C IM VIM KHP THIU NIN

T PHT KHNG TR
TI BNH VIN NHI NG 2
PGS.TS. Nguyn Th Thanh Lan
BS. NGUYN TH KIM YN
1. t vn
2. Mc tiu nghin cu
3. Phng php v i tng nghin cu
4. Kt qu v bn lun
5. Kt lun v kin ngh
2
NI DUNG
T VN
Vim khp thiu nin t pht: bnh khp
mn thng gp nht tr em
Tin lng chung thng tt, phn ln c
p ng vi NSAIDs
5 10% bnh nhn khng tr: khng p
ng vi DMARDs NSAIDs Corticoids
hoc c p ng nhng l thuc
Corticoids tin lng xu
3
T VN (tip theo)
Trn th gii: LPSH l mt bc tin mi
trong iu tr VKTNTP khng tr
Vit Nam: cha c nghin cu v nhm
khng tr, vic iu tr cn nhiu kh khn
Tin hnh NC: c im ca nhm khng
tr nhn din sm nhm nguy c cao
khng tr, gip can thip iu tr sm v
thch hp hn
4

Kho st c im dch t hc, lm sng,
cn lm sng, iu tr v bin chng ca
nhm tr vim khp thiu nin t pht c
biu hin khng tr
MC TIU TNG QUT
5
1. Xc nh t l VKTNTP khng tr
2. Xc nh t l cc c im v dch t hc,
lm sng, cn lm sng v chn on ca
nhm VKTNTP khng tr
3. Xc nh t l cc bin php iu tr can
thip trn nhm bnh nhn VKTNTP khng tr
4. Xc nh t l cc bin chng do hot tnh
bnh nng v do thuc iu tr

MC TIU C TH
6
PHNG PHP V
I TNG NGHIN CU
7
THIT K NGHIN CU
Thit k nghin cu: m t hng lot ca
C mu: ly trn mu
Dn s chn mu: tt c tr di 16 tui
nhp vin vo khoa Tim mch bnh vin
Nhi ng 2 c chn on VKTNTP c
biu hin khng tr t 01/2008 n thng
07/2013


8
Tiu chun chn on VKTNTP theo ILAR
Tiu chun khng tr: VKTNTP c coi l
khng tr khi cc triu chng ca bnh vn
tn ti hoc tin trin nng hn d c
iu tr vi Methotrexate liu 10mg/m/tun
v/hoc l thuc Corticoids (Prednisone
0,25mg/kg/ngy) trong thi gian 6 thng
TIU CH CHN BNH
9
X l d liu: d liu c nhp v x l
thng k bng phn mm SPSS 11.5
Tnh cc tr s trung bnh, trung v, lch
chun dnh cho bin nh lng
Tnh t l dnh cho bin nh tnh
PHN TCH D LIU
10
KT QU V BN LUN
11


T l VKTNTP khng tr: 10,9%



Y vn v NC khc: 5-10%
T l thc s / N 2: cao hn (?)
T l khng tr
12
Th lm sng VKTNTP VKTNTP khng tr
Th h thng 5% 35,8%
Th a khp RF (+) 5% 17,8%
Th a khp RF (-) 20% 17,8%
Th t khp 30% 14,3%
Vim im bm gn 25% 14,3%
Vim khp vy nn 5% 0%
Vim khp khng phn loi 10% 0%
Cc th lm sng
13








Nhn xt: n chim u th vi t l n/nam = 1,8/1

64.3%
35.7%
n
nam
Phn b phi tnh
14

Tui khi pht bnh:
trung bnh 6,6 2,9 tui

Thi gian mc bnh
trung bnh l 4,4 2 nm

Tui khi pht & thi gian mc bnh
15
Thi gian t khi khi pht triu
chng vim khp n khi c
chn on VKTNTP
S bnh
nhn
(n = 28)
T l
< 3 thng 5 17,8%
3 6 thng 15 53,6%
> 6 thng 8 28,6%
Thi gian t khi khi pht triu chng n
khi c chn on VKTNTP
16

S khp vim trung bnh: 10,7 5,6 khp



Alexeeva EI. : 11,8 2,4 khp
Flato v Modesto: s khp tn thng cng nhiu, tin
lng bnh cng xu

S khp vim
17
Khp gi (78,6%); khp c chn (64,3%),
khp ct sng 50% v khp hng 42,9%
Tn thng khp 2 bn: 85,7%.


VKTNTP / y vn: t gp tn thng khp ct sng v khp
hng, thng tn thng khp 1 bn
ACR 2011, Flato, Al-Matar: tn thng khp hng, ct sng
c; tn thng khp 2 bn: tin lng xu
V tr khp vim
18
Thnh phn
Gi tr cng thc mu, s bnh nhn (t l %)
Gim Bnh thng Tng Tng cao
Bch cu 3 (10,7%) 7 (25%) 8 (28,6%) 10 (35,7%)
Hemoglobin 16 (57,1%) 12 (42,9%)
Tiu cu 0 (0%) 10 (35,7%) 10 (35,7%) 8 (28,6%)
Gi tr cng thc mu
19

VS gi u trung bnh: 79,1 18,1mm
Tt c bnh nhn u c tng VS
57,1% c VS tng cao > 100mm

Tc lng mu
20
Thnh phn
Gi tr in di protein huyt tng,
s bnh nhn (t l %)
Gim Bnh thng Tng
Albumin 27 (96,4%) 1 (3,6%) 0 (0%)
1-globulin 14 (50,0%) 12 (42,9%) 2 (7,1%)
2-globulin 0 (0%) 12 (42,9% 16 (57,1%)
-globulin 2 (7,1%) 23 (82,2%) 3 (10,7%)
-globulin 2 (7,1%) 18 (64,3%) 8 (28,6%)
T l A/G 27 (96,4%) 1 (3,6%)
in di m mu
21

Tng IL-6: 92,3%; IL-6 tng cao ch yu l
nhng bnh nhn th h thng.
Tng TNF-: 85,7%
Tng c IL-6 v TNF-: 84,6% nhng u
th vn l tng IL-6.
C 1 trng hp ch tng TNF-, khng
tng IL-6, l bnh nhn khng tr th
vim im bm gn.

Cytokine mu
22
0% 20% 40% 60%
ri lon tng trng xng
dnh khp/ bin dng khp
hp khe khp
ph hy u xng
mt vi nng
mt vi r
mt vi nh
18%
25%
39%
32%
18%
29%
53%
Cc c im X quang khp
23
Phn nhm iu tr theo ACR 2011
S bnh
nhn
(n = 28)
T l %
Th h thng vi hot tnh bnh h thng 4 14,3
Th h thng vi vim khp hot ng 6 21,4
Vim 5 khp 14 50,0
Vim 4 khp 0 0
Vim khp cng chu hot ng 4 14,2
Phn nhm iu tr theo ACR 2011
24
nh gi hot tnh bnh v yu t
tin lng km theo ACR 2011
Yu t tin lng km: 100%
Hot tnh bnh trung bnh: 28,6%
Hot tnh bnh cao: 71,4%
25
Chc nng vn ng khp theo
Steinbrocker
26
0%
10%
20%
30%
40%
50%
giai on II giai on III giai on IV
42.9%
46.4%
10.7%
Tt c BN u c s dng NSAIDs trong
qu trnh bnh; 14,3% BN c p ng vi
n tr liu NSAIDs khi mi mc bnh.
Thi gian s dng Corticoids trung bnh
21,5 13,8 thng
Liu Corticoids ph thuc trung bnh l
Prednisone 0,99 0,33mg/kg/ngy


iu tr trc khi khng tr
27
67.9%
21.4%
7.1%
3.6%
methotrexate
sulfasalazine
cyclosporin
azathioprine
Thuc iu tr c bn
iu tr trc khi khng tr (tip theo)
28
50% bt u dng DMARDs tr hn so vi
khuyn co ca ACR 2011
Liu Methotrexate trung bnh 9,2 2,5
mg/m/tun

Harel, Ravelli: DMARDs sm ci thin tin lng tr VKTNTP v lm
chm tn thng xng
iu tr trc khi khng tr (tip theo)
29
Thi gian t khi khi pht
triu chng vim khp
n khi c chn on
VKTNTP
Thi gian t khi c
chn on VKTNTP
n khi khng tr
1 nm > 1 nm
6 thng 7 (35%) 13 (65%)
> 6 thng 7 (87,5%) 1 (12,5%)
Thi im khng tr
30
0%
5%
10%
15%
20%
25%
30%
35%
Corticoids +
1DMARDs
Corticoids +
2DMARDs
Corticoids +
1DMARDs +
LPSH
Corticoids +
2DMARDs +
LPSH
17.9%
28.6%
32.1%
21.4%
Cc bin php iu tr
VKTNTP khng tr
31
Cc bin php iu tr
VKTNTP khng tr
4 BN: tng liu Corticoids, gi nguyn
iu tr c bn vi 1 DMARDs
14 BN: phi hp 2 DMARDs 2 BN c
ci thin LS
15 BN: LPSH Tocilizumab (c ch IL-6)
v vn duy tr iu tr c bn vi
DMARDs c in


32
nh gi s ci thin triu chng sau
iu tr LPSH theo tiu chun ACR-Pedi
Ci thin theo
tiu chun
ACR-Pedi
Sau 3 thng iu
tr LPSH
(13 bnh nhn)
Sau 6 thng iu
tr LPSH
(5 bnh nhn)
ACR-Pedi 30 12 5
ACR-Pedi 50 7 5
ACR-Pedi 70 3 4
ACR-Pedi 90 0 1
33
0% 20% 40% 60% 80% 100%
hi chng thc bo
chm tng trng
vim mng b o
c thy tinh th
hi chng Cushing
long xng
thiu mu
teo c, cng khp
7.1%
71.4%
14.3%
17.9%
78.6%
82.1%
57.1%
71.4%
c im v bin chng
34
2 BN th h thng vi hot tnh bnh h
thng tin trin b hi chng thc bo mu
1 BN khng p ng vi iu tr v t vong
trong bnh cnh tn thng a c quan
BN cn li ngng c cc thuc iu
tr thc bo mu
Hi chng hot ha i thc bo
35
Chm tng
trng chiu
cao
Thi gian dng
Corticoids trung
bnh (thng)
Liu Corticoids ph
thuc trung bnh
(mg/kg/ngy)
C 24,5 1,2
Khng 16,5 0,5
.
Chm tng trng chiu cao
36
4/28 tr (14,3 %) b vim mng b o

5/28 tr (17,9%) b c thy tinh th. 5
tr ny u c thi gian s dng
Corticoids > 2 nm


Cc vn v mt
37

Corticoids: hi chng Cushing 78,6%
tng huyt p 28,6%
Methotrexate: tng men gan 14,3%
vim phi k 3,6%
Tocilizumab (15 BN): sc phn v 2 BN
d ng thuc 1BN



Mt s tc dng ph ca thuc
38
KT LUN

T l VKTNTP khng tr l 10,9%
a s thuc th h thng v th a khp
T l n/nam l 1,8/1
39
Nhm bnh nng:
Tn thng xng khp nng nh ph hy
u xng l 32%, dnh khp v bin dng
khp l 25% tn tt
Phn nhm iu tr theo khuyn co ACR
2011: tt c u c yu t tin lng km
vi hot tnh bnh t trung bnh n nng
Nhiu bin chng do hot tnh bnh tin
trin v do tc dng ph ca thuc
KT LUN (tip theo)
40
iu tr cn nhiu kh khn:
Chn on ban u tr khi u dng
DMARDs tr
Ph thuc Corticoids vi liu kh cao 0,99
0,33mg/kg/ngy v b nhiu tc dng ph
Phi hp tr liu cc thuc DMARDs c
in c ch min dch khc cho kt qu
hn ch
LPSH: chi ph iu tr cao
KT LUN (tip theo)
41
1. Lu kh nng mc bnh VKTNTP tr
c cc than phin v c xng khp trn 6
tun. nh gi hot tnh bnh v cc yu t
tin lng km ch nh DMARDs sm,
ph hp.
2. Cn to iu kin nhiu bnh nhi
VKTNTP khng tr c iu tr vi LPSH
KIN NGH
42
3. Cc yu t c th lin quan n khng tr
ghi nhn trong nghin cu ca chng ti
cn c chng minh vi thit k nghin
cu ph hp v dn s nghin cu ln
c tnh thuyt phc.
KIN NGH (tip theo)
43
CM N S
THEO DI CA
QU V!