N TP DC LM SNG 1

I. PHN L THUYT:
1. Cc tiu chun la chn thuc an ton, hp l? Phn tch tiu ch c u tin
trong thc t lm sng ?
Tiu chun 1: Hiu qu iu tr tt(H): L kh nng khi bnh tt, t l bnh nhn c
cha khi bnh cao.
+ Da trn ti liu nghin cu y v t nhng ngun tin cy.
+ Thuc c chng minh hiu qu iu tr thc t.
Tiu chun 2: An ton cao(A):ADR thp,t l hiu qu / ri ro cng cao cng tt.
+ Da trn d liu y v ng tin cy phn tch nguy c / li ch v chn thuc
c t l ph hp.
+ Thuc t phn ng c hi.
Tiu chun 3: Tin dng ( d s dng ) / ph hp(T):Bao gm cch a thuc, s ln dng
thuc trong ngy ph hp, cng n gin cng tt.
Tiu chun 4 : Kinh t(K):L chi ph tin thuc hp l cho mt ngy iu tr (DDD) hoc
cho c liu trnh iu tr.
+ Thuc c gi c hp l vi hiu qu iu tr.
Tiu chun 5 : Sn c
Ngha l thuc phi c c s iu tr, nh vy l phi u tin cho nhng thuc nm trong
danh mc thuc thit yu.
*** Cc tiu chun trn c tnh im u tin khc nhau ty theo bnh (cp tnh,
mn tnh, mc trm trng,)
lm r qu trnh la chn thuc hp l, xem xt 2 tnh hung lm sng sau:
V d 1: X tr mt trng hp bnh cp tnh
La chn thuc trong iu tr au tht ngc
au tht ngc l mt biu hin ca cn co tht mch vnh, nu khng x tr kp thi c
th dn n thiu mu v nhi mu c tim vi nguy c t vong cao. Nhim v y l
phi dng thuc dn mch vnh c tc dng nhanh. Trong trng hp nh vy tiu
chun hiu qu l quan trng nht. Tiu chun th hai cn c quan tm l phi d
dng (tin dng) v a s trng hp bnh nhn t x tr khi ln cn au. Tnh kinh t
v tnh an ton c nh gi thp hn v thuc ch dng trong mt t ngn.
Tuy nhin, nu la chn thuc d phng cn au tht ngc nhm lm gim nguy c
th 2 yu t an ton v kinh t li l yu t quan trng v khng phi l tnh hung cp
bch v phi dng lu di.
Ni chung tiu chun hiu qu trong mi trng hp u c nh gi rt cao nhng
chim t l bao nhiu so vi 4 tiu chun th ty tng trng hp.
V d 2: X tr mt trng hp bnh mn tnh
La chn thuc gim au cho mt trng hp vim khp mn tnh
Vim khp mn tnh l mt bnh ko di nhiu nm, din bin t t, thnh thong c
nhng t cp. Thuc gim au trong trng hp ny dng gii quyt cn au cp
tnh. S dng thuc chng vim khng steroid (NSAID) n c hoc phi hp vi
 paracetamol c th gii quyt c au trong hu ht cc trng hp. Cc thuc ny
dng ung, bi ngoi, rt sn c. Nh vy tiu chun hiu qu v tin dng trong a
s trng hp d c chp nhn. Tuy nhin cc thuc ny c rt nhiu chng loi c
c tnh dc ng hc rt khc nhau, mc gy tc dng khng mong mun (ADR)
cng khc nhau v c bit khc nhau nhiu v gi tin. Trng hp ny tiu chun an
ton v kinh t phi c cn nhc nhiu hn.
Nh vy t vn c cho bc s trong la chn thuc, ngi DSLS cn c nhng
kin thc rt ton din: hiu bit v bnh, v thuc v v ngi bnh.

2. Phn tch 4 k nng cn c ca ngi Dc s trong lm sng?

- K nng giao tip vi bnh nhn:
+ Thit lp mi quan h gn gi vi bnh nhn,to s hp tc t pha bnh nhn.
Giao tip thy thuc vi bnh nhn l mt giao tip c bit:
Phi to uy tn bnh nhn tin tng
Tng c ch, thi , li ni ca thy thuc u nh hng tm l bnh nhn
Y khoa l mt khoa hc chnh xc
+ Thuyt phc bnh nhn hiu c l do iu tr, phng thc iu tr v nhng vic
h cn lm tham gia vo iu tr thnh cng.
Giao tip bng ngn ng
Giao tip khng li : hnh th v thi
- K nng thu thp thng tin:Cn to mi quan h thu thp thng tin chnh xc,cn
c k nng kho lo trong vic t cu hi.
+ Thu thp thng tin v bnh nhn:
Tui
Gii tnh
Ngh nghip
Thi quen,
+ Thu thp thng tin v bnh:
Bnh mc phi hin ti
Tin s bnh
+ Thu thp thng tin v thuc:
Thuc ang dng
Lch s dng thuc
Tra cu thng tin thuc
Yu cu ca thng tin: t m v chnh xc
- K nng nh gi thng tin:
+ nh gi v bnh nhn
+ nh gi v bnh
+ nh gi cc thng tin lin quan n vic dng thuc trong qu trnh iu tr
+ Xc nh ng nguyn nhn tht bi iu tr (nu gp)
+ H tr thit lp thc hin y lnh v lch trnh iu tr hp l.
 nh gi c qu trnh tm nguyn nhn tht bi nu c,nh gi ng th gii quyt
ng.
- K nng truyn t thng tin:Cn to lng tin vi bnh nhn,c kh nng nh gi
nhn thc ca bnh nhn lng thng tin truyn t c hiu qu.
+ Gii thch tc dng ca thuc, tm quan trng ca vic tun th iu tr
+ Liu dng, cch dng
+ Bo qun thuc
+ Theo di tc dng ca thuc
+ Theo di ADR v cch x tr
Yu cu:
Chnh xc
C th
D hiu
Tin cy ( c tnh thuyt phc )
3. Trnh by v vai tr ca dc s lm sng trong bnh vin?
1) Tham vn cho thy thuc v chin lc tr liu:Li ch/ri ro,gi c/hiu qu,thuc
mi
2) Chun nh n thuc:chng ch nh,tng tc thuc,liu lng,cch dng
3) Theo di tc dng ph ca thuc,phi hp vi b phn cnh gic dc.
4) Hng dn bnh nhn sp xut vin v ch dinh dng v nhng cn trng khi
dng thuc
5) Gp phn xy dng v truyn b thng tin v thuc mi, cc pht iu tr chun,
gi c thuc
6) Hng dn, b xung hiu bit cho cc y t, iu dng v cch cho bnh nhn dng
thuc,c tnh ca thuc.
7) Theo di nng thuc trong dch c th v ngh hiu chnh liu lng cho tng
bnh nhn.
4. Thng s Gi tr sinh kh dng : nh ngha, cch tnh, yu t nh hng v
ngha ng dng trong iu tr?
- nh ngha: SKD (F) l thng s nh gi t l (%) thuc vo c tun hon chung
dng cn hot tnh so vi liu dng ( D O), tc (Tmax) v cng (Cmax) thuc
thm nhp vo c vng tun hon.
1) SKD tuyt i: l t l gia tr s AUC thu c khi a thuc ngoi ng tnh
mch (a qua ng ung) so vi tr s AUC a qua ng tnh mch ca cng
mt thuc.
AUC po Div
F ( )tuyt i = 100
AUC iv D po

ngha:
Nu thuc c a qua ng tnh mch th F = 1. Nu thuc c
a ngoi ng tnh mch th F < 1.
 Ftuyt i < 50% : kh t yu cu cho tc dng ton thn,cn tng liu nu
cn, cho tc dng ti ng tiu ha nu dng qua ng ung.
Ftuyt i > 50% : cho tc dng ton thn.
Ftuyt i > 80% : c th coi kh nng thm nhp ca thuc ung vo mu
xp x ng tim tnh mch.
2) SKD tng i: l t l so snh gia hai gi tr SKD ca cng mt hot cht, cng
mt ng a thuc, cng mt liu nhng ca hai nh sn xut khc nhau.
F ( ) ca hng A
F ( A B )t
ngi = 100
F ( ) ca hng B

Tng ng sinh hc: nhm so snh thuc generic vi thuc ca hng pht
minh hoc thuc c uy tn nht trn th trng.
Ngoi ra cn so snh Cmax , Tmax ( thng dao ng khong 80 125% ) so vi
thuc la chn th nghim.
Cc gi tr logarit ha, dao ng 80 120%.
F ( ) ca thuc generic
BE= 100
F ( ) ca thuc pht minh

ngha:
So snh thuc ca mt nh sn xut no vi mt thuc ang lu hnh
c uy tn trn th trng.
Ftng i , Cmax ,Tmax ~ 80 125% : hai ch phm thuc l tng ng
nhau v c th thay th nhau trong iu tr.
- Yu t nh hng:
Tnh cht thuc,dng bo ch, ng dng thuc
Hot cht
C ch lm trng d dy ca h tiu ha
Lng mu rut
Hiu ng vt qua ln u
Cc yu t khc ( thc n, tui tc, s tng tc vi cc thuc khc, bnh l,)
5. Thng s Th tch phn b : nh ngha, cch tnh, yu t nh hng v ngha
ng dng trong iu tr?
- nh ngha:
Th tch phn b biu th mt th tch cn phi c lng thuc trong c th
phn b nng bng nng trong huyt tng.
n v : L hoc L/kg . V d: Digoxin = 645 L
Cng thc:
Tng l thu
ng c a vo c th D F
V d= =
Nn g thuc trong huyt t
ng C p

Th tch phn b phn nh s lin quan gia s lng thuc trong c th v nng
thuc huyt tng.
 Kh nng khuch tn ca thuc vo mt t chc ph thuc:
+ H s phn b lipid/ nc ca thuc.
+ Bn cht ca t chc m thuc thm nhp.
Th tch phn b khng biu th mt th tch sinh l thc ( cn gi l th tch phn
b biu kin ).
Thng c tnh ton sn.
ngha ca tr s Vd:
- Vd dng d on v kh nng phn b thuc trong c th:
Vd < 1L/kg: phn b km m, thuc tp trung huyt tng hay dch
ngoi t bo.
Vd > 5L/kg: phn b tt trong m
- Vd nh:
Thuc tp trung ch yu ngn trung tm (huyt tng) v khu vc ngoi
bo => hiu qu trong iu tr cc bnh l khu vc ngoi bo.
D b thi loi bi cc k thut lc, thm tch mu
Vd d thay i, ph thuc nhiu vo th tch dch ngoi bo.
- Vd ln:
Thuc phn b tt vo t bo, t chc trong c th => hiu qu trong iu tr
cc bnh l khu vc ni bo.
t b thi loi bi cc k thut lc, thm tch mu ( kh khn trong gii c
khi dng qu liu).
Vd t chu nh hng ca th tch dch ngoi bo, n nh hn.
- Gip c on nng thuc ti thi im ban u,nng thuc t c vi
liu khuyn co.
- Gip tnh liu lng thuc:
DF V C p
V d= = D= d
Cp F

Cc yu t nh hng n tr s Vd:
Tng tc thuc
pH mu, pH nc tiu
T l m / nc trong c th
Chc nng gan.
nh hng ca chc nng gan n Vd:

Gim tng hp protein ti gan tr tun hon tnh mch ca

Th tch nc dch ngoi bo tng

Gim lin kt thuc - protein

Tng t l thuc dng t do Tng Vd Tng Vd

6. Thng s H s thanh thi: nh ngha, cch tnh, yu t nh hng v
ngha ng dng trong iu tr?
- nh ngha: thanh thi (Cl) biu th kh nng ca mt c quan no ca
c th (thng l gan v thn) lc sch thuc ra khi huyt tng khi mu tun
hon qua c quan .
- n v : mL/ pht hoc mL/ pht/ kg
- Clton phn = Clthn + Clgan + Clc quan khc
= Clthn + Clgan
= Clthn + Clc quan khc
ClT = ClR + ClER
- Cch tnh:
Dng thuc bng ng tim tnh mch:
D
ClT = AUC 0

Dng thuc bng ng ung:

DF
ClT = AUC 0

- ngha tr s Cl:
p dng tnh tc bi xut thuc ra khi c th: el (k )=Cl Cp
Tnh tc truyn: inf ( k o )=Cl Css
F D
Tnh nng thuc trng thi cn bng: Css= Cl t
Cl t l nghch vi T1/2
- Yu t nh hng h s thanh thi:
Dng bo ch, ng dng
tui,di truyn,h enzime
Chc nng gan
Chc nng thn
7. Thng s Thi gian bn thi: nh ngha, cch tnh, yu t nh hng v
ngha ng dng trong iu tr?
- nh ngha:
Cn c gi l na i thi tr
 L thi gian cn thit nng thuc trong huyt tng gim i mt
na
Cng thc tnh: t1 /2 =0.693/k e
ke l hng s tc thi tr ( h s gc hay dc ca ng biu din
nng thuc pha thi tr) ( k e =Cl /V d )
V
d
t1 /2 =0.693 . Cl

- ngha:
Quy tc 5 x t1/2: xc nh thi gian bo ha thuc trong mu v cc m
trong c th.
Quy tc 7 x t1/2: xc nh thi gian cn thit thuc c bi xut hon
ton ra khi c th.
Xc nh nng thuc mt thi im nht nh :
Ct = Co.e-k(t-t0)
k=0.693/t1/2
Xc nh khong cch (nhp) a thuc.
+ Mi lin quan gia khong thi gian bn thi v khong cch a
thuc:
Co
ln
Ct
= t
0.693 1/ 2
+ t1/2 v khong cch gia cc ln dng thuc:
o t1/2 ngn (vi pht 4 gi) : dng thuc nhiu liu lp li
o t1/2 >4 gi : thng dng hai liu cch nhau 12 gi
o t1/2 >12 gi : thng ch cn 1 liu/ ngy
Khi chc nng ca cc c quan bi xut thuc (thn, gan) b suy gim th
t1/2 b ko di c ngha l thuc b tch ly lu hn trong c th v nguy c
ng c ln hn.
+ Hiu chnh liu cho bnh nhn chc nng gan thn gim: (c thm)
o Gim liu mt ln a thuc nhng gi nguyn khong cch a
thuc
o Gi nguyn liu v ni rng khong cch a thuc ra
o Va gim liu va ni rng khong cch a thuc
- Cc yu t nh hng n thi gian bn thi:Cc yu t nh hng ln phn
b v thi tr.
+ Phn b :Kh nng lin kt ca thuc v protein,c tnh l ha thuc,s ti
mu cc c quan,i lc c bit vi m.
+Thi tr :Chc nng gan,thn,tui tc,yu t bnh l,tng tc thuc.
8. Trnh by cc tng tc lm thay i hp thu thuc? Cho v d?
Quan trng cc thuc c t1/2 ngn,cc thuc cn t nng cao trong mu tc
th(thuc gim au,thuc ng).Nn ung cch 2 n 3h trnh tng tc.
- Tng tc do thay i pH ti d dy:
+ Cc thuc duy tr pH ti d dy: v d: vitamin C
Thuc c bn cht acid yu (v d: thuc ng barbituric, sulfamide, dn
xut salicylate, phenylbutazon,) : tng hp thu, tng tc dng. (i vi
nhng thuc c phm vi iu tr hp cha chc c li)
Thuc c bn cht base yu (v d: theophyllin, quinine, morphin v dn
cht, atropine,): gim hp thu (=> bt li => cho ung cch xa t nht 2
ting)
Thuc km bn trong mi trng acid ( v d: ampicillin, cephalexin,
erythromycin, digoxin,) : mt tc dng.
+ Cc thuc lm tng pH d dy: v d: cc antacid, thuc gim tit HCl,
Thuc c bn cht base yu (v d: theophyllin, quinine, morphin v dn
cht, atropine,): tng hp thu
Thuc c bn cht acid yu (v d: thuc ng barbituric, sulfamide, dn
xut salicylate, phenylbutazon,) : gim hp thu
Thuc km bn trong mi trng acid ( v d: ampicillin, cephalexin,
erythromycin, digoxin,) : tng tc dng.
- Tng tc do hp ph,to phc kh hp thu hay chelat ha:
V d:
Than hot hp ph mt s c cht lm gim hp thu c cht
Antacid to chelat ha vi tetracyclin
Cholestyramin to phc vi digoxin,Wafarin,levothiroxin
Tetracyclin,Fluroquinolon to phc bn vi ion kim loi nng.
- Tng tc do cn tr b mt hp thu:
Cc thuc bao che nim mc tiu ha:
Smecta
Kaolin
Sucralfat
to lp mng ngn s tip xc ca thuc vi nim mc ng tiu ha.
- Tng tc do thay i nhu ng ng tiu ha,thay i tc lm rng
d dy:V nguyn tc,mt thuc tng nhanh khi d dy s c li cho vic hp
thu v t trng v rut l ni hp thu ti u,ngc li nu thuc b tng nhanh ra
khi rut s b gim hp thu.
Tng nhu ng => rt ngn thi gian dch chuyn ca cc thuc khc
trong lng d dy, rut. V d: metoclopramide, thuc nhun trng,
 Gim nhu ng => ko di thi gian dch chuyn ca cc thuc khc
trong lng d dy, rut. V d: cc cht khng cholinergic, cht phong b
hch giao cm, dn cht acid salicylic, dn cht t thuc phin,
Mui Al lm gim thi gian lm rng d dy lm gin hp thu Quinin
- Tng tc lm bin i h vi khun ng rut:
Vi khun rut c vai tr trong vic tng hp ( v d: vitamin K), hp thu (v d:
thuc trnh thai), chuyn ha (v d: Digoxin 40%) mt s cht thuc. V vy
khi s dng cc thuc lm bin i h vi khun rut (khng sinh) s gy ra
tng tc vi cc thuc ny.
- Tng tc lm nh hng ln s vn chuyn tch cc:
C ch hp thu cc cht rut non:
Lc
Vn chuyn th ng
Vn chuyn tch cc : cn nng lng
V d: + Phenytoin c ch s hp thu ca acid folic do chn h thng vn
chuyn tch cc.
+ Ru lm gim kh nng vn chuyn vitamin B1
+ Probenecid v khng sinh penicillin cnh tranh cht mang => penicillin
mt cht mang, gim hp thu.
Ngoi ra cn do mt s tng tc :
- Gim hp thu do thuc : Neomicin gy hi chng km hp thu lm gim hp
thu Digoxin
- Thuc tim : Adrenalin lm co mch,gim hp thu procain.
9. Trnh by cc tng tc lm thay i phn b thuc? Cho v d?
- Tng tc thuc y nhau ra khi protein lin kt: Lu cc thuc c t l
gn protein cao m phm vi iu tr hp.
C ch:
S c ch tng tranh: khi 2 thuc c cng ni gn vo protein lin kt,
thuc no c i lc ln hn s ginh ch ca thuc kia hoc y thuc kia
ra khi ni gn vo protein v do lm tng nng trong mu ca
thuc c i lc yu.
S c ch khng tng tranh: khi thuc s dng lm thay i cu trc ca
protein lin kt
V d:
- Miconazol => - Wafarin, Discoumarol, - Quinin => Digoxin
- NSAIDs - Tolbutamid, Carbutamid,
- Thuc chng ung th (y khi protein trong
( y khi protein trong huyt tng) m)

- Thay i t l nc ca dch ngoi bo:

Nhng thuc phn b nhiu trong nc nh Digoxin, Theophyllin, khng sinh
nhm Aminoglycosid, rt nhy cm vi s mt dch ngoi bo. Thuc li tiu
 l thuc gy mt dch ngoi bo mnh ( Furocemid ) s dn n tng nng
cc thuc nu trn. (thuc c Vd nh => phn b nhiu trong nc)
10. Trnh by cc tng tc lm thay i chuyn ha thuc? Cho v d?
- Thuc cm ng enzyme: lm tng hot tnh enzyme, ngha l lm tng qu
trnh chuyn ha thuc khc.
- Thuc c ch enzyme: lm gim hot tnh enzyme, ngha l lm gim qu
trnh chuyn ha ca cc thuc khc.
c ch cnh tranh
c ch khng cnh tranh
Lu cc thuc c chuyn ha qua gan,c phm vi iu tr hp,c h s
chit sut qua gan nh.
V d:
EH < 3 Cht cm ng Cht c ch
Hormon Phenobarbital Erythromycin
Thuc chng ng kinh Spironolacton Cimetidin
Thuc chng ng Griseofulvin IMAO
Thuc h ng huyt Rifampicin Miconazol
Thuc tim mch Ru, thuc l Isoniazid

11. Trnh by cc tng tc lm thay i thi tr thuc? Cho v d?

Do thay i sc lc cu thn:
Ketorolac c ch COX lm gim sn xut prostaglandin,lm co tiu ng
mch thn,gim lng mu n thn,gim tc lc,thi tr thuc chm.
Indomethacin c ch to prostaglandin lm co tiu ng mch thn,lm
gim lng mu n thn,lm gim bi tit lithium nn cn theo di Lithi
mu.
Do thay i ti hp thu ng thn,do thay i PH nc tiu :
Dng antacid kim ha nc tiu nn lm tng thi tr cc cht c bn
cht acid yu:barbiturate,salicilat.Lm chm thi tr cc cht c bn cht
bazo nh : alkaloid lm tng c tnh
Vitamin C : acid ha nc tiu,tng thi tr alkaloid lm mt tc dng ca
cc alkaloid ny.
Thay i bi tit ch ng/ tch cc qua ng thn:
Cnh tranh cht mang vi cc thuc thi tr qua thn theo c ch vn chuyn
tch cc c tiu th nng lng.
V d:
Probenecid lm gi li penicillin v cc thuc c tnh acid (Indometacin).
Dicoumarol lm gim bi tit cc sulfamid chng i tho ng
(clorpropamid).
 Aspirin lm gim bi tit Methotrexat lm tng nng
Methotrexat.Phi hp ny c bit nguy him v Aspirin cn y
Methotrexat ra khi protein huyt tng.
Bi tit qua mt v chu trnh gan rut :
Ethylestradiol v khng sinh ph rng : Thuc bi xut qua mt dng lin kt
vi acid glucuronic,nh vi khun ng rut b gy lin kt ny,thuc tr v
dng ban u,hp thu vo mu,chu trnh gan rut s ko di thi gian lu gi
thuc.Dng KS vi khun b tiu dit lm mt tc dng nga thai.
12. nh ngha phn ng c hi? Nu cc bin php phng trnh phn ng
c hi ca thuc?
nh ngha: Phn ng bt li ca thuc l mt phn ng c hi, khng c
nh trc v xut hin liu thng dng cho ngi phng bnh, chn
on hoc cha bnh hoc lm thay i mt chc nng sinh l.
nh ngha ny khng bao gm cc trng hp dng sai thuc, hay dng khng
ng liu ch nh.
Bin php phng trnh phn ng c hi ca thuc:
1. Hn ch s thuc dng:
+ Ch k n cc thuc tht s cn thit
+ Nu bnh nhn ang s dng ng thi qu nhiu thuc th cn cn nhc
tm ngng nhng loi thuc cha tht s cn thit. Cn nh gi c tng tc
bt li khng trc khi k n hoc pht thuc.
+ Kim tra v hi bnh nhn v nhng thuc bnh nhn ang dng.
2. Nm vng thng tin v loi thuc ang dng cho bnh nhn:
+ Hiu r tnh cht dc l, tng tc, c ch chuyn ha v ADR ca thuc.
Ch nn k n nhng thuc bit y thng tin.
+ Thng xuyn tham kho, cp nhp cc thng tin v thuc v tng tc thuc.
+ Thn trng khi k n nhng thuc d xy ra tng tc, c bit l cc tng
tc do v tnh nh tng tc ca thuc vi thc n, vi ru
3. Nm vng thng tin v cc i tng bnh nhn c nguy c cao:
Tr em, ngi cao tui, c c a d ng, c bnh l v gan, thn v cc bnh
nhn c bt thng v gen.
4. Theo di st bnh nhn, pht hin sm cc biu hin ca phn ng bt li do
thuc v c nhng x tr kp thi.
5. Tham gia xy dng h thng cnh gic dc.

13. Phn tch cc yu t lm tng nguy c xut hin phn ng c hi ca

thuc?
Yu t ca bnh nhn lin quan n pht sinh ADR:
Tui:
Tr s sinh v ngi cao tui l nhng i tng c nguy c cao:
 Ngi cao tui: mt s nghin cu cho thy ngi cao tui gp nhiu
ADR hn nhng bnh nhn khc do:
+ Lm dng thuc
+ Thay i v dc lc hc, dc ng hc do gim chc nng ca cc
c quan
+ Ngi cao tui thng mc nhiu bnh, s dng nhiu thuc nn d gp
tng tc thuc
Tr s sinh: Nguy c gp ADR ca tr s sinh tng ln, c bit l tr
non bi mt s enzyme lin quan n chuyn ha v thi tr thuc cha
y . Cc thuc hay gy c l: morphin, cc barbiturate, cc
sulfonamide, cc dn xut ca vitamin K v chloramphenicol.
Gii tnh: Ni chung khng c s khc bit ln v ADR gia 2 gii, tuy
nhin, mt s ADR hay gp ph na hn so vi nam gii,nguyn nhn
c th do cc yu t dc ng hc,min dch v hc mn.
V d:
+ Ph n c th nhy cm hn vi c tnh ca Digoxin, heparin v
captopril.
+ Thiu mu bt sn do chloramphenicol gp ph n nhiu gp 2 ln so
vi nam gii
+ Chng mt bch cu ht do Phenylbutazon gp ph n nhiu gp 3
ln so vi nam gii
Gen v chng tc:
S khc bit v gen m ha enzim chuyn ha thuc,cc th th,cc cht vn
chuynnh hng n hiu qu iu tr v c tnh ca thuc.V d: ngi
thiu G6DP khi dng cc thuc c tnh oxy ha d thiu mu tan mu.
Bnh mc km:
Nhng bnh mc km c th lm thay i p ng ca bnh nhn i vi
thuc hoc lm thay i dc ng hc ca thuc, dn ti pht sinh ADR.
V d:
+ ic khi dng khng sinh aminoglycoside ngi c bt thng v
thnh gic; hoc chy mu trm trng do dng warfarin, heparin ngi
c sn thiu ht v yu t ng mu.
+ Cc bnh nhn mc cc bnh v gan v thn c nguy c cao b cc ADR
ca nhng thuc thi tr dng cn nguyn hot tnh qua cc c quan
ny.
+ Bnh nhn nhim HIV: cc bnh nhn ny h min dch b suy gim
trm trng, kh nng thi tr thuc gim l nhng nguyn nhn lm
tng nhy cm vi c tnh ca thuc.
Tin s d ng hoc phn ng vi thuc:
 Nhng bnh nhn c tin s d ng vi mt thuc cng c th gp d ng
vi mt thuc khc c cu trc tng t , v d cc trng hp d ng vi
khng sinh penicilin cng c th c d ng cho vi khng sinh nhm
cephalosporin.
Yu t thuc v thuc lin quan n s pht sinh ADR:
c tnh ca thuc
Cht lng ca cc thnh phn thuc:
+ Cht lng hot cht: Mt nguyn liu c cht lng tt l cht hon
ton tinh khit v ng nht.Trong thc t kh c cht l tng, hon ton
tinh khit. V vy,trong mt chng mc no , ngi ta chp nhn vi
nguyn liu lm thuc ch t ti mt tnh khit nht nh v c cha
vi tp cht. Trong nhng loi tp cht ny cn phi ch n nhng tp
cht c hi: kim loi nng (Pb, Hg, As,), dung mi hu c
V d: trong thuc tetracyclin c cht 4-epianhydrotetracyclin, khng c
tc dng iu tr nhng li c tc dng c hi.
Thalidomide c hai ng phn: t trin v hu trin, ch c ng phn
hu trin c tc dng an thn cn ng phn t trin gy qui thai mc d
xut hin vi lng rt nh.
Penicillin b thoi ha thnh protein,peptid c th gy ra nhng tc
ng khng mong mun bnh nhn.
+ T dc:
Lm thay i s hp thu ca thuc. iu ny c th l nguyn nhn quan
trng ca mt s phn ng c hi trm trng.
Lm kt ta hn dch steroid khi n ng vai tr cht bo qun, c tc
dng khng khun, chng OXH (paraben, phenol)
Ngoi ra vi vai tr ca mt cht m pH, t dc r, n th t dc
cng c nhng nh hng nht nh trong s xut hin ca cc phn ng
c hi ca thuc.
+ Qu trnh sn xut:Phi m bo thc hin ng quy trnh tiu chun
GMP trnh cc nguy c trong qu trnh sn xut, nht l: nhim
cho,nhm ln trong pha ch
V d: sn xut thuc khng sinh thuc nhm -lactam (penicillin v cc
thuc khc cng nhm) phi cch ly hon ton cc dy chuyn sn xut
trnh nhim cho gy ra phn ng c hi cho cc bnh nhn nhy cm vi
nhm thuc ny.
+ Bo qun: y l qu trnh cho php duy tr cht lng thuc nh cht
lng ng k sau khi c a ra th trng. Trn thc t, phn ln
cc thuc c cht lng xu l do iu kin bo qun khng tt, chng
hn nh cc nh thuc khng bo qun khng sinh nhit quy nh;
cc thuc nhy cm vi nh sang li c trng by trong t knh Hn
 na a s cc thuc c bn di dng khng hp ng, khng toa
y l nhng sai lm trong vic phn phi thuc
+ Thuc gi: y l nguyn nhn quan trng gy ra nhng phn ng c
hi ca thuc, i khi rt trm trng.
Tng tc thuc:
Tng tc bt li ca cc thuc c th lm thay i sinh kh dng hoc
thay i dc lc hc ca thuc v do vy gy ra cc ADR trn bnh
nhn.
iu tr nhiu thuc:
+ Tn sut ADR tng ln theo cp s nhn vi s lng thuc c trong
mt ln iu tr
+ Tng tc thuc cng l mt yu t lm tng ADR
Liu trnh iu tr ko di:
Nhiu ADR t xut hin khi dng thuc trong thi gian ngn nhng t l
tng ln khi dng di ngy
V d: Xut huyt tiu ha do dng cc thuc chng vim khng steroid
(NSAID) hoc corticoid ko di
Yu t thuc v bc s lin quan n s pht sinh ADR:
Kin thc: Mt bc s cn phi c mt kin thc tt v dc l ca thuc.
Tuy nhin iu ny rt kh khn khi hin nay, c qu nhiu hot cht mi
vi c ch phc tp; hng lot cc bit dc khc nhau (cng hot cht)
c tung ra th trng.
Y c: Trc khi k n, bc s phi nh gi c ci li v hi do thuc
mang li bi v phn ng c hi ca thuc khng c tch ri khi tc
dng c li m thuc c c.
Sai lm trong s dng thuc : s dng nhm thuc,khng ng mc ch
iu tr nguy c ADR rt ln,c th t vong.
14. Nu cc bc trong quy trnh thng tin thuc?
Bc 1: Tip nhn yu cu v thng tin thuc
Bc 2: Xc nh i tng yu cu thng tin thuc
Bc 3: Phn loi, nh gi mc yu cu thng tin thuc
Bc 4: Tra cu, phn tch, tng hp thng tin thuc
Bc 5: Xy dng cch thc hi p thng tin thuc
Bc 6: Tr li thng tin thuc, ghi nhn phn hi, lu tr thng tin thuc.
15. Khi nim d ng thuc, biu hin lm sng, phn loi d ng thuc?
Khi nim: Theo t in bch khoa Dc hc: D ng thuc l mt loi phn
ng ph ca thuc xy ra thng qua h min dch ca c th.
Biu hin lm sng:
V tr Biu hin lm sng
 Da My day, ph Quincke, sn nga, vim da tip xc, da ton
thn, hi chng Stevens Johnson, hi chng Lyell
Phi Kh th, vim ph nang, hen suyn
Gan Vim gan, tn thng t bo gan, mt
Tim Vim c tim
Thn Vim cu thn, hi chng thn h
Mu Ban xut huyt gim tiu cu, thiu mu tan huyt, gim bch cu
trung tnh, tng bch cu a acid
Ton thn Sc phn v, h huyt p, st, vim mch, sung hch, bnh huyt
thanh
Tiu ha Nn ma, au bng qun, tiu chy

Phn loi d ng thuc:

Loi hnh d ng V d thuc Th hin lm sng in hnh
Loi hnh I (d ng Betalactam, insulin Sc phn v, my ay, ph Quincke
tc th)
Loi hnh II (gy Methyldopa Thiu mu tn huyt, xut huyt gim tiu cu
c t bo)
Loi hnh III (phc Globulin khng lympho Bnh huyt thanh, vim mch
hp min dch)
Loi hnh IV (d Kem corticoid Vim da tip xc
ng mun)
Loi hnh d ng Cht cn quang, aspirin Ban, sc phn v, co tht ph qun, vim mi
gi hiu
Ngoi 4 loi hnh d ng (I, II, III, IV) theo Gell v Coombs cn mt loi hnh d
ng gi hiu do cc thuc Aspirin, chng vim khng steroid (NSAID).
16. Mt s bnh cnh lm sng hay gp do d ng thuc?(sch tphcm trang
78)
Kiu d ng Bnh cnh
D ng thuc type I phn ng My ay, ph Quincke, hen ph qun, sc phn v,
tc th kiu phn v
D ng thuc type II phn Phn ng truyn mu, tiu huyt tr s sinh,
ng c t bo
D ng thuc type III phn Bnh huyt thanh, vim khp dng thp, vim cu thn, vim nt
ng tp phc hp min dch quanh ng mch, lupus ban h thng, x cng b,
D ng thuc type IV phn Qu mn kiu Tuberculin, qu mn cho tip xc,
ng chm/ qu mn chm

17. Phng php pht hin d ng thuc?

Khai thc tin s d ng ca bnh nhn
 Nm vng cc thuc c kh nng gy d ng cao
Da vo bnh cnh lm sng
Tin hnh cc th nghim pht hin sm d ng thuc:
+ Cc th nghim b:
Th nghim gi git
Th nghim ly da v rch b
Th nghim p da
+ Cc th nghim kch thch:
Th nghim kch thch nim mc mi
Th nghim kch thch nim mc di li
Cc phn ng in vitro:
+ nh lng khng th d ng gin tip
+ inh lng khng th d ng trc tip
18. Phng nga v iu tr d ng thuc?
Cc bin php phng trnh d ng thuc:
Tuyn truyn s dng thuc hp l v an ton
Pht hin sm d ng thuc
m bo t vn s thuc an ton
iu tr d ng thuc:
Nguyn tc chung:
Khng ngi bnh tip xc nhiu hn hoc tip xc tr li vi thuc
gy d ng, hn ch dng thuc khc.
S dng cc thuc chng d ng nh cc khng histamine, corticoid,
vitamin C liu cao.
Dng cc thuc cha bnh triu chng.
B nc v in gii (khi mt nc v in gii), cho thuc li tiu, tng
cng chc nng gan.
Chng bi nhim (nu c), nhng cn phi la chn khng sinh thch hp
m bo an ton.
Gii quyt tt vn dinh dng v h l i vi cc trng hp d ng
thuc nng.
X tr cc trng hp d ng:
Tm hiu v loi b nguyn nhn gy d ng
X tr ti ch:
+ Bin php h tr
+ Bin php dng thuc:
o iu tr triu chng
o B nc v in gii, tng cng chc nng gan
o Chng bi nhim
 + Bin php phi hp khc:
o Ra d dy, th oxy, xoa bp lng ngc,
o Gii mn cm
Chuyn bnh nhn b d ng thuc trm trng n c s y t gn nht.
19. K tn mt s ch s sinh ha thng gp, gii hn bnh thng ca cc
ch s . Bnh l gp phi nu bt thng?
Stt Thng s
1 Glucose
2 Hemoglobine A1C (HbA1C)
3 Ur (Urea)
4 Creatinine
5 H s thanh thi creatinine
6 Protein huyt thanh
7 in di Albumin
protein
Globulin
Gi tr bnh Bnh l
thng
Lc i: 70-110 - Tng ng huyt: tiu ng,
mg% (3,9-6,1 basedow, u no, vim mng no,
mmol/L) suy gan, vim thn cp.
- Gim ng huyt di 53 mg%:
hn m h ng huyt, gng sc
ko di, dng insulin qu liu, suy
gip, suy gan nng.
4-7% Tng trong bnh tiu ng
8-20 mg% hay 3- - Tng ure mu: do n nhiu
7,4 mmol/L protid, st, bnh thn (vim cu
thn, ng thn, suy thn cp, mn)
- Gim: suy gan nng giai on
cui him gp
- H s thanh thi ure bnh thng
75 ml/pht h s ny gim ngi
suy thn.
0,5-1,5 mg% hay Tng trong suy thn, b tiu
44-132 mol/L
70-140 ml/pht Suy thn: h s thanh thi < 70
ml/pht
6-8 g/L - Gim : trong suy dinh dng, ri
lon tiu ha, ung th, suy gan, x
gan, hi chng thn h
- Tng: c c mu, mt nc, ri
lon globulin mu (a u ty
(Kahler))
60% protein ton - Gim (ch yu l albumin) gp
phn trong suy dinh dng, ri lon tiu
2,3-3,5 g/dL ha, ung th, suy gan, x gan.
l thiu ht trong tng hp. Protein
huyt h cn do tng o thi: hi
chng thn h, mt protein theo
 nc tiu nhiu, bng rp,mt qua
da
- Tng trong c c mu, do c th
mt nc v mt s bnh ri lon
globulin huyt: a u ty (bnh
Kahler), bnh macroglobulin huyt
Waldenstrom
8 Bilirubine trong mu < 1 mg% - Tng bilirubin ton phn v gin
(17mol/L) tip: vng da do tiu huyt (thiu
Bilirubin trc tip mu tiu huyt, st rt,sau truyn
< 0,2 mg% mu khc loi), bnh Gilbert,
Bilirubin gin vng da s sinh.
tip < 0,8 mg% - Tng bilirubin ton phn v trc
tip: tc mt trong gan (vim gan,
x gan)
- Bilirubin niu = sc t mt: bnh
thng khng c. Xut hin khi b
vng da do tc mt, vim gan, x
gan.
9 Cc Amylase 31-123 U/L Tng trong bnh ty tng, vim
Enzymes ty cp, bnh bng khng phi
(men) bnh ty
Lipase < 190 U/L Tng trong: vim ty cp, ung th
ty, lot d dy t trng thng vo
ty, x gan, tc mt
o
Alanin 0-49 U/L 37 C Tng trong vim gan, tn thng
aminotransferas t bo gan, tc mt
e (ALT)
Aspartate 0-49 U/L
aminotransferas
e (AST)
Alkalin 25-85 U/L - Tng trong tc mt, bnh thng
phosphatase hoc tng nh trong vim gan, c
(ALP) th tng mt s bnh ngoi gan
nh cng tuyn cn gip, thiu
vitamin D, bnh xng
- Gim c tnh gia nh, nhc
gip, thiu vitamin C
Gamma < 40 U/L Tng trong bnh l gan mt (x
Glutamyl gan, vim gan cp v mn, ung th
tranferase gan, vng da mt), s dng lu
 (GGT) di mt th thuc (chng co tht,
chng trm cm, thuc nga
thai), nghin ru nng v mn
(nhim c alcohol)
Cholinesterase 3000-4000 U/L Gim trong suy gan mt kh nng
(CHE) tng hp, ng c phosphor hu
c
Creatinine 10-125 U/L - Khi tn thng m c xng gy
Kinase CK = tng CK huyt thanh: phn hy c
Creatinin vn cp do chn thng, do hn
phosphokinase m ko di, do dng thuc qu
CPK liu. Nhiu thuc dng liu iu
tr hoc qu liu c biu hin trn
c vn lm tng CK: cocaine,
amphetamine, theophylline, khng
histamine, barbiturate, mt s
khng sinh
- CK tng sm trong nhi mu c
tim
- CK-MB tng sm v c hiu
trong nhi mu c tim
- CK-BB tng trong nhi mu no
10 Lipid mu Triglycerid 10-160 mg% Tng trong ung ru nhiu, bo
ph, tiu ng, bnh l thn mn,
stress nng
Cholesterol v Cholesterol ton Tng trong vng da tc mt, ri
cc thnh phn phn: 125-239mg lon chuyn ha lipid (bo ph,
cholesterol % tng cholesterol mu di truyn gia
nh), tiu ng, cao huyt p, x
va ng mch
HDL cholesterol: - Gim: x va ng mch, bnh
> 35 mg% mch vnh, bo ph, ht thuc,
km tp luyn
- Tng: gim nguy c x va ng
mch v bnh mch vnh
LDL cholesterol: Tng: Nguy c x va ng mch
< 150 mg% v bnh mch vnh

20. Nu c cc k thut xt nghim vi sinh?

1. Pht hin trc tip:
Soi knh hin vi: soi trc tip, soi sau khi nhum, soi di knh hin vi in t
 Tm s hin din ca c t
Tm khng nguyn: phn ng huyt thanh hc
Cc xt nghim phn t: d tm gen, cc xt nghim khuch i (phn ng
PCR)
2. Cy:
Cy vi khun: cy phn lp v cy thun chng
Th nghim nhy cm khng sinh (th nghim khng sinh )
Cy virus
Cy nm
Cy n bo
3. Phng php huyt thanh hc: k thut gin tip v k thut trc tip
Cc xt nghim tm khng th
Cc xt nghim tm khng nguyn
4. Cc chun on phn t: phn ng PCR, phn ng LCR, khuch i TMA,
chui DNA nhnh, khuch i NASBA, xt nghim lai vi cc on d nuceid
acid, xt nghim chui trnh t ca gen, hnh thi cc on ct gii hn
5. Mt s xt nghim khc:
Xt nghim huyt hc: pht mu; xt nghim ty xng; th nghim ng
mu, cc sn phm ging ha fibrin, cc D-dimer; th nghim lnh ngng kt;
s lng cc loi bch cu trong mu ngoi bin; tc lng hng cu v CRP;
nng Ferritin; glucose 6-phosphate dehydrogenase; nng hemoglobin
(Hb) v cc thng s lhacs ca hng cu (c bit l MCV); sng lc tn huyt
(gm c m hng cu li); xt nghim du n (xt nghim Paul Bunnell);
gim tiu cu; nng vitamin B12
Cc phng php dng tia x: X-quang n gin; cc phng php xt
nghim hnh nh tinh vi: MRI, CT tng phn cao, siu m
Cc phn ng sinh ha: -fetoprotein (AFP); kh mu ng mch; protein C
hot ha; nng Creatinin phosphokinase; chuyn ha glucose; nng
haptoglobin; nng lactate; bt thng cc thng s lipid (cholesterol,
triglyceride); cc xt nghim chc nng gan; AP; bilirubin; GT; nng
amylase tuyn ty; phn tch dch mng phi; nng Na+ .
21. Vai tr ca cc xt nghim vi sinh trong chn on bnh nhim trng,
ng dng trong mt s bnh thng gp?
Vai tr:
+ Pht hin trc tip:
Soi knh hin vi: tm tc nhn gy bnh nh :k sinh trng, vi khun,
virus
V d: Soi trc tip: tm k sinh trng trong phn, tm k sinh trng st rt
trong mu,pht mu soi trng roi
Soi sau khi nhum: v d nhum carbofushin tm trc khun lao
 Soi knh hin vi in t:i vi virus v cc tc nhn gy bnh khc
Tm s hin din ca c t, v d vi Clostridium difficile
Tm khng nguyn: phn ng huyt thanh hc
+ Cy: gip chun on tc nhn gy bnh do vi khun, nm, n bo hay virus,
ngoi ra cy phn lp cn l bc u trong th nghim khng sinh .
+ Phng php huyt thanh hc: lin quan n vic s dng cc phn ng khng
nguyn khng th nhm mc ch chn on. Chn on da trn vic pht
hin khng th hoc khng nguyn trc tip trong mu v hoc trong cc dch
sinh hc khc ca c th hoc xc nh tc nhn gy bnh thng qua cc mu
nui cy.
K thut gin tip nhm pht hin cc khng th c hiu c to ra trong c
th p ng vi mt hay nhiu khng nguyn trong c th hay trn b mt tc
nhn gy bnh. Cc khng th ny c tm thy trong mu ca bnh nhn hoc
trong cc dch c th.
K thut trc tip nhm pht hin cc khng nguyn c hiu ca tc nhn gy
bnh. V k thut ny c th xc nh v phn loi tc nhn gy bnh nn n
khng ch c gi tr trn lm sng ni ring m cn c ng dng quan trng v
mt dch t.
Virus vim gan B l 1 v d in hnh ca mt nhim trng trong c khng
nguyn v khng th u c vai tr quan trng trong chn on, theo di iu
tr, sng lc bnh v dch t.
+ Cc chn on phn t:
Tm v xc nh ti lng virus theo di iu tr vi HCV, HIV, HBV,
CMV
Tm cc vi sinh vt c tc tng trng chm nh lao, lao khng in
hnh
Chn on cc tc nhn gy bnh c kh nng nguy him tim tng cho
nhn vin xt nghim khi x l nh virus st xut huyt, u ma
Pht hin cc vi sinh vt b git bi khng sinh trc khi tin hnh mu
nui cy. V d nh trong nhim trng mu do mng no cu.
Pht hin vi sinh vt khng th nui cy c nh virus vim gan C
(HCV)
Pht hin cc bnh bt thng ca giun, nm
Pht hin c cht tinh vi mt s lng nh tit ra bi vi khun nh c
cht gy shock
nh lng nng ca mt nhim trng nh ti lng virus trong bnh
HIV
Pht hin cc t bin gen biu hin khng khng sinh (xt nghim
kiu gen khng). V d nh trong HIV, CMV, lao.
Lm sng t cc tc nhn gy bnh m cha c tm ra
 + Mt s xt nghim khc:
Xt nghim huyt hc: Nhiu bnh nhim trng c biu hin trn s thay
i v huyt hc, rt c gi tr trong chn on
Cc phng php dng tia x: chn on thng qua hnh nh
Cc phn ng sinh ha: nhiu xt nghim sinh ha c ch trng vic chn
on v nh gi tnh trng bnh nhim trng.
ng dng trong mt s bnh thng gp:
1. Lao: gm cc bnh phi v bnh ngoi phi
Chn on:
+ Bng chng phim XQ
+ Kim tra dch sinh hc (m, nc tiu, dch d dy)
+ Xt nghim PCR
+ XN mantoux: xt nghim nhy cm trn da
Cc xt nghim h tr iu tr:
+ KS
+ Nng khng sinh trong huyt thanh
+ XN chc nng gan
+ XN trn da
+ D tm gene (nu khng Rifampicin)
+ Lao v sinh thit: nu nghi ng lao ngoi phi
2. Bnh tiu chy:
Chn on: Xem phn
Xt nghim:
+ Cy phn v th nhy cm
+ Soi phn tm trng, t bo v k sinh trng
+ XN huyt thanh hc
+ XN h tr: KS
3. Bnh vim phi:
Chn on:
+ XQ ngc
+ XN huyt thanh hc
+ XN m, ph qun, dch ph qun ph nang: soi v cy
+ XN h tr: KS , ti XN li (nu cn)
+ Siu m ngc
+ Cc XN chc nng phi (nu cn)
4. Nhim trng ng tiu:
Chn on: au khi tiu tin
Xt nghim:
+ Cy nc tiu
+ Soi (nu nhim nm, k sinh trng)
+ XN h tr: XN c thai, tm KN tuyn tin lit c hiu, chp tia x ng
thn.
 22. Nhng khc bit v dc ng hc tr em v lu khi dng thuc?
Khc bit v DH tr em:
Cc thng s Thay i so vi ngi tui hon thin Kt qu thay i dc ng
trng thnh nh ngi trng hc
thnh
Hp thu
pH Tng pH acid ( cha tit 3 thng Tng SKD thuc base, gim
acid) SKD thuc acid
Nhu ng d Gim nhu ng d dy rut 6-8 thng Khng d on c SKD
dy rut (thi gian tho rng d dy v ko di thi gian t Cmax
l 6 8 gi khi mi sinh)
Dch d dy Gim dch mt v enzyme Khong 1 tui Gim SKD thuc tan trong
rut ty m
Tim bp Gim ti mu ?
ng bi Tng hp thu 4 thng (lp biu Tng hp thu
ngoi da b)
Phn b
% nc trong Tng tng lng nc trong 12 tui Tng Vd ca thuc tan
c th c th trong nc
Tng dch ngoi bo, thay
i nhanh trong nm u
i.
% m trong S sinh thng 12-16%, 17 tui
c th tng trong tui 5-10,
nhng nm sau gim
Protein huyt Gim protein tp, albumin, Thay i trong Tng Vd v dng t do ca
tng 1 glycoprotein mt nm u i thuc lin kt protein
Tng bilirubin khng lin Thay i trong Nguy c th ch bilirubin
hp v acid bo t do. mt nm u i trong lin kt protein
Hng ro Cha hon thin ? Tng nng trong h thn
mu no kinh
Chuyn ha : thp khi mi sinh
H men chuyn ha cha Gim chuyn ha (pha 1 v
y . pha 2)
Thuc (aspirin) -> bilirubin Tng bilirubin hi no
t do
Thi tr
Chc nng Thp khi mi sinh, c bit 3-6 thng Tng thi gian bn thi
lc cu thn tr thiu thng
Tit ng thn Thp khi mi sinh 7 thng 1 tui Tng thi gian bn thi
 Lu khi dng thuc:
1. La chn thuc ph hp
Mt s tc dng khng mong mun bt thng:
Chm ln: corticoid, tetracyclin
Dy th sm: androgen
Tng p lc s no: corticoid, vitamin A, D , acid nalidixic
Vng da: novobiocin, sulfonamide, vitamin K3
Li thp, vng rng: tetracyclin
Bin dng sn tip hp: fluoroquinolon
D b ngt v lit h hp: opiate
2. Liu lng thuc ph hp:
Khng coi tr em l ngi ln thu nh
Tra liu cho tr em trong cc sch tra cu:
Dc th Anh v thuc dng cho tr em
Khng c cng thc no cho bit khong cch dng thch hp
Tnh liu cho tr em:
+ Tui
+ Cn nng, din tch b mt c th
+ Kh nng hon thin cc c quan gan, thn
3. La chn ch phm v ng a thuc:
Cc yu t quyt nh la chn:
Trng thi bnh
Tui
Liu php phi hp iu tr ang tin hnh
Thi im dng thuc thun li
Kh nng sn c dng dng
Chn ch phm v ng a thuc:
- ng ung: la chn dng bo ch
Dng bo ch thch hp (TE < 7 tui): dung dch, siro, bt pha hn
dch, thuc git
Thay th bng nghin vin v pha hn dch, khng nghin vin gii
phng ko di.
- t trc trng
- ng tim: ng tim tnh mch khuyn dng cho tr
4. S tun th iu tr
23. Nhng khc bit v dc ng hc ca ngi cao tui v lu khi dng
thuc?
Nhng khc bit v dc ng hc ca ngi cao tui:
Qu trnh DH Bin i so vi ngi tr Nguyn nhn
S hp thu thuc: Kh nut Dng vin nn, vin nang
- Ung Gim hp thu (chm) Gim acid dch v v gim tho rng d dy,
Gim ti mu, gim vn chuyn ch ng
- Tim bp Gim hp thu Gim ti mu v khi lng c.
S phn b thuc Tng Vd ca thuc Tng m, gim c bp, gim nc/ c th
Gim thi gian xut hin tc Gim hiu sut tun hon
dng
Tng thi gian tc dng Tng m d tr thuc
Tng thuc t do/ mu Gim albumin - mu
(Naproxen, Phenytoin,
Tolbutamid, Warfarin,)
S chuyn ha Tng tc dng, c tnh Gim chuyn ha, gim mu qua gan
thuc
S bi tit thuc Gim Cl, tng T1/2 Gim chc nng thn
Lu khi dng thuc:
1. Ch dng thuc khi tht cn thit, cn nhc bin php khng dng thuc:
Trc khi dng thuc, cn tr li nhng cu hi sau:
- C tht s cn dng thuc hay cha?
- C bin php no thay th hay khng?
V d:
- iu tr tng huyt p mc nh: iu chnh ch n, luyn tp,
- iu tr mt ng: trnh ung nc trc khi ng, trnh cht kch thch bui
chiu ti, mi trng ti, yn tnh,
2. Quan tm m bo cht lng cuc sng:
Mc tiu iu tr ngi cao tui:
- Ko di cuc sng
- m bo cht lng cuc sng
V d: Thoi ha khp nng : thay khp vi NSAIDs
iu tr i tho ng, tng huyt p: ch iu tr vi ngi cao tui.
3. Quan tm ti tin s dng thuc:
- Hn ch tng tc thuc bt li
- Qu liu
4. Cn nhc cc tnh trng sinh l v bnh l mc km nh hng ti s dng
thuc:
- Bnh tim mch
- Suy gim chc nng gan thn
- Ri lon tiu ha
- Gim tr nh
- Mt km
- Run tay
- Long xng
- Thch lm dng thuc
 5. Bin php tng liu dn dn: ty vo p ng lm sng, iu chnh liu theo
chc nng thn
6. Chn dng bo ch thch hp vi ng gi v nhn mc r rng
7. Lu gi h s bnh nhn, gim st cht ch v hiu qu v cc ADR
8. Lu vn tun th iu tr:
- Gii thch y trc iu tr
- Chn pht n gin, dng t ln, t thuc
- Lu gi tin trong iu tr.
24. Ngi suy gan, suy thn s dng thuc phi lu nh th no?
Lu chnh liu bnh nhn suy thn:
Thuc c tht s cn thit?
Tin s: bnh l thn, mc suy thn
+ tn thng c quan, thuc khc
Trnh thuc c thn/ chn t c thn nht
iu chnh liu thch hp cn c chc nng thn
thanh thi Creatinin/ GFR (suy thn mn)
Bnh nhn chy thn hoc lc mu?
Theo di nng v tc dng c tnh thuc.
Lu chnh liu bnh nhn suy gan:
Thuc c tht s cn thit?
Hi tin s, loi bnh l gan nh hng n chuyn ha thuc
Trnh thuc c gan/ chn thuc t c gan nht
iu chnh liu thch hp cn c bnh l gan (suy gan nng : Albumin
mu, INR).
Theo di nng , tc dng c tnh ca thuc.
25. Trnh by mi lin quan gia c ch tc dng v tc dng ph ca
glucocorticoid? Cc tc dng ph thng gp v cch khc phc?
Tc dng trn s tng trng ca tr em:
GC kch thch s tit hormone tng trng liu sinh l nhng li c ch s tit
hormone ny khi dng liu cao.
Khuyn co bt buc : Gy chm ln tr em
Gy xp xng:
Do GC tng cng s hy xng, nhng li c ch qu trnh to xng,
do ngn cn s i mi ca m xng v lm tng qu trnh tiu
xng.
GC ngn cn hp thu Calci t rut v tng thi Calci qua nc tiu.
T l gy tai bin ng tiu ha : ~ 1.8%
Tng kh nng b nhim trng:
GC c tc dng c ch min dch
Chm lin so:
 GC c ch tng hp protein
GC c ch hnh thnh t bo si, gim to collagen, gim s hnh thnh
m lin kt.
Suy thng thn cp: l mt tai bin ng ngi khi dng corticoid, thng xy
ra khi dng thuc liu cao, ko di.
Khc phc:
Theo di cht ch bnh nhn
Khng ngng thuc t ngt, phi gim liu t t
Nn dng ch ung 1 ln/ ngy vo 6 8 gi sang, lc no
Nu cn iu tr ko di nn p dng li iu tr cch ngy mc liu duy tr.
26. Trnh by mi lin quan gia c ch tc dng v tc dng ph ca
NSAIDs? Cc tc dng ph thng gp v cch khc phc?
Tc dng ph:
Lot d dy t trng:
Do c ch COX-1, lm gim s to prostaglandin nn gim s to cht
nhy v NaHCO3 ti d dy lm tng nguy c gy lot ng tiu ha m
ch yu hay gp l lot d dy. Tc dng ph ny gp c khi dng bng
ng tim hoc bi ngoi trn din rng lin quan n kh nng thm
thuc vo mu.
Ngoi xut huyt tiu ha v lot d dy, cc NSAID cn gy tn thng
ng tiu ha di (on cui ca rut non v rut gi), tc ng tiu ha
do to thnh cc cht hp (c trng ca tn thng rut do NSAID). Tai
bin ny thng gp vi dng thuc phng thch chm v dng vin bao
tan trong rut.
tan thp v kch ng cao ca ch phm do tnh acid ca phn t
lm trm trng thm tc dng ph ny.
Cch khc phc:
Vi vin nn trn (khng c mng bao c bit): ung thuc vo ba
n v nhai vin thuc, ung km theo mt cc nc to (>200ml)
To vin bao tan trong rut, loi vin ny phi ung xa ba n nu l
bao c vin
To vin si bt hoc cc dng dung dch ung: th d gi bt
aspegic
Cc dng bo ch s dng cc t dc che ch nh -cyclodextrin
cng nhm mc ch gim s tip xc trc tip ca phn t thuc vi
nim mc ng tiu ha (d dy rut)
Lng nc ung phi ln (200-250 ml)
Cng c mt s tc gi khuyn dng km cc thuc chng lot d
dy nh cc cht khng th th H2 (ranitidine, famotidine), cc cht
chn bm proton (omeprazole, lanzoprazol). Tuy nhin do cn tr
 v gi thnh iu tr cng nh tc dng ph ca thuc phi hp nn
cha c mt phc chnh thc no c chp nhn. Cn lu hn
ch dng cc antacid v cc cht bao bc nim mc v hiu qu km
v gy tng tc dn n gim nng NSAID.
Prostaglandin (cytotex) l mt cht phi hp rt tt gim kh nng
gy lot d dy ca cc NSAID nhng gn y khng cn dng na
do c nhiu tc dng bt li, c bit l gy a chy 1 t l ln bnh
nhn.
S ra i ca nhng thuc c ch chn lc COX-2 (meloxicam,
celecoxib, rofecoxib) gim khong 50% t l lot d dy nhng
cn thi gian kim chng v thy c ADR nguy him khng km cho
bnh nhn, v d: ngng dng rofecoxib do tai bin trm trng trn
tim v t qu.
Chy mu:
Cc NSAID lm gim kt tp tiu cu nn ko di thi gian ng mu.
Cch khc phc:
Khng s dng trong nhng trng hp st c xut huyt v tng
chy mu.
Khng s dng cng cc thuc chng ng (warfarin,)
C th p dng trong iu tr nga ng mu nhm trnh cc tai
bin mch vnh, nhi mu c tim. (aspirin,)
Mn cm:
- Hin tng ny hay gp nht khi dng aspirin: ban da, my
ay,hen, sc qu mn v thng xy ra bnh nhn c tin s d ng, c
bnh hen, polyp mi, hoc st (c bit l st do virus); v vy phi thn
trng khi dng cho bnh nhn c c a d ng hoc c tin s d ng,
hen do dng aspirin.
- Khng dng ch phm NSAID h st cho tr em (nguy c gp hi
chng Reye).
II. PHN BI TP:
1. Bc s k n cho bnh nhn s dng Digoxin 0.25 mg ngy 1 vin. Tnh
thi gian hp l t thi im bnh nhn bt u ung thuc n lc c th
th nng Digoxin trong mu? Cho bit Digoxin c thi gian bn thi l
36 gi.
T=36/2=18 gi

2. Mt b c 80 tui, nng 36kg. Xt nghim sinh ha cho thy Creatinin

huyt thanh l 1.2 mg/dl. Tnh thanh thi thn ca bnh nhn ny?
Cng thc ca Cockroft v Gault:
 ( 140Tui ) th trng ( kg)
0.85
ClCR = mg
Creatinin( )72
dl
(14080)36
ClCR = 0.85=21.25 ml / pht
1.2 72

3. Bc s cho tim mch 1 loi Cephalosporin th h 3 cho 1 ngi n ng

58 tui, nng 75kg, liu 5mg/kg. Khng sinh c c tnh dc ng hc 1
ngn (one compartment) v c thi gian bn thi 2 gi. Th tch phn b
biu kin l 0.28 L/kg v thuc gn vo protein huyt tng 35%
a. Tnh nng ban u ca thuc trong huyt tng?
b. Tnh lng thuc cn trong ngi bnh sau 8 gi?
c. Cn thi gian bao lu thuc thi ra khi c th ng 75%?

a. V tim tnh mch nn F=1

DF DF 51
Ta c: Vd = Cp => Cp = Vd = 0.28 = 17.86 mg/L
b. Liu lng thuc vo c th = 5 x 75 =375 mg
Ta c:
S thi gian t1/2 % b thi tr ca liu thuc
1 50%
2 75%
3 87.5%
4 93.75%
T1/2 = 2 gi => sau 8 gi lng thuc cn li l:
375 : 100 x (100-93.75) = 23.4375 mg
c. T bng trn ta thy cn 2 ln t1/2 th thuc thi ra khi c th ng
75% tc l 4 gi
4. Phn tch tng tc gia Cimetidin v Tetracyclin?
Cimetidine lm tng pH d dy nn lm gim ha tan, gim hp thu tetracyclin

5. Phn tch tng tc gia Probenecid v Cefotaxim?

Probenecid cnh tranh trn cng cht vn chuyn (carrier) ng thn vi
penicilin G, ampicilin, carbenicilin, cephalosporin, nn probenecid y ngc
nhng thuc ny tr li dch k v lm chm o thi tch cc ca chng (li ch
iu tr ca khng sinh -lactam).