nhn khng theo li ch dn cu Bc-s. i khi nhng bnh nhn dng thuc bo ch chng loi (generic preparations) thng khng t c kt qu tt v bioavailability ca chng qu thp i vi loi thuc c tn c ch (name brand drugs). V l do ta phi cho bnh nhn dng thuc c ch. Trnh khng nn dng thuc qu liu v n s nh hng ti s bin th ca xng (gy nn bnh sp xng) c bit vi ph n trong giai on hu kinh k v thuc qu liu cng lm cho nhng triu chng v tim thm nng. V l do nhng bnh nhn ung thyroxine cn phi c theo di k cng bng cch o nng TSH, trnh gy nn cng tuyn gip v ung thuc qu liu. Th nghim TSH nhy cm s gip o c nng TSH thp ti 0.05 milliunit /L. Nng TSH phi c duy tr trong mc bnh thng gia 0.5 v 5 milliunits/L. Khi bnh nhn cng gi i, kch thch t tuyn gip c sn xut ra cng gim, do lng thyroxine cn thit cng gim. Vi bnh nhn trn 65 70 tui, liu thuc thyroxine c gim t 10 n 15%.

BS Trnh Cng TN-USA Ti liu tham kho:

1. Cohn ' s current Therapy, Rakel, 2. Harrison ' s principles of Internal Medicine 3. Woeber, KA. Update on the management of hyperthyroidism and hypothyroidism. Archives of Family Medicine. 2000; 9: 743-747. 4. Hueston, WJ. Treatment of hypothyroidism. American Family Physician. 2001; 64: 1717-1724.

5. Reasner CA, Talbert RL. Thyroid disorders. In: Dipiro JT, Talbert RL, Yee GC et al, eds. Pharmacotherapy: a pathophysiologic approach. 5th Ed. Chicago: McGraw-Hill, 2002: 13591378. 6. The American Thyroid Association. Available at: http://www.thyroid.org/ 7. Hypothyroidism. Mayo Clinic.com. Available at: http://www.mayoclinic.com/invoke.cfm?id=DS00353. 8. National Institutes of Health. Clinical Trials. Available at: http://www.clinicaltrials.gov/.

TCObesityAF

Obesity and the Risk of New-Onset Atrial Fibrillation Thomas J. Wang, MD; Helen Parise, ScD; Daniel Levy, MD; Ralph B. DAgostino Sr, PhD; Philip A. Wolf, MD; Ramachandran S. Vasan, MD; Emelia J. Benjamin, MD, ScM JAMA. 2004;292:2471-2477. Context Obesity is associated with atrial enlargement and ventricular diastolic dysfunction, both known predictors of atrial fibrillation (AF). However, it is unclear whether obesity is a risk factor for AF. Objective To examine the association between body mass index (BMI) and the risk of developing AF. Design, Setting, and Participants Prospective, community-based observational cohort in Framingham, Mass. We studied 5282 participants (mean age, 57 [SD, 13] years; 2898 women [55%]) without baseline AF (electrocardiographic AF or arterial flutter). Body mass index (calculated as weight in kilograms divided by square of height in meters) was evaluated as both a continuous and a categorical variable (normal defined as <25.0; overweight, 25.0 to <30.0; and obese, 30.0). In addition to adjusting for clinical confounders by multivariable techniques, we also examined models including echocardiographic left atrial diameter to examine whether the influence of obesity was mediated by changes in left atrial dimensions. Main Outcome Measure Association between BMI or BMI category and risk of developing new-onset AF. Results During a mean follow-up of 13.7 years, 526 participants (234 women) developed AF. Age-adjusted incidence rates for AF increased across the 3 BMI categories in men (9.7, 10.7, and 14.3 per 1000 person-years) and women (5.1,

8.6, and 9.9 per 1000 person-years). In multivariable models adjusted for cardiovascular risk factors and interim myocardial infarction or heart failure, a 4% increase in AF risk per 1-unit increase in BMI was observed in men (95% confidence interval [CI], 1%-7%; P = .02) and in women (95% CI, 1%-7%; P = .009). Adjusted hazard ratios for AF associated with obesity were 1.52 (95% CI, 1.09-2.13; P = .02) and 1.46 (95% CI, 1.03-2.07; P = .03) for men and women, respectively, compared with individuals with normal BMI. After adjustment for echocardiographic left atrial diameter in addition to clinical risk factors, BMI was no longer associated with AF risk (adjusted hazard ratios per 1-unit increase in BMI, 1.00 [95% CI, 0.97-1.04], P = .84 in men; 0.99 [95% CI, 0.96-1.02], P = .56 in women). Conclusions Obesity is an important, potentially modifiable risk factor for AF. The excess risk of AF associated with obesity appears to be mediated by left atrial dilatation. These prospective data raise the possibility that interventions to promote normal weight may reduce the population burden of AF.