Hoa Dư C-Dư C Lý III

b Y t
ha dc - dc l iii
(dc lm sng)
sch o to dc s trung hc
M s: T.60.Z.4
Ch bin
PGS.TS. Hong Th Kim Huyn
Nh xut bn y hc
h ni - 2007
1
Ch o bin son:
V Khoa hc v o to, B Y t
Ch bin:
PGS. TS. Hong Th Kim Huyn
Nhng ngi bin son:
GS. ng Hanh Phc
ThS. Bi c Lp
ThS. Phan Qunh Lan
ThS. Nguyn Th Lin Hng
ThS. Phm Th Thu Vn
DS. Nguyn Thnh Hi
DS. V nh Ha
Tham gia t chc bn tho:

TS. Nguyn Mnh Pha
ThS. Ph Vn Thm
Bn quyn thuc B Y t (V Khoa hc v o to)
2
Li gii thiu
Thc hin mt s iu ca Lut Gio dc, B Y t ban hnh chng

trnh khung v chng trnh gio dc ngh nghip cho vic o to trung
cp ngnh y t. B Y t t chc bin son ti liu dy - hc cc mn c s v
chuyn mn theo chng trnh trn nhm tng bc xy dng b sch chun
trong cng tc o to nhn lc y t.
Sch Ha dc - Dc l III (Dc lm sng) c bin son da
trn chng trnh gio dc ngh nghip ca B Y t bin son trn c s
chng trnh khung c ph duyt. Sch c cc nh gio, cc chuyn
gia giu kinh nghim v tm huyt vi cng tc o to bin son theo
phng chm: Kin thc c bn, h thng; ni dung chnh xc, khoa hc; cp
nht cc tin b khoa hc, k thut hin i v thc tin Vit Nam. Sch
c cu trc gm phn l thuyt v thc hnh, trong i su vo phn
thc hnh v mc tiu chnh ca h trung hc l thc hnh.
Sch Ha dc - Dc l III (Dc lm sng) c Hi ng
chuyn mn thm nh sch v ti liu dy - hc ca B Y t thm nh vo
nm 2005. B Y t ban hnh l ti liu dy - hc chnh thc ca Ngnh Y t.
Trong qu trnh s dng, sch phi c chnh l, b sung v cp nht.
B Y t xin chn thnh cm n cc cn b ging dy B mn Dc lm
sng trng i hc Dc H Ni dnh nhiu cng sc hon thnh cun
sch ny; cm n TS. Khng Chin v DS. Nguyn Huy Cng c,
phn bin cun sch c hon chnh kp thi phc v cho cng tc o
to nhn lc y t.
Ln u xut bn nn cn c khim khuyt, chng ti mong nhn c
kin ng gp ca ng nghip, cc bn sinh vin v cc c gi ln
xut bn sau c hon thin hn.
V khoa hc v o to
B Y t
3
4
Mc lc
Trang
Li gii thiu 3
Phn 1. L thuyt 9
Bi 1. Bi m u 11
1. i cng 11
2. Nhng ni dung phi thc hin t c mc tiu s dng 13
thuc an ton - hp l
Bi 2. Cc thng s dc ng hc ng dng trong lm sng 19
1. Sinh kh dng 20
2. Thi gian bn thi 22
Bi 3. Tng tc thuc 28
1. Tng tc dc lc hc 29
2. Tng tc dc ng hc 30
3. Tng tc thuc vi ung 31
4. nh hng thc n n thuc 33
5. Hng dn thi gian ung thuc hp l 35
Bi 4. Phn ng bt li ca thuc v cnh gic thuc 44
ThS. Phm Th Thu Vn
1. Phn ng bt li ca thuc 44
2. Cnh gic thuc 52
Bi 5. Thng tin thuc 59
ThS. Nguyn Th Lin Hng
1. Phn loi thng tin thuc 60
2. Yu cu v ni dung ca thng tin thuc 62
3. K nng thng tin thuc cho bnh nhn 63
5
Bi 6. Xt nghim lm sng v nhn nh kt qu 68
GS. ng Hanh Phc - ThS. Nguyn Th Lin Hng
1. H thng SI trong y hc 68
2. Mt s xt nghim sinh ho mu 71
3. Mt s xt nghim huyt hc 77
Bi 7. S dng thuc cho cc i tng c bit 85
ThS. Phan Qunh Lan
1. S dng thuc cho ph n c thai 86
2. S dng thuc ph n thi k cho con b 89
3. S dng thuc trong nhi khoa 91
4. S dng thuc cho ngi cao tui 95
Bi 8. Nguyn tc s dng thuc khng sinh v khng khun 102
1. Nhc li mt s khi nim c bn lin quan n s dng 102
khng sinh
2. Tc dng khng mong mun v chng ch nh 104
3. Nguyn tc s dng khng sinh trong iu tr 106
Bi 9. Nguyn tc s dng vitamin v cht khong 114
1. Nhu cu hng ngy v vitamin v cht khong 115
2. Thiu vitamin v cht khong 116
3. Tha vitamin v cht khong 119
Bi 10. Nguyn tc s dng thuc chng vim cu trc steroid v 124
khng steroid
1. Glucocorticoid 124
2. Thuc chng vim khng steroid (NSAID) 128
Bi 11. S dng thuc trong iu tr hen ph qun 137
ThS. Bi c Lp
1. Vi nt v bnh hen ph qun 137
2. Cc thuc iu tr hen ph qun 138
3. Cc bin php iu tr h tr hen bng thuc v khng 142
dng thuc
6
Bi 12. S dng thuc trong iu tr to bn v tiu chy 145
ThS. Phan Qunh Lan
1. To bn 145
2. Tiu chy 148
Phn 2: Thc hnh 153
DS. Nguyn Thnh Hi, DS. V nh Ho

2.1. Thc hnh hng dn s dng thuc ti lp hc 155
Bi 1: K nng giao tip v khai thc thng tin t bnh nhn 156
Bi 2: K nng khai thc thng tin s dng thuc 159
Bi 3: K nng Hng dn s dng thuc 162
2.2. Thc hnh cc hot ng hng dn s dng thuc ti 167
hiu thuc
Ph lc 168
p n 172
7
8
Phn 1
L thuyt
9
10
Bi 1
Bi m u
Mc tiu:
1. Trnh by c ba mc tiu cho hc phn Dc lm sng h trung hc.
2. Nu v phn tch c 4 tiu chun cn thit trong la chn thuc an
ton hp l.
3. Phn tch c 4 k nng m dc s lm sng cn c thc hin c
hng dn iu tr tt.
1. i cng
1.1. nh ngha
"Dc lm sng l mn hc ca ngnh Dc nhm ti u ho vic s
dng thuc trong iu tr v phng bnh trn c s nhng kin thc v Dc,
Y v Sinh hc".
1.2. Vi nt v s ra i v pht trin ca mn Dc lm sng
C hai yu t dn n s ra i mn hc Dc lm sng:
Khch quan: S pht trin nhanh chng trong lnh vc sn xut thuc
lm cho th trng thuc va phong ph v s lng dc cht mi, va
a dng v chng loi vi s ra i nhiu dng bo ch mi (dng gii
phng ko di, gii phng c kim sot, dng bao tan trong rut...) khc
hn cc dng kinh in gy khng t lng tng cho thy thuc. T
ny sinh nhu cu t pha ngi k n v s c mt bn cnh h cc
dc s vi nhim v t vn v hng dn s dng thuc, l cc dc
s lm sng.
Ch quan: Bn cnh vic b sung vo chng trnh o to nhiu kin
thc lin quan n Y - Sinh hc, s ra i mn Dc ng hc lm sng
l nn tng quan trng cc dc s lm sng hot ng thnh cng.
Dc ng hc lm sng l mn hc da vo vic xc nh nng
thuc trong mu v dch sinh vt ca ngi s dng thuc. Mn hc
ny ra i l nh c nhng phng tin hin i cho php xc nh
c nhng nng thuc rt nh trong mi trng mu hoc dch
sinh vt (nc tiu, nc bt) ca ngi s dng.
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Nh vy vai tr ca dc s lm sng khng ch cung cp cc thng tin
lin quan n thuc m cn cho cc bc s iu tr bit c nng thuc
c th hiu chnh li liu lng cho ph hp vi tng c th v trng thi
bnh l, lm cho hiu qu iu tr chc chn hn v ngn chn c nguy c
ng c hoc gp tc dng khng mong mun do qu liu.
1.3. Vi nt v mn hc dc lm sng trn Th gii v Vit Nam
Th gii
Dc lm sng l mt mn hc rt tr so vi cc mn hc truyn thng
c ca c hai ngnh Y - Dc. Mn hc ny c khai sinh M vo
nhng nm 60 ca th k XX.
Ti chu u, s ra i ca Dc lm sng mun hn khong 10 nm
tc l khong nhng nm 70. Dc lm sng c chnh thc a vo ging
dy bc i hc M nm 1964 v Php nm 1984.
Ti chu , nhng nc chu nh hng ca M nhiu nh Thi Lan,
Philipin, Singapore..., Dc lm sng pht trin rt sm v hin nay c
nhiu thnh qu nht nh trong h thng iu tr.
Ti chu Phi, thng qua cc d n v chm sc sc kho ca T chc Y
t Th gii (WHO), cc t chc phi Chnh ph... kin thc dc lm sng
thm nhp vo Zimbabwe, Zambia, Ghana... nh cc chng trnh ti tr
o to v s dng thuc an ton - hp l.
Ti Vit Nam
Dc lm sng du nhp vo Vit Nam nm 1990 t chng trnh s
dng thuc an ton - hp l vi s ti tr ca t chc Tm nhn th gii
Australia.
Nhn thc c tm quan trng ca mn hc ny, Trng i hc
Dc H Ni tin phong trong vic a mn Dc lm sng vo o to
bc i hc t nm 1993. B mn Dc lm sng c B Y t cng nhn
nm 1998 ti Trng i hc Dc H Ni. Cng trong thi gian ny, hot
ng Dc lm sng c m rng quy m c nc. Theo quyt nh ca
V iu tr - B Y t, cc t Dc lm sng c hnh thnh ti nhiu bnh
vin vi s kt hp ca c Y v Dc. Mn hc Dc lm sng c a vo
ging dy khng ch ti Trng i hc Dc H Ni m c Trng i hc
Y - Dc thnh ph H Ch Minh, Trng i hc Y - Dc Hu, Trng i
hc Y khoa Thi Nguyn, Hc vin Qun y...
12
1.4. Dc lm sng bc trung hc Dc
Sau khi mn hc Dc lm sng ra i chnh thc, thng qua cc lp
tp hun v Dc lm sng cho bc s v dc s do Trng i hc Dc H
Ni, i hc Y - Dc thnh ph H Ch Minh, V iu tr... t chc, nhng
nh lnh o ti cc c s iu tr nhn thc c tm quan trng ca cng
tc dc lm sng ti bnh vin nn sm a cng tc ny thnh mt
trong nhng hot ng chnh thc trong cng tc iu tr. Do c im c
cu dc s i hc nc ta cha p ng cng tc iu tr, nhiu lc
lng c huy ng vo lm cng tc dc lm sng, trong ngoi lc
lng dc s i hc c c bc s v dc s trung hc. Trc thc t ,
khng ch cc trng i hc Y chuyn mnh th hin qua vic nh hng
li mn hc Dc l, chuyn sang ging dy thm kin thc dc l lm
sng, m c cc trng trung hc Y - Dc cng bt u a mn hc ny
vo ging dy di hnh thc lng ghp kin thc vi mn Ho dc - Dc
l vi mc tiu hng dn s dng thuc hp l - an ton.
1.5. Mc tiu cho hc phn Dc lm sng h trung hc Dc
Sau khi hc xong hc phn ny, hc vin c kh nng:

(1). Trnh by c nhng kin thc c bn lin quan n s dng
thuc v phng nga phn ng c hi do thuc (ADR) gy ra.
(2). Lit k v phn tch c nhng nguyn tc s dng an ton - hp
l ca 3 nhm thuc thng dng:
Khng sinh.
Vitamin v cht khong.
Thuc chng vim (cu trc steroid v khng steroid).
(3). Hng dn s dng c mt s thuc trong iu tr 2 nhm bnh
thng thng theo cc nguyn tc an ton - hp l:
Bnh lin quan n ri lon h hp: Hen ph qun.
Bnh lin quan n ri lon tiu ho: To bn v tiu chy.
2. nhng ni dung phi thc hin t c mc tiu S

Dng Thuc an ton - hp l
S dng c thuc hp l (SDTHL) l nhim v quan trng ca ngnh
y t. t mc tiu ny trch nhim trc tip thuc v ba i tng: Ngi
k n (bc s iu tr), dc s lm sng (DSLS) v ngi s dng thuc,
trong DSLS ng vai tr l cu ni gia bc s - ngi a ra y lnh v
ngi s dng - ngi phi thc hin y lnh.
13
SDTHL trc ht phi chn c thuc hp l. Hp l l phi cn
nhc sao cho ch s Hiu qu/Ri ro v Hiu qu/Chi ph t cao nht.
Tuy nhin, mt thuc hp l phi nm trong mt n hp l, ngha l
ngoi tiu chun hp l ca tng thuc ring bit cn phi tnh n nhiu
mt khc, trong ba vn quan trng nht l:
Phi hp thuc phi ng (khng c tng tc bt li).
Kh nng tun th iu tr ca ngi bnh cao (s ln dng trong ngy
t, kh nng chi tr ph hp vi ngi bnh).
C ch dn dng thuc ng.
Mun s dng thuc hp l khng ch cn n cc kin thc lin quan
n thuc v bnh m cn phi a cc kin thc ny ln ngi bnh c th,
c ngha l phi hiu r cc c im ca ngi bnh nh cc bnh mc km
(gan, thn, tim, phi...), cc bt thng v sinh l (bo ph, c thai...), tui
tc (tr em, ngi gi) n cc thi quen (nghin ru, thuc l, n
king...) v c hon cnh kinh t. Nh vy trong iu tr phi tnh n ngi
bnh ch khng phi ch l bnh n thun.
Sau y l mt s ni dung c th lin quan n s dng thuc an
ton - hp l.
2.1. Cc tiu chun la chn thuc an ton - hp l

Bng 1.1. Bn tiu chun cn thit trong la chn thuc an ton - hp l
TT Tiu chun la chn K hiu

1 Hiu qu iu tr tt H
2 An ton cao A
3 Tin dng (D s dng) T
4 Kinh t (R nht so vi cc thuc t ba tiu chun trn) K
Hiu qu l kh nng khi bnh tt, t l bnh nhn c cha khi cao.
An ton l kh nng xut hin tc dng khng mong mun thp, ngha
l t l Hiu qu/Nguy c ri ro cao.
Tin dng hay d s dng bao gm cch a thuc, s ln dng thuc
trong ngy... ph hp, cng n gin cng tt.
Kinh t c th tnh theo chi ph tin ca loi thuc cho 1 ngy iu
tr (Liu DDD) hoc cho c liu trnh iu tr. Gi thuc c th chn l
thuc sn xut trong nc hoc ca ngoi nhp. C nhng trng hp
ngi ta tnh vo chi ph iu tr c tin ca cc xt nghim cn lm
sng cn phi lm khi s dng thuc.
14
C nhiu ti liu cn a vo thm mt tiu chun 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.
2.2. Cc k nng cn c ca DSLS khi hng dn iu tr

Hng dn iu tr l nhim v ca DSLS. hng dn iu tr tt,
ngi DSLS cn c cc k nng sau:
(1). K nng giao tip vi bnh nhn
(2). K nng thu thp thng tin
(3). K nng nh gi thng tin.
(4). K nng truyn t thng tin.
Nh nu phn trn, mun iu tr thnh cng th ngoi yu t
nm vng thuc v bnh cn phi bit r v bnh nhn v to c s hp
tc ca h trong iu tr.
Vi nhng trng hp iu tr ngn ngy, s tun th ca ngi bnh
d dng hn. Tuy nhin trong trng hp bnh mn tnh hoc ko di nhiu
ngy th vn tr nn kh khn hn nhiu. Kt qu iu tr cc bnh mn
tnh khng phi lc no cng nh mun. Vy khi gp tht bi hoc khi kt
qu iu tr cha t yu cu th phi lm g t mc tiu iu tr
t ra.
Ni dung c th mi k nng:
1. K nng giao tip vi bnh nhn
thc hin c k nng ny, DSLS phi to lp mi quan h gn gi

vi bnh nhn bi v iu tr tt khng th khng c s hp tc t pha
bnh nhn. Mun lm c nh vy phi lm cho bnh nhn hiu c l do
iu tr, phng thc iu tr v nhng vic m h cn lm tham gia vo
iu tr thnh cng.
Khi bnh nhn hiu v bnh th h s t gic chp hnh y lnh v
nhiu trng hp gip bc s tm ra nguyn nhn tht bi do quan h ci m
vi thy thuc.
2. K nng thu thp thng tin
Thu thp thng tin lin quan n c im ca bnh nhn (tui, gii,
thi quen, ngh nghip...).
15
Thng tin thu thp phi t m v chnh xc. Thng th qu trnh ny
c lm t ln khm bnh u tin trc khi bt u thit lp ch iu
tr nhng cng c th cha khai thc ht hoc li xut hin nhng tnh
hung mi lin quan n bnh.
3. K nng nh gi thng tin
nh gi cc thng tin lin quan n vic dng thuc trong qu trnh

iu tr l mt vic lm cn thit trc khi a ra kt lun v bin php can
thip.
Phi nh gi c cc thng tin lin quan n vic dng thuc trong
qu trnh iu tr tm ra nguyn nhn tht bi (nu gp).
Nguyn nhn tht bi trong iu tr rt phc tp, trong vic bnh
nhn t b thuc hoc s dng khng ng liu, khng thi gian l rt
thng gp. Nhng nguyn nhn ny c th lin quan n tc dng ph ca
thuc, cng c th do gi thnh thuc qu cao so vi iu kin kinh t. Tht
bi iu tr cng c th do phc c khng cn ph hp do bnh tin trin
nng thm (vi ngi cao tui, do tui tc ngy mt cao nn nhiu bnh mc
km hn, th d xut hin thm bnh tiu ng hoc x va ng mch
cng lm cho huyt p khng th bnh n vi mc liu c c na...).
Khi tm c nguyn nhn, DSLS c th gip ngi bnh thc hin li
y lnh lp li mt lch trnh iu tr ng.
4. K nng truyn t thng tin
Cc thng tin phi truyn t c lin quan n hng dn dng thuc

v theo di iu tr.
thc hin mc ch hng dn iu tr tt, ngi DSLS phi hng
dn chnh xc v t m cch thc thc hin y lnh bao gm vic dng thuc
v cc du hiu cn nhn bit v tin trin theo chiu hng xu ca bnh.
Mun lm tt vic ny, ngi DSLS phi to lp c lng tin t pha bnh
nhn v phng php kim tra kh nng nhn thc ca h vi cc thng tin
c truyn t; thng th nn ngh bnh nhn hoc ngi nh bnh
nhn (vi bnh nhn nh tui hoc ngi b bnh tm thn...) nhc li.
V d: Cc thng tin lin quan n gi ung thuc, cch ung thuc l
nhng thng tin thng gp nht. Vi bnh nhn mc bnh mn tnh nh
bnh lao, bnh tng huyt p,... thng tin v di liu trnh iu tr m
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bnh nhn phi thc hin l rt quan trng. Nhng thng tin lin quan n
cch thc theo di tin trin ca bnh ti nh (th d cch kim tra huyt
p), chu k ti khm... l nhng thng tin phi truyn t v phi xc nh
chc chn bnh nhn hiu v tin tng thc hin.
Kt lun
S dng thuc hp l l mc tiu t ra vi c ngnh y t, trong vai
tr ca ngi dc s lm sng l rt quan trng.
La chn c mt thuc hp l l vic lm u tin; nhim v ny
khng ch ngi k n phi lm m c ca DSLS .
La chn thuc hp l nhm thit lp c mt phc iu tr hp l
cho bnh nhn. Trong khu ny, nhim v hng dn iu tr thuc v
DSLS.
Mt phc iu tr c thit lp ng l rt quan trng nhng nu
thc hin khng ng (khong cch a thuc, gi ung thuc, cch s dng
cc dng bo ch) th hiu qu iu tr s khng th t c. Nh vy, vai
tr ngi DSLS xuyn sut t khu u n khu cui.
Nhng ni dung trn chnh l nhim v m ngi DSLS phi hc hi
v rn luyn gp phn thc hin mc tiu s dng thuc an ton - hp l
m ngnh y t t ra.
T lng gi
in t thch hp vo ch trng (t cu 1 n cu 4)
1. Dc lm sng l mn hc ca ngnh ..(A)... nhm ti u ho vic... (B)...
trong iu tr v phng bnh trn c s nhng kin thc v ...(C)...
2. Cc tiu chun cn thit trong la chn thuc an ton - hp l:
A. Hiu qu iu tr tt
B. .....
C. .....
D. .....
3. hng dn iu tr tt, ngi DSLS cn c cc k nng sau:
A. ....
B. .....
C. ......
D. K nng truyn t thng tin
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4. thc hin mc ch hng dn iu tr tt, ngi DSLS phi hng
dn cho bnh nhn mt cch ...(A)... cch thc thc hin y lnh bao gm
...(B)... v cc du hiu ...(C)...
Chn cu tr li ng nht (t cu 5 n cu 8)
5. Nu DSLS giao tip tt vi bnh nhn, nhng thun li thu c l:
A. C c s hp tc t pha bnh nhn
B. Bnh nhn s t gic chp hnh y lnh
C. C th gip bc s tm ra nguyn nhn tht bi trong iu tr
D. C 3 trn
6. Nhng nguyn nhn dn n tht bi trong iu tr sau y u ng,
tr:
A. Bnh nhn t b thuc
B. S dng khng ng liu
C. Dng thuc ko di
D. Gp tc dng ph
7. Thng tin cn cho s dng thuc hp l l:
A. Gi ung thuc
B. Cch ung thuc
C. di ca t iu tr
D. Du hiu ca tc dng ph
E. Tt c cc trn
8. Vi bnh nhn b bnh tm thn hoc bnh nhn nh tui, khi truyn t
thng tin v s dng thuc, khng c:
A. Truyn t trc tip cho bnh nhn
B. Truyn t cho ngi thn ca bnh nhn
C. Truyn t cho ngi h l gip bnh nhn iu tr
D. C 3 trn
Tr li cc cu hi ngn (t cu 9 n cu 10)
9. Phn tch 4 tiu chun Hiu qu - An ton - Tin dng - Kinh t trong
la chn thuc.
10. Lit k nhng thng tin lin quan n c im ca bnh nhn cn thu
thp hng dn s dng thuc an ton hp l.
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Bi 2
cc thng s Dc ng hc
ng dng trong lm sng
Mc tiu
1. nh ngha c hai thng s dc ng hc lm sng c bn lin quan
n s hp thu v bi xut thuc trong c th l sinh kh dng v thi
gian bn thi (t1/2).
2. Trnh by c cc yu t nh hng n hai thng s ny.
3. Nu c ngha ca sinh kh dng v t1/2 trong iu tr.
M u
Dc ng hc lm sng (DHLS) l mn hc tnh ton cc thng s
trong mi giai on tun hon ca thuc trong c th v tm ra mi lin h
ca cc thng s ny vi p ng dc l ca thuc.
Dc ng hc lm sng c vai tr rt quan trng trong vic c th ho
qu trnh iu tr tng bnh nhn, khu mu cht trong vic thc hin s
dng thuc an ton - hp l.
Nhim v c bn ca dc ng hc lm sng l gim st iu tr da
trn nng thuc trong mu (huyt tng, huyt thanh), hiu chnh liu v
khong cch a thuc cho ph hp vi tng c th.
Ni dung chng trnh ny nhm cung cp nhng kin thc phc v
cho cc thng tin c trong bn hng dn s dng thuc, hng dn cho
ngi bnh dng thuc ng da trn thng tin c.
Cc qu trnh tun hon ca thuc trong c th c phn nh thng
qua nhng thng s dc ng hc lin quan n mi giai on tun hon
ca thuc:
Kh nng thm nhp ca thuc vo vng tun hon chung, th hin
qua thng s sinh kh dng (SKD, F%).
Kh nng phn b ca thuc n cc c quan v t chc ca c th, th
hin qua th tch phn b (Vd).
19
Kh nng chuyn ho v bi xut thuc ca c th, th hin qua h s
thanh thi (Clearance = Cl) v thi gian bn thi (hay na i thi
tr, t1/2).
Sau y, chng ti xin gii thiu hai thng s sinh kh dng v t1/2
phc v cho phn hng dn s dng thuc.
1. Sinh kh dng (Bioavailability, k hiu: F)
1.1. nh ngha
Sinh kh dng (F) l thng s nh gi t l (%) thuc vo c vng
tun hon chung dng cn hot tnh so vi liu dng (D0) v tc
(Tmax), cng (Cmax) thuc thm nhp c vo vng tun hon.
1.2. Cch tnh sinh kh dng

tnh SKD, ngi ta phi s dng mt i lng l AUC, c gi l
din tch di ng cong.
1.2.1. Khi nim v din tch di ng cong

Din tch di ng cong, k hiu AUC (Area Under the Curve).
C (mg/l)
t (h)
Hnh 2.1. S bin i nng thuc theo thi gian
Ghi ch: Thuc a theo ng tnh mch

Thuc a theo ng ung
(2 ch phm ca cng 1 hot cht)
Din tch di ng cong (ca th biu din s bin thin ca nng

thuc trong mu theo thi gian) biu th tng trng cho lng thuc vo
c vng tun hon dng cn hot tnh sau mt thi gian t.
20
n v tnh AUC l mg.h.L-1 hoc g.h.mL-1.
Cch tnh ton c th s hc mn hc Dc lm sng ca chng
trnh i hc.
1.2.2. Sinh kh dng tuyt i

Sinh kh dng tuyt i l t l gia sinh kh dng ca cng mt
thuc a qua ng ung so vi a qua ng tnh mch.
AUC po
F (%) tuyt i D IV x 100
= x
AUC IV
D po
Nu thuc c a qua ng tnh mch (I.V) th F = 1.

Cn nu thuc a ngoi ng tnh mch th lun c mt lng nht
nh b tn hao khi i t v tr hp thu vo mu hoc b mt hot tnh khi
qua gan, do F lun < 1.
Nu ta tm chp nhn tt c lng thuc vo c vng tun hon
chung dng cn hot tnh s pht huy tc dng dc l th tr s AU C 0 cho
php nh gi c cht lng ca dng bo ch.
1.2.3. Sinh kh dng tng i

Sinh kh dng tng i l t l so snh gia hai gi tr sinh kh dng
ca hai ch phm c cng hot cht, cng hm lng, cng dng bo ch
nhng ca hai hng sn xut khc nhau
F (%) ca hng A
F % tng i =
F (%) ca hng B
Thc cht khi so snh, ngi ta s dng hai ch phm cng mt mc

liu, do :
AUC ca hng A
F % tng i = x 100
AUC ca hng B
1.3. Nhng yu t nh hng n sinh kh dng
1.3.1. Tng tc thuc

Tng tc ca thuc - thuc, thuc - thc n, thuc vi ung c th
lm thay i sinh kh dng ca cc thuc dng theo ng ung nu dng
ng thi (xem Bi 3. Tng tc thuc).
21
1.3.2. nh hng ca la tui
Cc la tui hai cc: Tr nh v ngi gi, do cc c im bin i
ca dc ng hc so vi ngi trng thnh nn cng c nhng khc bit v
sinh kh dng ca mt s thuc khi s dng cho cc i tng ny (xem
Bi 7. S dng thuc cho cc i tng c bit).
1.3.3. nh hng ca chc nng gan

S suy gim chc nng gan lm gim kh nng chuyn ho thuc
vng tun hon u (1st pass), do c th lm tng SKD ca nhng thuc
chuyn ho mnh qua gan.
1.4. ngha
Sinh kh dng tuyt i thng c cng b vi cc loi thuc vin
dng theo ng ung. Nhng loi thuc c sinh kh dng > 50% c coi l
tt khi dng theo ng ung. Nu sinh kh dng > 80% th c th coi kh
nng hp thu ca ng ung tng ng vi ng tim v nhng trng
hp ny ch tim trong trng hp khng th ung c.
Ngi ta hay dng sinh kh dng tng i nh gi ch phm mi
hoc ch phm xin ng k lu hnh vi mt ch phm c uy tn trn th
trng. Nu t l ny t 80 - 125% th c th coi hai ch phm thuc
tng ng nhau v c th thay th nhau trong iu tr. Lu l tng
ng iu tr trong nhiu trng hp cn phi xem xt c n Tmax v Cmax,
c bit vi thuc c phm vi iu tr hp.
Trong iu tr, phi lu n cc yu t c th lm thay i SKD nh
nu trn.
2. Thi gian bn thi (t1/2)
2.1. Khi nim

Thi gian bn thi (t1/2) l thi gian cn thit nng thuc trong
mu gim i mt na.
tnh t1/2 ngi ta thng dng cng thc sau:
0,693
t 1/ 2 =
K
K: l hng s tc thi tr c tnh t th bn logarit (Hnh 1.2).
Cch tnh ton c th s hc mn hc Dc lm sng ca chng
trnh i hc.
22
C (mg/l) ln C
t (h) t (h)
A: Theo t l thng B : Theo t l bn logarit
Hnh 2.2. ng cong bin i nng thuc theo thi gian

khi a qua ng tnh mch (I.V)
2.2. Nhng yu t nh hng n thi gian bn thi
2.2.1. nh hng ca tng tc thuc

Tng tc ca thuc, c bit l tng tc giai on thi tr c th
ko di hoc rt ngn t1/2 ca nhng thuc thi tr phn ln dng cn hot
tnh qua thn (xem Bi 3. Tng tc thuc).
2.2.2. nh hng ca la tui

Cc la tui hai cc: Tr nh v ngi gi, do s yu km hoc suy
gim chc nng thn cng lm thay i t1/2 ca nhng thuc thi tr phn
ln dng cn hot tnh qua thn (xem Bi 7. S dng thuc cho cc i
tng c bit).
2.2.3. nh hng ca chc nng thn

S suy gim chc nng thn lm chm bi xut thuc, do c th
ko di t1/2 ca nhng thuc thi tr phn ln dng cn hot tnh qua thn.
23
2.2.4. nh hng ca chc nng gan
S suy gim chc nng gan lm gim qu trnh chuyn ho thuc. Do
vy nhng thuc thi tr phn ln nh chuyn ho thnh dn cht khng
cn hot tnh ti gan s b chm bi xut, tch lu lu hn trong c th, dn
n ko di t1/2.
2.3. ngha ca tr s t1/2

Bng 2.1. Lin quan gia t1/2 v lng thuc c thi tr
S ln t1/2 Lng thuc c thi tr (%)

1 50
2 75
3 88
4 94
5 97
6 98
7 99
Quy tc 5 t1/2: Sau thi gian ny, thuc s bo ho cc m trong c

th. Lc ny, lng thuc vo t chc v lng thuc thi tr bng nhau v
nh vy nng thuc trng thi cn bng (Css).
Quy tc 7 t1/2: L thi gian cn thit thuc c bi xut hon ton
ra khi c th.
Tr s t1/2 l mt trong nhng yu t quyt nh nhp a thuc. Nhng
thuc c t1/2 di s c a t ln trong ngy hn loi c t1/2 ngn.
Khi chc nng c quan bi xut thuc (gan, thn) b suy gim th t1/2 b
ko di c ngha l thuc b tch lu lu hn trong c th v nguy c ng
c ln hn.
Kt lun
Nhng kin thc lin quan n Dc ng hc lm sng c vai tr rt
quan trng trong s dng thuc hp l - an ton. Nm vng c c im
cc ng dng thuc, cc quy lut ca tun hon thuc trong c th s gip
cho cc dc s hiu c y lnh ca thy thuc v hng dn bnh nhn
tun th iu tr tt hn.
24
T lng gi
in t thch hp vo ch trng (t cu 1 n cu 8 )
1. Din tch di ng cong nng thi gian biu th tng trng ...(A)...
vo c vng tun hon ...(B)... sau mt thi gian t.
2. Sinh kh dng tuyt i l t l ...(A)... ca mt thuc a qua ...(B).... so
vi a qua ...(C)...
3. Sinh kh dng tng i l t l so snh ...(A).... ca hai ch phm ...(B)...,
cng hm lng, cng ...(C).... nhng ca hai hng sn xut khc nhau.
4. Cc yu t nh hng n sinh kh dng c th l:
A. Chc nng gan
B. ..
C. ...
5. S suy gim chc nng gan lm gim kh nng chuyn ho thuc ...(A),
do c th lm ...(B)... SKD ca nhng thuc chuyn ho mnh ...(C)...
6. Thi gian bn thi (t1/2) l ...(A)... nng thuc ...(B)... gim i ...(C)...
7. Cc yu t nh hng n thi gian bn thi:
A. La tui
B. .
C. .
D. .
8. S suy gim chc nng thn lm ...(A)... bi xut. thuc, do
c th ...(B)... t1/2 ca nhng thuc thi tr phn ln ...(C)... qua thn.

9. Sinh kh dng ca thuc l:
A. Tng lng thuc cn hot tnh vo c vng tun hon chung.
B. Tng lng thuc cn hot tnh vo c vng tun hon chung v
tc thuc thm nhp c vo vng tun hon.
C. T l % thuc cn hot tnh vo c vng tun hon chung so vi
liu s dng.
D. T l % thuc cn hot tnh vo c vng tun hon chung v tc
, cng thuc thm nhp c vo vng tun hon chung.
E. Tr s AUC tnh c t th din bin nng thuc theo thi
gian.
25
10. Thuc s t trng thi cn bng sau:
A. 5 t1/2
B. 7 t1/2
C. 1 t1/2
11. Sau 7 t1/2 thuc s:
A. t nng cn bng trong mu
B. Thi tr ht ra khi c th
C. t nng iu tr trong mu
D. t nng ti a trong mu.
Nhng cu sau y u ng, tr:

12. Thi gian bn thi:
A. Thi gian bn thi ca thuc l thi gian cn thit nng thuc
trong mu gim i mt na (50%).
B. Thi gian bn thi ca thuc l thi gian cn thit mt na lng
thuc (50%) bi xut ra khi c th.
C. Thi gian bn thi ca thuc l thi gian cn thit nng thuc
trong mu t n trng thi cn bng.
D. Sau 7 ln thi gian bn thi, thuc b loi tr gn nh hon ton ra
khi c th.
E. Sau 5 ln thi gian bn thi, nng thuc trong mu t n trng
thi cn bng.
Phn bit ng/sai (t cu 13 n cu 26)

S
13. Nu hai thuc c SKD bng nhau th c th thay th nhau
trong iu tr.
14. Khong cch a thuc tu thuc t1/2.
15. La tui ca bnh nhn khng nh hng n SKD ca thuc.
16. Chc nng gan c nh hng n sinh kh dng ca thuc.
17. Chc nng thn c nh hng n t1/2 ca thuc.
18. Chc nng gan c nh hng n t1/2 ca thuc.
26
S
19. Sinh kh dng tuyt i cho bit s khc nhau v t l thuc
c hp thu vo vng tun hon chung gia hai bit dc.
20. Sinh kh dng tng i cho bit kh nng thm nhp ca
thuc vo vng tun hon chung.
21. AUC l i lng cho bit sinh kh dng ca thuc.
22. n v ca AUC l m2 hoc cm2.
23. n v ca AUC l mg.h.L-1.
24. Tng tc thuc c th gy thay i sinh kh dng.
25. Khi chc nng gan hoc thn suy gim, thi gian bn thi c
th rt ngn li.
26. Nu nh ngha 2 thng s dc ng hc c bn:
Sinh kh dng (SKD).
Thi gian bn thi (t1/2).
27. Lit k v phn tch 3 yu t nh hng n SKD.
28. Lit k v phn tch 4 yu t nh hng n t1/2.
29. Trnh by quy tc 5 t1/2 v 7 t1/2.
27
Bi 3
Tng tc thuc
Mc tiu
1. Trnh by c c ch tng tc dc lc hc.
2. Trnh by c c ch tng tc thuc giai on hp thu.
3. Nu c cc li ch ca nc khi ung thuc. K tn 4 loi nc cn
trnh khi ung thuc.
4. Nu c 4 yu t quyt nh thi im ung thuc.
M u
Trong iu tr, vic s dng ng thi nhiu thuc trn mt bnh nhn
l c th gp phi do bnh nhn t mua thm thuc ngoi n ca bc s;
cng c th do bc s ch k. Mc ch s dng nhiu thuc cng mt lc
rt khc nhau:
C th do bnh nhn mc mt lc nhiu bnh.
C th l do bc s mun li dng tc dng hip ng ca cc thuc
trong iu tr bnh.
C th do thy thuc mun phi hp thm thuc gim mt tc dng
khng mong mun no do thuc chnh gy ra.
C th do mun s dng thm thuc nhm h tr sc kho (cc vitamin
hoc thuc b khc).
iu ng lu trong trng hp ny l liu c gp phi nhng tc
dng bt li no do phi hp thuc khng?
Tng tc thuc l tc ng qua li gia cc thuc xy ra trong c th
khi dng ng thi dn n nhng thay i v tc dng dc l hoc c tnh.
T l tng tc thuc tng theo cp s nhn so vi s thuc c trong n.
Nh vy, vic nm vng kin thc v tng tc thuc s gip cho vic
iu tr t kt qu tt hn vi an ton cao hn.
28
Chuyn ny nhm mc ch cung cp nhng kin thc v c ch
tng tc thuc v hng x l khi gp tng tc. Cc loi tng tc s trnh
by bao gm tng tc dc lc hc, tng tc dc ng hc ca thuc vi
thuc, tng tc ca thuc vi thc n, tng tc thuc vi ung. Chng
ti khng trnh by tng tc thuc vi kt qu xt nghim sinh ho (kh
nng gy sai lc kt qu xt nghim do dng thuc).
1. tng tc dc lc hc
Tng tc loi ny xy ra khi cc thuc phi hp c v tr tc dng trn
cng mt th th (receptor) hoc khc th th nhng cng ch tc dng.
Hu qu ca tng tc c th l:
Li dng nhm to ra nhng hip ng c li cho iu tr
V d:
dit vi khun gy lot d dy - t trng Helicobacter pylori, vic
phi hp 2 khng sinh (v d: amoxicilin v clarithromycin) vi mt
thuc gim tit acid dch v (v d: omeprazol) s em li t l thnh
cng cao hn nhiu so vi ch dng mt khng sinh hoc ch dng thuc
gim tit n c.
iu tr lao thng phi phi hp 2, 3, 4 hoc thm ch 5 thuc
nhm tng cng hiu qu v gim kh nng khng thuc ca vi
khun lao.
Li dng tc dng i lp nhm gii c thuc
V d:
Naloxon l cht i khng vi morphin do tranh chp th th vi
morphin, c dng gii c morphin.
Atropin c dng gii c physostigmin do tranh chp th th M.
Phi hp to tc dng i khng lm gim tc dng dc l hoc
tng c tnh
V d:
S dng ng thi cloramphenicol vi erythromycin, to ra s cnh
tranh ti th th 50S ca ribosom vi khun, hu qu gim tc dng
khng khun ca khng sinh.
Dng furosemid (Lasix) c th gy gim K+/mu, lm tng c tnh ca
digoxin trn c tim.
V cc tng tc dc lc hc c hc k trong mn Dc l nn
29
chuyn ny ch nhc li mt s nt c bn. Cc kin thc v phn ny xin
xem li trong phn Dc l i cng.
2. tng tc dc ng hc
Dc ng hc ca thuc l qu trnh hp thu (A), phn b (D), chuyn
ho (M), thi tr (E), ngha l s phn ca thuc t khi vo c th cho n
khi b loi tr ra khi c th. Cc kiu phi hp thuc lm thay i qu trnh
ny gi l cc tng tc dc ng hc. Hu qu ca tng tc dc ng hc
thng dn n thay i nng thuc trong mu.
Trong chuyn ny, chng ti xin cp n mt s loi tng tc
giai on hp thu, lin quan n ch nh gi ung thuc hp l.
Tng tc do thay i pH dch v
Dch v c pH t 1 - 2. S thay i pH ti d dy do mt thuc gy ra s
nh hng n s hp thu ca thuc dng ng thi.
Nhng thuc lm thay i pH dch v theo kiu lm tng pH l cc thuc
iu tr lot d dy - t trng nh cc antacid (Maalox, Phosphalugel...) hoc
cc thuc gim tit HCl (omeprazol...). Khi pH d dy tng, mt s thuc
nh ketoconazol s hp thu km hn.
Thuc lm pH dch v gi mc acid lu hn l vitamin C. Khi dch
v gi mc acid lu hn s nh hng n cc thuc km bn trong mi
trng acid (ampicilin, cephalexin, erythromycin...) lm tng phn hu cc
thuc ny v gy gim sinh kh dng.
Tng tc do to phc kh hp thu
iu ny hay xy ra khi ta s dng cc thuc c cha cc ion kim loi
ho tr cao nh Al+++, Ca++, Mg++, Fe++, Fe+++... ; phc cht to ra gia ion kim
loi vi thuc s khng qua c nim mc rut v do s hp thu b cn
tr. Thuc hay b to chelat nht l cc khng sinh nhm tetracyclin,
fluoroquinolon. Tng tc ny cng gp khi dng cc khng sinh nu trn
vi sa.
Cholestyramin (mt cht lm ta mui mt dng ngn cn qu
trnh hp thu cc cht bo, dng trong iu tr chng tng lipid huyt) cng
c th to phc vi mt s thuc v cn tr hp thu; th d vi digoxin.
Tng tc do cn tr b mt hp thu
Cc thuc bao nim mc nh Smecta, Sucralfat... ngn cn s vn
chuyn nhiu thuc qua nim mc ng tiu ho v lm gim nng thuc
phi hp.
30
trnh xy ra tng tc dn n gim nng thuc vi cc trng
hp trn, phi ung cc thuc cch nhau ti thiu 2 gi.
3. Tng tc thuc vi ung

Trong mi trng hp, nc l ung thch hp cho mi loi thuc v
khng xy ra tng k khi ho tan thuc.
u im ca vic dng nc ung thuc
Nc lm thuc d dng tri t thc qun xung d dy, trnh s ng
vin thuc hoc hot cht li thnh thc qun v nh gim tc dng
gy kch ng v gy lot ca mt s thuc nh quinin, erythromycin,
doxycyclin, st, aspirin... iu ny c bit quan trng vi ngi gi v
i tng ny lng dch tit t v thnh thc qun kh nn kh dn
thuc.
Nc lm tng tan ca thuc, gip cho thuc khuch tn n khp
b mt ng tiu ho v do to iu kin cho s hp thu tt hn. Nh
vy, nc c nh hng ln ti nhng thuc c tan thp nh
amoxycilin, theophylin, penicilin V dng acid...
Lng nc nhiu s gip thuc bi xut nhanh qua thn v do
gim c c tnh ca nhiu loi thuc nh cyclophosphamid; hoc
gim tc dng ph do to si ca cc sulfamid. Ni chung, lng nc
cn ung thuc phi t 100 - 200 ml. Khng nn nut chng thuc
khng c nc. Ngoi l c mt s loi thuc ch cn dng mt lng
nc nh chng 30 - 50 ml chiu thuc. Th d:
+ Thuc ty sn niclosamid cn to nng thuc m c quanh
thn sn.
+ Kavet hoc cc thuc dng gi bt cha vim lot d dy theo c ch
gim toan (antacid) cn to mt lng bt snh gi lu trong d
dy tng tc dng trung ho acid.
+ Cc loi thuc dng vin bao tan trong rut hoc vin gii phng
chm ch cn ung khong 50 ml nc, a vin thuc xung
rut. Nu ung qu nhiu nc, thuc c th b chuyn qu
nhanh trong lng rut v ra ngoi trc khi hp thu hon ton ti v
tr nh.
Nhng loi ung nn trnh
Cc loi nc hoa qu, nc khong kim hoc cc loi nc ngt ng
hp c gas v cc loi nc ny c th lm hng thuc hoc gy hp thu
thuc qu nhanh.
Khng dng sa ung thuc v bn cht ca sa l caseinat calci.
31
Ion calci c th to phc vi nhiu loi thuc, th d tetracyclin nu
ung cng vi sa s b cn tr hp thu.
Cc lipid trong sa c th ho tan mt s thuc vo trong v gi
thuc li. Cc hp phn protein trong sa c th lin kt vi mt s thuc c
i lc cao vi protein. Tt c cc qu trnh ny u cn tr hp thu thuc. a
phn cc khng sinh thng dng u b sa lm gim hp thu nh
erythromycin, penicilin V, cc tetracyclin...
C ph, ch: Tanin trong ch c th gy ta nhiu loi thuc c cha
st hoc alcaloid. Cafein trong c ph c th lm tng ho tan ca
mt s thuc nh ergotamin nhng li cn tr hp thu cc loi thuc
lit thn (neuroleptic).
Ru (alcol): Nhiu bnh nhn b bnh tm thn do nghin ru, do
kh nng gp phi trng hp bnh nhn va ung thuc, va ung
ru khng phi l him. Cn lu trnh nhng tng tc sau:
+ Ru v cc thuc tc dng ln thn kinh trung ng:
. Cc benzodiazepin nh diazepam khi ung cng vi ru s gy thay
i tm tnh rt mnh ngay liu thng dng. S thay i ny ch
c th gp liu rt cao nu dng n c khng c ru.
. Tc dng kch thch liu nh, c ch liu cao ca ru lm nh
hng nhiu n tc dng iu tr ca cc nhm thuc chng trm
cm, thuc ng, thuc chng ng kinh.
+ Ru v thuc gim au khng steroid: Ru lm tng tc dng ph
trn ng tiu ho nh vim, lot, chy mu ca cc thuc chng
vim khng steroid (aspirin...).
+ Ru ung cng vi paracetamol: Lm tng nguy c vim gan.
+ Ru v thuc khng histamin:
. Cc loi khng H1 c tc dng c ch thn kinh trung ng, do
khi ung cng vi ru s xut hin tc dng c ch qu mc ngay
liu thp.
. Cc loi khng H2 do tc dng km hm men microsom gan, lm
chm qu trnh chuyn ho ru v tng mc alcol trong mu, gy
nhc u, bun nn...
+ Ru v thuc chng tng huyt p:
. Do tc dng gin mch ngoi vi ca ru, nu ung ng thi vi cc
thuc chng tng huyt p c th c nguy c gy tt huyt p t
ngt qu mc cn thit.
. Alcol cn l dung mi tt cho nhng thuc c h s m/nc cao (nh
thuc chn beta), lm cho thuc hp thu qu nhanh, gy tc dng
32
t ngt do tng nng thuc trong mu trn mc iu tr.
+ Ru v thuc chng i tho ng:

. Tc dng hp ng ln chuyn ho hydratcarbon dn n nguy c h
ng huyt t ngt, gy hn m.
. Mt s sulfamid nh tolbutamid khi ung cng vi ru gy phn
ng antabuse (s ru).
+ Ru v thuc khng khun: Mt s cht khi dng vi ru s gy
phn ng antabuse (s ru) nh cc cephalosporin, isoniazid,
metronidazol...
4. nh hng ca thc n n thuc

Trong chuyn ny, chng ti ch cp n nh hng ca thc n
i vi qu trnh hp thu thuc, lm c s cho vic hng dn gi ung thuc
so vi ba n.
Thc n lm thay i thi gian rng ca d dy. Nu ung thuc lc
i, thuc ch lu li d dy chng 10 - 30 pht ri c tng ngay
xung rut. Tri li, nu ung thuc sau ba n, thi gian lu li d
dy ca thuc c th t 1 - 4 gi. iu ny nh hng ti sinh kh dng
ca nhiu thuc.
V d:
+ Cc thuc c tan km (nh propoxyphen) s c li khi lu li d
dy lu v thi gian ny gip thuc chuyn thnh dng tan tt hn
trc khi chuyn xung rut hp thu.
+ Tri li, cc thuc km bn trong mi trng acid nh ampicilin,
erythromycin, lincomycin... nu b lu li d dy lu s tng kh
nng b ph hu v do gim sinh kh dng.
+ Vi cc thuc c bo ch di dng vin bao tan trong rut, vin
gii phng chm th vic gi li d dy lu l hon ton bt li v
mng bao vin c th b v, gy nh hng n tc dng ca thuc.
Do nn ung cc thuc loi ny trc ba n chng 30 pht n 1
gi hoc 1 - 2 gi sau khi n.
Thc n lm cn tr s di chuyn ca thuc trong lng rut, do nu
ung thuc sau ba n, thuc s b khi thc n cn tr v di chuyn
chm trong ng tiu ho. Li dng: Cc thuc gii phng chm, thuc
cn tc dng ti ch trong lng rut, nu ung vo thi im sau khi n
chng 1 - 2 gi l thch hp.
33
Thc n kch thch s tit mt, c bit l thc n giu cht bo. iu
ny s c li cho vic hp thu cc thuc tan nhiu trong m nh
griseofulvin; vitamin A, D, E, K...
Thc n hot ho h thng men vn chuyn cc cht qua thnh rut,
nh vy m s hp thu cc thuc c bn cht l cc hp phn dinh
dng nh cc vitamin, glucose, acid amin, cc mui khong... s d
dng hn.
nh hng ca cc hp phn thc n n s hp thu thuc: Ba n
giu cht bo, qu nhiu ng, qu mn hoc qu chua u cn tr s
di chuyn ca khi thc n t d dy xung rut. iu ny s nh
hng khng tt n cc thuc km bn trong mi trng acid ca d
dy v lm chm s di chuyn ca thuc n v tr hp thu ti u l
rut non.
nh hng ca thc n n s hp thu thuc cn ph thuc nhiu vo
dng bo ch ca thuc: Cc dng thuc rn, thuc c tan thp b
nh hng bi thc n nhiu hn cc dng thuc lng, thuc dng
dung dch, cn thuc...
V d: Aspirin dng vin nn ung sau khi n s b gim sinh kh dng
50%, trong khi aspirin si bt li khng b thc n cn tr hp thu.
y cn phi phn bit khi nim: Gim hp thu v chm hp thu.
+ Mt thuc b thc n lm gim hp thu tc l tng lng thuc vo
mu nu ung cng vi ba n s gim so vi ung cch xa ba n.
Trng hp ny nn ung cch xa ba n (trc 30 pht - 1 gi hoc
sau khi n 2 gi).
+ Mt thuc b thc n lm chm hp thu c ngha l thi gian
thuc t nng ti a trong mu nu ung sau khi n s di hn
nu ung xa ba n (lc i), nhng tng lng thuc vo mu c th
khng b nh hng. V d: Cc sulfamid khng khun, amoxicilin,
digoxin... Trng hp ny c th ung thuc sau khi n trnh tc
dng ph do kch ng ng tiu ho (nu c).
+ Nhng thuc khng b thc n lm nh hng n hp thu c th
ung lc no tu nhng ung vo ba n vn tt hn v s gim
c tc dng ph do kch ng ng tiu ho. Trng hp ny
thng xy ra vi thuc c tan km; lc ny lng cht lng dng
km c nh hng nhiu n s hp thu thuc: Lng nc cng
nhiu, thuc hp thu cng tt.
34
+ Nhng thuc c thc n lm tng hp thu nn ung trong hoc
ngay sau khi n tng sinh kh dng.
5. Hng dn thi gian ung thuc hp l
5.1. Nhng yu t quyt nh thi im ung thuc

y Mc ch dng thuc
V d:
Thuc ng ung vo bui ti trc khi i ng.
Thuc h st gim au ung khi c st, c au.
y Dc l thi khc tc l nh hng ca nhp thi gian i vi tc
dng sinh hc ca thuc
V d: Cc thuc loi corticoid nn ung vo bui sng khong 6 - 8 gi,
v y l thi im nng hydrocortison trong mu t cao nht trong
ngy. Ung lc ny s khng ph v nhp sinh l hot ng ca tuyn
thng thn v t gy hin tng c ch trc di i - yn - thng thn.
y Tng tc ca thuc - thc n
Nhng thuc b thc n lm gim hp thu s c ung xa ba n
(trc khi n t 30 pht n 1 gi). Nhng thuc khng b nh hng ca
thc n nn ung khi n gim tc dng ph trn ng tiu ho. Cc thuc
c thc n lm tng hp thu cng c th chn thi im ung vo ba n.
Tuy nhin, mt s trng hp tc hp thu nhanh qu c th gy nhiu tc
dng ph hoc c tnh th nn chn ung xa ba n.
y Tng tc gia cc thuc vi nhau
Nhng thuc khi ung cng nhau gy cn tr hp thu ln nhau phi
c ch nh ung cch nhau t nht 2 gi v lu thuc no cn hp thu
phi c a trc.
V d: Khi ung licomycin cng Smecta, phi ung lincomycin trc, 2
gi sau mi c ung Smecta, nu lm ngc li th do kh nng gy cn
tr b mt hp thu ca smecta ko di nn 2 gi sau vn khng th dng
lincomycin c.
5.2. La chn thi im ung thuc

y ung vo ba n
Nhng thuc kch ng mnh ng tiu ho nh doxycyclin, khng sinh
nhm quinolon, mui kali... Nhng thuc ny ung vo lc n v thc n
khng lm gim hp thu thuc. Nu thuc kch ng ng tiu ho
35
mnh nhng li b thc n lm gim hp thu th c th ung vo ba n
vi iu kin chuyn thuc thnh dng lng (nhai v ung nhiu nc)
hoc chn dng bo ch thch hp, th d trng hp aspirin.
Nhng thuc hp thu qu nhanh lc i, dn n vic tng tc dng
ph do s tng nng t ngt trong mu nh levodopa, diazepam...
Nhng thuc c thc n lm tng hp thu nh cc loi vitamin, mui
khong, mt s khng sinh chng nm (ketoconazol).
y Ung cch xa ba n
(Tc l khong 1 gi trc khi n hoc 1-2 gi sau ba n)
Thuc nhm ny gm c:
Cc thuc b gim hp thu do thc n, th d lincomycin.
Cc dng vin bao tan trong rut, th d aspirin pH8.
Cc thuc km bn trong mi trng acid dch v, th d: erythromycin,
ampicilin.
y Thuc c th ung vo thi im tu
Thuc nhm ny l cc thuc khng b gim hp thu do thc n hoc c
th b thc n lm chm hp thu. Vi nhng thuc ny ta c th cho ung
vo ba n nu thuc kch ng mnh ng tiu ho hoc khi mun s dng
thc n gi cho nng thuc trong mu n nh.
5.3. Hng dn thi gian ung thuc (vi mt s thuc thng dng)
Bng 3.1. Hng dn thi gian ung thuc
Thi gian ung Nn ung

Tn quc t Lu khc
ung thuc cn trnh nhiu nc
xa lc n ty
ba
n
Amoxicilin o +
Ampicilin z +
Oxacilin z
Penicilin V- K z +
Pivmecilinam o sa, alcol
36
Amoxicilin + o sa
A.Clavulanic
Cefaclor o
Cefalexin o sa, alcol
Cefadroxil o
Cefradin o alcol
Tt c tetracylin z sa Khong cch

th h 1 2 - 3 gi gia
thuc v thc
n c sa
Doxycylin z sa Khng ung

thuc t th
Mynocyclin z sa nm
Erythromycin o nc qu + Kch ng
ethylsuccinat ng tiu ho
Erythromycin o nc qu + nt
propionat
Josamycin o nt
Spiramycin o nt
Clindamycin o nc soda Khng ung

t th nm
Lincomycin z nc soda Khng ung

t th nm
Cloramphenicol o alcol
Co-trimoxazol o
Acid nalidixic o Khng ung

v m v gy
mt ng
Acid oxolinic o nt
Acid pipemidic o nt
Peflacin o nt
37
Rosoxacin o Ung trc khi
i ng gim
tc dng ph
Ethambutol o Tt c thuc
chng lao
Isoniazid z alcol trnh thc n ung cng mt
c tyramin lc vo bui
sng lc i
Rifampicin z
AmphotericinB z
Griseofulvin z alcol Thc n m

lm d hp thu
Ketoconazol o alcol nhiu nc nt

qu
Metronidazol o alcol
Cloroquin
Chng ng mu vo mt gi c nh alcol Trnh thc n

AVK gau vitamin K
Hydralazin z alcol
Prazosin o alcol
Captopril o alcol
Enalapril o alcol
Ramipril o alcol
Atenolol o alcol
Bisoprolol o alcol Bui sng
Celiprolol o alcol Trc ba

im tm
Labetalol o alcol Sau khi n
Nadolol alcol
Propranolol o alcol Dng LP ung

vo bui sng
38
Sotalol o alcol
Oxprenolol o alcol
Acebutol o alcol
Hydrocloro- o Tc dng tt
thiazid vo bui sng
Furosemid o nt
Amilorid z nt
Carbamazepin z alcol Khng c Lun ung vo

ung nhiu mt gi nht
nc nh
Phenytoin z alcol
Valproat Na z soda so vi ba n
Lithi o alcol Gi ch nt
mui Na hng
nh
L-dopa o alcol
D/c sulfonylure o alcol, nc

ngt
D/c biguanid z alcol, nc

ngt
Corticoid o nc ngt Ung vo bui

sng (phn
ln)
L-thyroxin o
Antacids z alcol Ung 1 gi 30'

sau khi n
hoc lc au
Khng H2 o cafe C th ung

mt liu duy
nht trc khi
ng
Sucralfat z Ung 1 gi
trc ba n
39
Aspirin z alcol Tc dng giao
ng theo thi
im ung
Paracetamol o alcol, nc
qu
Propoxyphen o alcol
Theophylin o o sa Tc dng tt
vo bui sng
Theophylin LP o Nh trn,
nhng thng
ung m
bo v gic
ng
Thuc chng ung o Khng nhai

th hoc ph v
vin
Vitamin + mui z
khong
Ghi ch : z: bt buc tun th o: c th thay i thi im ung
Kt lun
Tng tc thuc c ngh quan trng trong iu tr. Nhng tng tc
c li c s dng rt nhiu nhm lm tng hiu qu hoc lm gim tc
dng ph. gc dc lm sng, nhng thng tin trn gip cho ngi dc
s nm c cc tng tc bt li c th bo m an ton cho ngi s
dng. Mi quan h ca thuc - thc n, thuc vi ung cng l nhng
kin thc c bn hng dn cho ngi bnh cch ung thuc ng v vic
ung thuc tu tin khng ng nguyn tc s dn n nhng hu qu kh
lng, khng ch gy lng ph thuc m cn c th gy ng c.
T lng gi
1. Bn loi nc cn trnh khi ung vi thuc l:
A. ung c cn (ru)
B ..
40
C ..
D .
2. Nc lm thuc d dng tri t thc qun xung ...(A)..., trnh s ng
vin thuc hoc hot cht li ...(B)... v nh gim tc dng ....(C).... ca
mt s thuc.
3. Mt thuc b thc n lm chm hp thu c ngha l thi gian thuc t
nng ti a trong mu nu ung sau khi n s ...(A)... hn nu ung xa
ba n (lc i), nhng tng lng thuc vo mu c th ...(B)...
4. Bn yu t quyt nh thi im ung thuc l:
A. Mc ch dng thuc
B. .
C. .
D. ..
5. Thuc c ung khi n l:
A. Cc thuc kch ng mnh ng tiu ho
B. .
C. .
6. Ba loi thuc cn ung xa ba n l:
A. Cc thuc b gim hp thu do thc n
B. .
C. .
Chn cc cu tr li ng (t cu 7 n cu 13)
7. S dng "Ampicilin v Vitamin C" ng thi theo ng ung:
A. To tng tc dc ng hc
B. To tng tc dc lc hc
C. To tng tc giai on hp thu
D. Gy gim nng vitamin C trong mu
E. Gy gim nng ampicilin trong mu
F. Tng phn hu ampicilin ti d dy
G. Tng phn hu vitamin C ti d dy
H. Ampicilin gy cn tr hp thu vitamin C
41
I. Vitamin C gy cn tr hp thu ampicilin
J. Phi ung cch nhau 2 gi bo m sinh kh dng
8. S dng "Aspirin - Smecta" ng thi theo ng ung:
A. To tng tc dc ng hc
B. To tng tc dc lc hc
C. To tng tc giai on thi tr
D. Gy gim nng aspirin trong mu
E. Gy gim nng Smecta trong mu
F. Tng phn hu aspirin ti d dy
G. Tng phn hu Smecta ti d dy
H. Smecta gy cn tr hp thu aspirin
I. Aspirin gy cn tr hp thu Smecta
J. Phi ung cch nhau 2 gi bo m sinh kh dng
9. Vic phi hp thuc trong iu tr lao:
A. L li dng tng tc hip ng theo c ch dc lc hc
B. Lm tng tc dng iu tr
C. Lm gim tc dng khng mong mun
D. Lm gim kh nng khng thuc ca vi khun
10. Dng atropin gii c physostigmin:
A. L li dng tng tc dc lc hc
B. L tng tc gy tng thi tr thuc
C. Atropin y physostigmin ra khi receptor
D. Physostigmin y atropin ra khi receptor
E. Atropin ngn cn hp thu physostigmin
11. Tng tc thuc l:
A. L tc ng qua li gia hai thuc khi s dng ng thi.
B. C th c li dng gii c
C. L s trn ln thuc vi nhau trc khi a vo c th
D. Lm thay i c tnh hoc tc dng dc l
12. Tng tc dc ng hc:
A. Xy ra cc giai on hp thu-phn b-chuyn ho-thi tr ca thuc.
B. Xy ra trn cng mt receptor
42
C. C th gy tng nng thuc trong mu
D. C th gy gim nng thuc trong mu.
13. Cc tng tc xy ra trn cng mt receptor l:
A. Tng tc dc lc hc
B. Tng tc dc ng hc
C. C 2 phng n trn u ng
14. Nhng thuc cn ung vo ba n l:
A. Nhng thuc c thc n lm tng hp thu
B. Nhng thuc kch ng mnh ng tiu ho (bun nn, lot d dy...)
C. Nhng thuc cn c thc n gim bt tc hp thu.
D. C A, B, C u ng
E. C A, B, C u sai
15. Tng tc dc lc hc:
A. L tng tc xy ra trn cng mt th th (receptor)
B. C th c li dng tng hiu qu iu tr
C. C th dn n gim tc dng ca thuc
D. C A, B, C u ng
E. C A, B, C u sai
16. Thuc ung xa ba n s:
A. Tng thi gian lu ti d dy
B. Gim c kch ng vi ng tiu ho
C. Gim kh nng ph hu thuc ti d dy (vi thuc km bn trong
mi trng acid)
D. C A, B v C u ng
17. Lit k 4 yu t quyt nh vic ch nh thi im ung thuc. Cho th
d minh ho tng trng hp.
18. K tn 3 nhm thuc nn ung xa ba n (lc i). Cho ti thiu 1 th d
minh ho cho mi nhm.
19. Lit k cc li ch ca nc khi ung thuc. K tn 3 loi nc cn trnh
khi ung thuc.
43
Bi 4
Phn ng bt li ca thuc
v cnh gic thuc
Mc tiu
1. Trnh by c nh ngha v 3 cch phn loi ADR.
2. Trnh by c hai nhm yu t lin quan n s pht sinh ADR.
3. Trnh by c 4 bin php hn ch ADR.
4. Trnh by c 3 lnh vc u tin ca cnh gic thuc.
M u
1. Phn ng bt li ca thuc (Adverse Drug reaction - ADR)
Hu ht cc thuc, cho d c k n bi cc thy thuc lm sng gii
cng c th gy ra phn ng bt li (ADR) trn bnh nhn, thm ch l
nhng ADR nghim trng. Thy thuc v bnh nhn c th chp nhn nguy
c ca mt ADR nghim trng nu nh bn thn cn bnh ang c iu
tr rt nng, nhng khng th chp nhn thuc c nguy c ADR cao iu
tr nhng bnh thng thng. Do vy, kh nng gy ADR ca mt thuc (k
c tn sut, mc nghim trng v loi ADR chng gy ra) quyt nh vic
la chn thuc . Nhiu ADR c th trnh c, nu nh thy thuc k n
c hiu bit r v c tnh dc l, c ch ca ADR v cc yu t nh hng,
c bit l nhng yu t to nn tnh nhy cm c trng ca ngi bnh.
Thy thuc lm sng c trch nhim nhn ra ADR, hng dn, cnh bo
bnh nhn v kh nng xy ra ADR v bo co cc ADR cho c quan c
trch nhim.
1.1. nh ngha v phn loi ADR

1.1.1. nh ngha
Theo T chc Y t Th gii (WHO): 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.
44
nh ngha ny khng bao gm nhng phn ng do dng sai thuc,
dng sai liu, dng liu cao c ch nh hoc v tnh. Trong nh ngha ny,
yu t p ng c th l rt quan trng
C nhiu trng hp tai bin pht sinh trong qu trnh iu tr m
nguyn nhn cha c xc nh. Nguyn nhn trong nhng trng hp ny
khng ch do thuc gy ra m c th do cc yu t khc nh s tin trin
nng thm ca bnh hoc do mt bnh khc pht sinh. Nhng trng hp
nh vy gi l bin c bt li ca thuc (adverse drug experience/adverse
drug event).
1.1.2. Phn loi ADR

a. Phn loi theo tn sut gp:
Thng gp ADR > 1/100
t gp 1/1000 < ADR < 1/100
Him gp ADR < 1/1000
b. Phn loi theo mc nng ca bnh do ADR gy ra
Nh: Khng cn iu tr, khng cn gii c v thi gian nm vin
khng ko di.
Trung bnh: Cn c thay i trong iu tr, cn iu tr c hiu hoc
ko di thi gian nm vin t nht 1 ngy.
Nng: C th e do tnh mng, gy bnh tt lu di hoc cn chm sc
tch cc.
T vong: Trc tip hoc gin tip lin quan n t vong ca bnh nhn.
Cc cch phn loi ny gip ngi thy thuc cn nhc trc khi k
n mt thuc c t l ADR cao hoc c th gy cc tn thng trm trng
c bin php theo di, x tr thch hp.
c. Phn loi theo typ
Typ A
Cc ADR typ A c cc c im sau:
Tin lng c.
Thng ph thuc liu dng (do cc ADR typ A thng gp i vi
cc thuc c phm vi iu tr hp).
L tc dng dc l qu mc hoc l mt biu hin ca tc dng dc
l mt v tr khc.
45
Sau y l mt s v d cho cc ADR typ A:
L tc dng iu tr nhng cng vt qu mc cn thit nh: Chy
mu khi dng thuc chng ng mu, h ng huyt khi dng thuc
iu tr i tho ng, ...
L tc dng iu tr nhng v tr hoc c quan khc hoc do tnh cht
khng chn lc trn cc th th, v d: Tc dng trn h tiu ha ca
cc cht c ch cyclooxygenase khng chn lc (cc NSAID).
L tc dng dc l khc ca thuc nhng khng phi l tc dng iu
tr, v d: Cc thuc chng trm cm 3 vng th hin c tc dng khng
th th muscarinic, khng c vai tr trong iu tr chng trm cm
nhng thng gy kh ming, gim th lc... hoc tc dng khng
androgen ca cimetidin.
Typ B
Cc ADR typ B c cc c im sau:
Thng khng tin lng c.
Khng lin quan n cc c tnh dc l bit ca thuc.
Thng c lin quan ti cc yu t di truyn hoc min dch, u bu
hoc cc yu t gy qui thai.
D ng thuc l mt v d in hnh cho ADR typ B v khng tin lng
c v khng ph thuc liu dng. D ng thuc c gii thch hon ton
thng qua c ch min dch d ng, khng lin quan n cc tc dng dc l
ca thuc. Biu hin lm sng ca d ng thuc rt a dng, cc c quan b
tn thng c th l da, gan, thn, ng tiu ha hoc ton thn; mc
nghim trng t nh (pht ban da, nga...) n rt nng, thm ch gy t
vong cho bnh nhn nh sc phn v, hi chng Lyell, Stevens - Johnson...
Tuy khng tin lng c nhng c th hn ch s xut hin ca d
ng thuc nu cc nhn vin y t c bin php theo di cht ch v pht
hin sm.
1.2. Nhng yu t lin quan n s pht sinh ADR
1.2.1. Yu t thuc v bnh nhn

a. 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:
46
Lm dng thuc.
Thay i v dc ng hc, dc lc hc do gim chc nng 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 tr s sinh tng ln, c bit l tr non bi v
mt s enzym lin quan n chuyn ha v thi tr thuc cha y . Cc
thuc hay gy c l: Morphin, cc barbiturat, cc sulfonamid, cc dn xut
ca vitamin K v cloramphenicol.
b. Gii tnh
Ni chung khng c s khc bit ln v nguy c gp ADR gia hai gii.
Tuy nhin, mt s ADR hay gp ph n hn so vi nam gii.
V d:
Ph n c th nhy cm hn vi c tnh ca digoxin, heparin v
captopril.
Thiu mu bt sn do cloramphenicol gp ph n nhiu gp 2 ln so
vi nam gii.
c. a dng v gen v chng tc
Nhiu phn ng trc c m t l cc phn ng c ng ngy nay
c lm sng t l c cc nguyn nhn v gen. V d nhng ngi
thiu ht men G6PD do di truyn khi dng nhng thuc c tnh oxy ha th
c th b thiu mu tan mu.
d. 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 aminoglycosid 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.
e. 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 nh cc trng hp d
ng vi khng sinh penicillin cng c th c d ng cho vi khng sinh
nhm cephalosporin.
47
1.2.2. Yu t thuc v thuc
a. c tnh ca thuc
nh hng ca k thut bo ch: Kch thc tiu phn, lng thuc
trong ch phm, tnh cht v khi lng t dc... c th dn ti thay
i tc gii phng hot cht, gy ADR typ A. S dng mt s t dc
cho cc nhm bnh nhn nhy cm nh cc bnh nhn hen, cc tr s
sinh nh cn v s thay i hn hp t dc lm thay i sinh kh
dng ca thuc nh digoxin v phenytoin cng gy ra mt s ADR.
nh hng ca cht lng sn phm: Trong phn ln cc trng hp,
khi dng mt thuc b phn hy th dn n tht bi iu tr, nhng
mt s sn phm phn hy ca thuc c th gy c hoc thm ch gy
t vong (v d nh s dng diethylen glycol lm dung mi cho cn
thuc sulphanilamid gy ra 105 ca t vong ti M nm 1937, sn
phm phn hy ca tetracyclin gy hi chng Fanconi,...). Cc t dc
hay gy phn ng qu mn l: Polypropylen glycol, carboxymethyl
cellulose v tartrazin.
b. 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.
V th, khi iu tr nhiu thuc trong cng mt thi im th tn sut
gp ADR tng ln theo cp s nhn vi s lng thuc.
c. 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 hoc corticoid ko di...
1.3. Bin php hn ch ADR
1.3.1. 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.
Kim tra v hi bnh nhn v nhng thuc bnh nhn t dng.
1.3.2. Nm vng thng tin v loi thuc ang dng cho bnh nhn
Hiu r tnh cht dc l, tng tc, c ch chuyn ho v ADR ca
thuc. Ch nn k n nhng thuc bit y thng tin.
48
Thng xuyn tham kho, cp nht 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...
1.3.3. Nm vng thng tin v cc i tng bnh nhn c nguy c cao
Tr em, ngi gi, c c a d ng, c bnh l v gan, thn v cc bnh
nhn c bt thng v gen.
1.3.4. 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.
1.4. Bo co ADR
1.4.1. S cn thit phi gim st v bo co ADR
Cc thng tin v tnh an ton trong qu trnh nghin cu v th
nghim lm sng ca mt thuc khng th ghi nhn tt c cc ADR c th
xy ra do cc nguyn nhn sau:
Cc th nghim trn ng vt khng xc nh an ton ca
thuc trn ngi.
Nhng bnh nhn tham gia th nghim l nhng i tng qua la
chn v c s lng hn ch, iu kin th nghim thuc c khc bit so
vi thc t s dng trn lm sng v thi gian th nghim thng l
ngn. Do vy nhng d liu v tnh an ton trn nhng i tng ny
cha phn nh y cc ADR ca thuc.
Ti thi im lu hnh thuc, thng tin v cc ADR, cc tng tc
thuc... thng khng y do s lng ngi s dng thuc cha
ln, kh pht hin c cc ADR c tn sut thp.
Do vy, vic gim st sau khi lu hnh thuc rt quan trng, cho php
pht hin cc ADR khng ph bin nhng i khi rt nghim trng v
thc hin tt cng vic gim st ny, vic bo cc ADR cho cc c quan c
trch nhim l mt trong nhng nhim v ca cc cn b y t.
1.4.2. Vai tr ca cc bo co ADR
Cung cp thng tin gip thu hi cc thuc c c tnh cao: Trc y,
tri qua thi gian di, ngi ta mi xc nh r rng ADR ca cc thuc
nh aspirin, phenacetin, amidopyrin... v phi mt vi nm mi lin
quan gia d tt bm sinh mt chi v thalidomid mi tr nn r rng.
Sau thm ha thalidomid, nhiu quc gia thit lp h thng theo di
thuc sm pht hin v ngn nga ADR v t vong do thuc, do vy
gip thu hi cc thuc gy nguy him trn th trng hoc hn ch
vic s dng chng nh bromfenac, temafloxacin, terfenadin,...
49
Thay i thng tin trn nhn ca sn phm: Rt nhiu thuc phi
thay i hoc b sung thm thng tin ghi nhn ca sn phm sau khi
ghi nhn nhng thng tin mi t cc bo co ADR.
V d:
+ Losartan c a ra th trng M nm 1995. Sau khi thuc c lu
hnh, mt s ADR mi c pht hin v c b sung nh vim
mch, ban xut huyt d ng, sc phn v, phn ng kiu phn v.
+ Levofloxacin c lu hnh ti M nm 1997, n thng 2/2000, thng
tin ghi nhn ca thuc b sung thm ADR mi l gy xon nh.
1.4.3. Vai tr ca cc nhn vin y t trong vic bo co ADR

Cc cn b y t l nhng ngi trc tip chm sc bnh nhn hng
ngy v c iu kin tt nht bo co cc nghi ng v mt ADR xy ra
bnh nhn. Tt c nhng ngi tham gia vo h thng chm sc sc khe
nhn dn nh bc s, nha s, dc s, y s, y t, iu dng vin... u cn
phi bo co cc ADR v vic lm ny tr thnh mt phn trong trch
nhim chuyn mn ca h, ngay c khi ADR b nghi ng cha c mi quan
h r rng vi vic iu tr.
1.4.4. Nhng ADR (hoc nghi ng ADR) cn bo co

i vi cc thuc mi c a ra th trng, phi bo co mi phn
ng ng ng, k c cc phn ng nh (nhiu nc coi mt thuc l mi
khi thi gian a ra th trng cha qu 5 nm).
i vi nhng thuc c bit r hoc nghin cu y : Bo co
tt c cc nghi ng v mt ADR nghim trng hoc cha c ghi nhn
trc (bt thng).
Bo co khi thy mt ADR no xut hin ngy cng nhiu.
Bo co tt c cc ADR nghi ng lin quan n tng tc thuc - thuc,
thuc - thc n, hoc thuc - thc phm b sung (k c cc sn phm
lm t dc liu v thuc b).
Bo co cc ADR trong nhng lnh vc c quan tm c bit: Lm
dng thuc, dng thuc cho ph n c thai v cho con b, v ADR lin
quan n vic ngng thuc.
Bo co cc phn ng xy ra do dng qu liu hay do sai st trong iu tr.
Bo co khi thuc khng c hiu qu hoc do nghi ng c sai st v
sn phm.
Nh vy, cn bo co cng sm cng tt tt c cc nghi ng v ADR
c coi l quan trng trn lm sng.
50
1.4.5. Cch bo co ADR
Mu bo co do trung tm ADR quc gia (hoc trung tm cnh gic
thuc) pht hnh (xem ph lc). Mi quc gia c mt mu bo co ADR
ring, nhng bao gi cng c 4 phn nh sau:
a. Thng tin v bnh nhn
Thng tin xc nh bnh nhn (h v tn, a ch...).
Tui bnh nhn ti thi im c ADE (Bin c bt li) hoc ngy sinh.
Gii tnh.
Trng lng c th.
b. Thng tin v ADR (hoc ADE) hoc cc vn v dc phm
M t s c hoc vn v sn phm.
Thi gian xy ra s c.
Thi gian lm bo co.
Cc kt qu xt nghim cn lm sng c lin quan n s c (nu c).
Thng tin khc ca bnh nhn (lch s dng thuc, tin s bnh...) c
lin quan.
Hu qu ca ADE trn bnh nhn.
c. Thng tin v dc phm b nghi ng
Tn thuc (tn quc t v bit dc).
Liu dng, s ln dng v ng dng.
Ngy bt u iu tr.
L do dng thuc.
Kt qu sau khi ngng dng thuc hoc sau khi gim liu.
S l.
Hn dng.
S c xut hin sau khi ti s dng thuc .
Cc thuc khc dng km v thi gian iu tr cc thuc ny.
d. Thng tin v ngi bo co
H v tn, a ch v s in thoi.
Chuyn mn v ngh nghip.
Cc bo co sau khi hon thnh, cn gi n trung tm ADR quc gia
hoc n nh sn xut ca dc phm b nghi ng.
51
2. Cnh gic thuc (pharmacovigilance)
2.1. Khi nim v cnh gic thuc
2.1.1. nh ngha
Cnh gic thuc l mt khoa hc v nhng hot ng lin quan n
vic pht hin, nh gi, x l v ngn nga phn ng bt li hoc bt k s
c no lin quan n thuc.
Gn y nh ngha ny c m rng khng ch i vi thuc m c
i vi cc sn phm sinh hc, dc liu, thuc y hc c truyn, thuc b, sn
phm mu, dng c y t v vaccin.
Nh vy thc cht cnh gic thuc l mt mn khoa hc nghin cu
gim st tnh an ton ca thuc, v vy phm vi ca cnh gic thuc khng
ch dng li ADR m cn bao gm c cc vn :
Thuc km cht lng.
Ng c thuc.
T vong lin quan n thuc.
Lm dng hoc dng sai thuc.
Tng tc bt li ca thuc.
2.1.2. Mc tiu ca hot ng cnh gic thuc

Pht hin sm nhng phn ng bt li hoc tng tc thuc cha bit.
Pht hin s thay i tn sut ca cc phn ng bt li bit.
Xc nh cc yu t nguy c v c ch ca cc phn ng bt li.
nh gi ch s li ch/nguy c v ph bin nhng thng tin cn thit
ci thin vic k n v qun l thuc.
2.2. Mt s lnh vc u tin ca cnh gic thuc

thc hin cc mc tiu hot ng ca chng trnh cnh gic thuc,
cc hot ng sau c ch trng tng cng:
2.2.1. Pht hin cc ADR

Pht trin v b sung h thng gim st ADR cc c s iu tr cng
nh trong cng ng nhm pht hin v chn on chnh xc cc ADR
trn lm sng.
Thc hin cc nghin cu v vn an ton thuc nh: Nghin cu ca
i chng, nghin cu dch t hc, ...
52
Xc nh an ton ca cc sn phm chuyn khoa nh vaccin, sn
phm sinh hc, thuc th y, dc liu, cc sn phm ca cng ngh
sinh hc v cc thuc dng thm d, chn on. Vic xc nh tnh
an ton ca cc sn phm ny kh kh khn v i hi s hp tc ca
nhiu chuyn gia trong cc lnh vc khc nhau.
Ci thin h thng pht hin du hiu bng cch cho php tip cn
thun tin hn cc d liu v ADR c sn. (Du hiu l thng tin c
bo co v mt bin c bt li lin quan n mt thuc. Bin c ny,
trc cha c bit hoc cha c cp y . Thng thng,
phi cn nhiu bo co pht hin ra mt du hiu, ph thuc vo
mc nghim trng ca s c v cht lng ca thng tin).
2.2.2. nh gi ADR
Vic nh gi cc ADR thng c thc hin ti cc trung tm ADR
quc gia hoc quc t. thc hin cng vic ny, cn tng cng hn na
h thng pht hin cc du hiu trong cc chng trnh gim st t
nguyn v cn s hp tc cht ch gia cc quc gia, khu vc trn th gii
chia s thng tin v cc du hiu thu thp c v c cc hp tc hnh
ng khi xy ra cc s c v an ton thuc.
2.2.3. D phng ADR

d phng tt cc ADR trn lm sng cn ch trng thc hin cc
cng vic sau:
Cung cp cc thuc hiu qu v an ton trong iu tr cc bnh thng
gp cc nc ang pht trin, c bit l trong cc chng trnh y t
ln (v d: Chng trnh chng lao quc gia, chng trnh chng st rt,
tim chng m rng,...).
Tng cng nhn thc v an ton thuc v s dng thuc hp l i vi
cc chuyn gia y t v cng ng, k c cc thuc y hc c truyn v
dc liu. Cung cp thng tin thuc chnh xc cho cc nhn vin y t.
Kt hp cc hot ng cnh gic thuc vi chnh sch thuc quc gia v
cc chng trnh y t khc (v d: Cc hng dn iu tr chun, danh
mc thuc thit yu...).
a cc nguyn tc cnh gic dc vo thc hnh lm sng v o to
y - dc khoa.
53
2.3. Vai tr v nhim v ca cc t chc v c nhn thc hin
cng tc cnh gic thuc
2.3.1. C quan m bo cht lng v an ton thuc ca WHO

y l mt b phn ca T chc Y t Th gii (WHO) ph trch v
thuc thit yu v chnh sch y t. C quan ny c nhim v cung cp cc
hng dn v h tr cho cc quc gia v vn an ton thuc.
2.3.2. Trung tm theo di Uppsala (Thy in)

Chc nng chnh ca trung tm l qun l c s d liu quc t v cc
bo co ADR nhn c t cc trung tm ADR quc gia. Gn y, trung tm
ny m rng vai tr nh l mt trung tm o to tuyn truyn v an
ton thuc thng qua cc bn tin th (Newsletters), hi ngh hng nm ca
cc trung tm ADR quc gia, cc nhm tho lun, trang web,...
2.3.3. Trung tm cnh gic thuc (trung tm ADR) quc gia

Thu thp v phn tch cc bo co v ADR.
Pht hin cc du hiu t cc thng tin thu c.
Cnh bo thy thuc k n, cc nh sn xut dc phm v cng ng
bit v cc phn ng c hi mi.
2.3.4. C quan qun l

Quan tm n cht lng, hiu qu v an ton ca thuc (cc thuc
mi trong giai on th nghim lm sng v c cc thuc trong giai on
sau cp php lu hnh) thng qua vic gim st tch cc v theo di cc
ADR tim n v lu di ca thuc, qua a ra cc bin php qun l nh
thu hi, hn ch s dng hoc b sung thng tin ghi nhn ca sn phm...
Nhim v ca cc c quan qun l l gim st cc th nghim lm sng
thng qua hot ng ca hi ng o c, gim st thc hin tiu chun
th nghim lm sng tt (GCP), gim st cc hot ng qung co thuc,
tng cng tuyn truyn v an ton thuc cho cc nhn vin y t v cho
ngi bnh...
2.3.5. Bnh vin, vin nghin cu, c s o to

Thit lp h thng gim st phn ng bt li v cc sai st trong tr
liu ti cc khoa, phng khm, phng cp cu v iu tr.
Tin hnh cc nghin cu xc nh nhng ADR ca thuc sau khi
lu hnh.
Ging dy, o to v xy dng chnh sch v an ton thuc.
54
2.3.6. Cn b y t
X tr v tch cc bo co nhng tai bin lin quan n vic s dng
thuc cho cc t chc, c quan c thm quyn.
2.3.7. Nh sn xut dc phm

Cc nh sn xut dc phm c trch nhim cao nht i vi an
ton ca thuc t khi bt u nghin cu trin khai n khi kt thc i
sng ca sn phm v c trch nhim thit lp h thng theo di cht lng
thuc v tng cng trao i thng tin vi cc c quan qun l.
Kt lun
Thuc l con dao hai li. Bn cnh nhng li ch to ln trong phng
nga v iu tr bnh, bn thn thuc cng c th gy ra nhng phn ng
bt li, nhng bnh l nghim trng, thm ch gy t vong cho ngi dng
thuc. Khi p dng cc bin php hn ch ADR, cc cn b y t hn ch
c tn sut xut hin cng nh mc nghim trng ca cc phn ng
bt li ny trn tng ngi bnh c th. ng thi khi pht hin v bo co
y cc s c bt li ca thuc cho cc c quan c trch nhim, cc cn b
y t tham gia vo h thng cnh gic thuc nhm hn ch cc ADR tm
quc gia v quc t. Bn cnh , chnh nhng thng tin thu thp c t
cc bo co ny li gip cc cn b y t s dng thuc an ton hp l hn cho
bnh nhn. Chnh v vy, bt k cn b y t no cng cn thc v trch
nhim ca mnh trong h thng hot ng cnh gic thuc nhm hng ti
mc tiu s dng thuc an ton hp l.
T lng gi

1. Theo nh ngha ca WHO: Phn ng bt li ca thuc l mt phn ng
...(A).... khng c....(B)...v xut hin liu...(C).... cho ngi phng
bnh, chn on hoc cha bnh hoc lm thay i mt chc nng
sinh l.
2. Trong nh ngha ADR ca WHO, yu t ....(A) .... l rt quan trng.
3. ADR nh: Khng cn ....(A)..., khng cn ...(B)... v thi gian nm vin
khng ko di.
4. ADR trung bnh: Cn c ...(A).... trong iu tr, cn ...(B)... hoc ko di
thi gian nm vin t nht 1 ngy.
5. ADR nng: C th ...(A)..., gy ...(B)... hoc cn chm sc tch cc.
55
6. ADR gy t vong: ...(A)... hoc ...(B)... lin quan n t vong ca bnh nhn.
7. Phn loi ADR theo tn sut gp:
Thng gp ADR > ...(A)
t gp ....(B).... < ADR < ...(C)...
Him gp ADR < ...(D)...
8. Cc ADR typ A c cc c im sau:
....(A).....
Thng ph thuc ...(B).... (do cc ADR typ A thng gp i vi cc
thuc c phm vi iu tr hp).
L ....(C).... qu mc hoc l mt biu hin ca ...(D)... mt v tr khc.
9. Cc ADR typ B c cc c im sau:
Thng khng ....(A).....
Khng lin quan n cc .....(B).... bit ca thuc.
Thng c lin quan ti cc yu t di truyn hoc min dch, u bu
hoc cc yu t gy qui thai.
10. nh ngha cnh gic thuc: Cnh gic thuc l mt khoa hc v nhng
hot ng lin quan n vic ....(A)..., .....(B)..., ...(C)... v ngn nga
phn ng bt li hoc bt k s c no lin quan n thuc.
11. Phm vi ca cnh gic thuc khng ch l ADR m cn bao gm c cc
vn :
Thuc km cht lng
...(A)...
T vong lin quan n thuc
...(B)... hoc dng sai thuc
Tng tc bt li ca thuc.
12. Mc tiu ca hot ng cnh gic thuc:
Pht hin sm nhng ...(A)... hoc tng tc thuc cha bit
Pht hin s ...(B)... ca cc phn ng bt li bit
Xc nh cc ... (C)... v c ch ca cc phn ng bt li
nh gi ch s li ch/nguy c v ph bin nhng thng tin cn thit
ci thin vic k n v qun l thuc.
56
13. Cc ADR l phn ng:
A. Do thuc gy ra
B. Do s tin trin nng thm ca bnh trong qu trnh iu tr
C. Do xut hin bnh mi mc ng thi trong qu trnh iu tr
D. C 3 trn
14. Cc ADR xy ra khi dng thuc vi liu:
A. Liu iu tr bnh thng
B. Liu cao (ng c)
C. Liu thp
D. C 3 trn
15. Nguy c gp ADR tng ln trong cc trng hp:
A. Ngi bnh l ngi cao tui D. Ngi bnh l nam gii
B. Ngi bnh l tr s sinh E. C A, B, C
C. Ngi bnh l ph n F. C A, B, D
16. Cc yu t sau lm tng nguy c gp ADR:

A. K thut bo ch D. iu tr ko di
B. Cht lng sn phm E. C 4 trn
C. iu tr nhiu thuc
17. Cc bin php hn ch ADR:
A. Hn ch s thuc dng
B. Nm vng thng tin v loi thuc ang dng cho bnh nhn
C. Nm vng thng tin v cc i tng bnh nhn c nguy c cao.
D. Theo di st bnh nhn, pht hin sm cc biu hin ca phn ng
bt li do thuc v nhng x tr kp thi.
E. C 4 trn
S
18. Cc bnh nhn gim chc nng gan, thn c nguy c cao b ADR ca
nhng thuc thi tr cn nguyn hot tnh qua cc c quan ny
57
S
19. Bin c bt li ca thuc (adverse drug experience/adverse drug
event - ADE ) l tai bin pht sinh trong qu trnh iu tr
20. Nguyn nhn gy ra cc ADE khng ch do thuc gy ra
21. H ng huyt khi dng thuc iu tr i tho ng l ADR
typ B
22. Lot ng tiu ha khi dng NSAID l ADR typ A
23. To bn khi gim au bng morphin l ADR typ B
24. D ng thuc l ADR typ A
25. Tr s sinh l i tng c nguy c gp ADR cao v mt s enzym
lin quan n chuyn ha v thi tr thuc cha y
26. Ngi cao tui t gp ADR hn thanh nin
27. 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
28. S khc bit v gen v chng tc khng lm khc bit v tn sut
gp ADR.
29. Thay i k thut bo ch dn ti thay i tc gii phng hot
cht c th gy ADR typ A
30. Sn phm phn hy ca thuc c th gy ra ADR typ B
31. iu tr ko di khng lm tng tn sut ca ADR
32. iu tr nhiu thuc khng lm tng tn sut ADR
58
Bi 5
Thng tin thuc
Mc tiu
1. Trnh by c cc cch phn loi thng tin thuc.
2. Lit k c 5 yu cu ca mt thng tin thuc.
3. Trnh by c nhng ni dung v k nng cn thit khi thng tin thuc
cho bnh nhn.
M u
Trn th gii, thut ng Thng tin thuc c cp nhiu vo
nhng nm u ca thp k 60 v gn vi thut ng ny l cc khi nim
Trung tm thng tin thuc v Chuyn gia thng tin thuc. Trc thi
gian ny, cc cu hi v cc thng tin lin quan n thuc hu ht do cc
dc s tr li bng cch tham kho mt s ti liu nh Dc th hay Dc
in. Tuy nhin, cng vi s pht trin ca khoa hc k thut, m hnh ny
bt buc phi thay i. u tin l s bng n s lng cc thuc iu tr:
Cc thuc mi ngy cng a dng v c ch tc dng, yu cu v k thut
bo ch ngy cng cao, ngy cng nhiu vn v c tnh ca thuc i hi
phi cn nhc trong khi s dng, v cng vi iu , t l bnh do thuc
gy ra cng ngy cng tng. Trong cng thi gian ny, cc ti liu lin quan
n thuc cng c tng ln nhanh chng.
S pht trin ca cc trung tm thng tin thuc v cc chuyn gia
thng tin thuc l im khi u ca khi nim Dc lm sng. N t nn
tng cc dc s chia s trch nhim vi cc bc s trong vic s dng
thuc cho bnh nhn. Bng vic s dng hiu qu cc thng tin thuc, ngi
dc s s c nhng kin thc su rng v thuc v c th m nhim c
vai tr t vn trong iu tr.
Nhng kin thc trong chng ny nhm gip cc hc vin c kh nng
nm bt, khai thc v s dng cc thng tin lin quan n s dng thuc
thc hin c vai tr t vn ca dc s lm sng.
59
1. Phn loi thng tin thuc
C nhiu cch phn loi thng tin khc nhau, sau y l mt s cch
phn loi hay c p dng.
1.1. Phn loi thng tin theo i tng c thng tin

Thng tin cho cn b y t:
+ Cho c nhn:
. Thy thuc k n.
. Y t iu dng.
. Dc s bnh vin, ca hng.
. Ngi bn thuc.
+ Cho t chc:
. Hi ng thuc v iu tr.
. Bo him y t.
...
Thng tin cho ngi s dng:
+ Bnh nhn, ngi dng thuc.
+ Nhn dn, ngi tiu dng thuc
1.2. Phn loi thng tin theo ni dung ca thng tin

Thng tin v c tnh dc l ca thuc (c tnh dc ng hc v dc
lc hc).
Thng tin v iu tr (nguyn tc la chn, cch dng, liu dng...).
Thng tin v phn ng bt li ca thuc (ADR).
Thng tin v nh sn xut, gi c v hot ng kinh doanh thuc.
...
1.3. Phn loi thng tin theo ngun thng tin

Ngun thng tin thng c chia thnh ba loi: Ngun thng tin loi I
(primary resources), ngun thng tin loi II (secondary resources) v ngun
thng tin loi III (tertiary resources). Vic phn loi ny da vo ngun gc,
thnh phn v chc nng ca thng tin.
60
Ngun thng tin loi I
L cc bi bo, cng trnh gc ng ti y trn cc tp ch hoc a
ln mng Internet, cc bo co chuyn mn, kho lun tt nghip ca sinh
vin, s tay phng th nghim... Cc thng tin ny thng do tc gi cng b
cc kt qu nghin cu ca mnh m khng c s can thip, nh gi ca
bn th hai. Khi s dng ngun thng tin loi I, ngi s dng thng tin c
th xc nh c phng php nghin cu, kt qu nghin cu v cc kt
lun c th m tc gi t c. Hin nay, ngun thng tin ny ang pht
trin rt mnh m, trn th gii c trn 20.000 tp ch y sinh hc c tn tui
c xut bn hng nm cha k cc thng tin c cng b di dng bo
co khoa hc hay a ln mng.
Ngun thng tin loi II
Bao gm h thng mc lc cc thng tin hoc cc bi tm tt ca cc
thng tin thuc ngun thng tin th nht, c sp xp theo cc ch nht
nh. Khi mun tm hiu mt vn c th, ngi s dng c th tham kho
ngun thng tin loi II c c mt danh mc cc thng tin c lin quan
hoc c th c tm tt cc thng tin cng ch vi vn mnh quan tm.
Nh vy ngun thng tin th hai gip ngi s dng tip cn vn mt
cch ton din hn, nhng khi mun hiu y mt thng tin c th no
, ngi s dng s phi quay li ngun thng tin ban u (loi I). Hin
nay, c cc ngun thng tin loi II c lu tr trong CD-ROM hoc a
ln mng internet, gip ngi s dng tm tin d dng v nhanh chng hn.
Ngun thng tin loi III
L cc thng tin c xy dng bng cch tng hp cc thng tin t hai
ngun thng tin trn. Tc gi ca ngun thng tin loi III thng l cc
chuyn gia v thuc trong mt lnh vc no , v t cc kin thc chuyn
su trong lnh vc h s phn tch tng hp cc thng tin lin quan
a ra thng tin mang tnh khi qut v mt vn . Cc thng tin thuc
ngun thng tin th ba thng c cng b di dng sch gio khoa, cc
bn hng dn iu tr chun... Ngi s dng phn ln khai thc ngun
thng tin ny v cc thng tin thng ngn gn, sc tch v khi qut ho
cao (do c x l bi cc chuyn gia). Tuy nhin, nhc im ca ngun
thng tin loi III l tnh cp nht km, tin cy ph thuc vo nng lc
ca tc gi (v c th c sai st do thnh kin ca ring tc gi, sai st trong
qu trnh chuyn ti thng tin hoc do tc gi khng tp hp c y
cc thng tin ban u c lin quan hay nh gi sai lch cc thng tin ny...)
v cng nh khi s dng ngun thng tin loi II, khi cn tm hiu chnh xc
mt thng tin c th no , ngi s dng c th phi quay li ngun thng
tin ban u.
61
2. Yu cu v ni dung ca thng tin thuc
2.1. Yu cu
Mt thng tin phi c y nhng yu cu sau:
Khch quan
Chnh xc
Trung thc
Mang tnh khoa hc
R rng v dt khot
2.2. Ni dung
Tu theo i tng c thng tin la chn ni dung thng tin thuc
cho ph hp.
2.2.1. Thng tin thuc cho cn b y t

Cn cung cp mi thng tin c lin quan gip cho vic k n iu tr
hp l an ton, bao gm:
Cc thng tin chung v thuc: Cc cch phn loi thuc (danh mc
thuc thit yu, thuc khng cn n (OTC), thuc phi c n, m
phn loi gii phu - iu tr - ho hc (ATC), danh mc cc tn thuc
gc, tn thng mi, thuc c php lu hnh, s ng k,...
C ch tc dng ca thuc.
c tnh dc ng hc: Hp thu, phn b, chuyn ho, thi tr ca thuc.
Cc ch nh, chng ch nh.
Cch dng, liu lng.
Cc phn ng bt li (ADR) c th xy ra.
c tnh, biu hin ng c, x tr.
Tng tc v tng k ca thuc (Thuc vi thuc, thuc vi thc n,
vi nc ung).
Thang bc gi c...
Trn y mi ch l nhng thng tin tng i tnh v thuc, hin nay
m bo yu cu s dng thuc hp l, cc nhn vin y t cn c nhu cu
c cung cp cc thng tin mang tnh ng - l nhng thng tin bin
i theo thi gian nh thng tin nh gi hiu qu v an ton ca cc
thuc mi (da vo cc kt qu nghin cu v thuc c tin hnh bi rt
62
nhiu cc nhm nghin cu ti khp ni trn th gii), thng tin so snh
gia cc thuc/nhm thuc khc nhau trong iu tr v mi phng din
hiu qu, an ton, tnh kinh t..., thng tin cp nht v cc phc iu
tr/cc hng dn iu tr chun...
2.2.2. Thng tin thuc cho bnh nhn

Bnh nhn l khu cui cng thc hin cc s dng thuc t
hiu qu cao v an ton. Nu bnh nhn khng thc hin ng y lnh th
mi c gng ca y bc s, dc s, y t... u khng c hiu qu v tr thnh
v ch. Mun thc hin ng v tham gia ng gp tch cc vo qu trnh
iu tr, bnh nhn phi c hiu r li ch, tc hi ca thuc trnh cc
biu hin sai lch, khng chnh xc hay c hi. t c nhng mc tiu
ny, thng tin thuc cho bnh nhn phi c c nhng ni dung sau:
Tn thuc (tn gc, tn bit dc).
Tc dng.
Dng dng, liu dng, cch dng.
Hng dn s dng cc dng bo ch c bit.
Hng dn quan st, theo di cc triu chng khc l trong dng thuc
(nh k theo di tip cho nhng ln dng thuc sau).
Nhng triu chng ca tc dng khng mong mun, cch x tr.
K nng t theo di tc dng thuc trong qu trnh iu tr.
Tng tc thuc (thuc - thuc, thuc - thc n, thuc - nc ung).
Cch bo qun lng thuc mua, c cp.
3. K nng thng tin thuc cho bnh nhn

Thng tin thuc cho bnh nhn l mt nhim v quan trng ca ngi
dc s. hon thnh tt cng vic ny, bn cnh vic phi c kin thc
chuyn mn tt m bo cung cp y cc ni dung thng tin nh
cp trn, yu cu cn phi c k nng thng tin thuc thch hp. C th,
khi thng tin thuc cho bnh nhn, ngi dc s cn lu cc vn sau:
Phi nm vng tinh thn:
+ V sc kho bnh nhn.
+ Khng lm phin bnh nhn.
Thi tc phong, cch tip xc v ng x (khoa hc hnh vi):
+ Ngn t n gin, r rng, dn d, d hiu; trnh dng thut ng
khoa hc kh hiu, thut ng a phng.
63
+ Li ni nh nhng, n cn quan tm.
+ n mc gn gng, nghim tc, trnh dim da (gy kh gn).
+ To c khng gian tip xc thch hp khng to cm gic xa
cch, tt nht nn c a im ni chuyn ring bit.
+ Quan tm n hon cnh gia nh bnh nhn, nhng trnh i su
vo nhng iu thm kn nu bnh nhn khng t nguyn ni ra.
Kt lun
Thng tin thuc rt a dng phong ph. nng cao chuyn mn, dc
s phi lun lun phi khai thc, cp nht thng tin v thuc v tu theo
yu cu c th chn ngun thng tin thch hp. Ngi dc s phi ng
vai tr l ngi cung cp thng tin thuc, thu thp thng tin thuc t bnh
nhn; do , c l thuyt v k nng thng tin cn c hnh thnh ngay t
khi cn ang ngi trn gh nh trng v cn lin tc c i mi v pht
trin trong sut qu trnh hot ng chuyn mn sau ny.
T lng gi
1. C 3 cch phn loi thng tin thuc hay c p dng:
Phn loi thng tin theo...(A)...
Phn loi thng tin theo ni dung ca thng tin
Phn loi thng tin theo...(B)...
2. Mt thng tin thuc cn phi c y 5 yu cu sau:
Khch quan
...(A)...
Trung thc
....(B)....
...(C)....
3. Khi lm nhim v thng tin thuc, phi cn nhc xem i tng c
thng tin l ...(A)....hay ....(B).... la chn ni dung thng tin cho ph
hp.
4. Ni dung thng tin thuc cho bnh nhn bao gm:
Tn thuc (tn gc, tn bit dc)
64
.... (A)....
.... (B)....
Hng dn s dng cc dng bo ch c bit .
Hng dn quan st, theo di cc triu chng khc l trong dng thuc
(nh k theo di tip cho nhng ln dng thuc sau).
....(C)...
K nng t theo di tc dng thuc trong qu trnh iu tr.
...(D)....
...(E)....
5. Khi thng tin thuc cho bnh nhn cn chn ngn t ...(A)...; trnh dng
thut ng ...(B)..., thut ng a phng.

6. Ngun thng tin loi I:
A. Bao gm cc thng tin y do tc gi trc tip cng b kt qu
nghin cu ca mnh
B. Bao gm cc thng tin di dng bi tm tt
C. L ngun thng tin hn hp
D. C A, B u ng
7. Ngun thng tin loi III:
A. Cung cp cc thng tin mang tnh khi qut
B. Cung cp cc thng tin mang tnh chi tit v mt nghin cu c th
(nh phng php nghin cu, kt qu nghin cu, kt lun c
th...)
C. L ngun thng tin c tnh cp nht km
D. C A, C u ng
8. Thng tin thuc cn cho cc i tng
A. Thy thuc k n
B. Y t iu dng
C. Bnh nhn
D. Tt c cc i tng trn
65
9. Trong cc thng tin v mt thuc sau, thng tin no khng cn cung cp
cho bnh nhn:
A. Tn thuc
B. M phn loi gii phu - iu tr - ho hc (ATC) ca thuc
C. Tc dng ca thuc
D. Nhng triu chng ca tc dng khng mong mun, cch x tr
10. Khi thng tin thuc cho bnh nhn, cn lu :
A. Dng cc thut ng chuyn mn nng cao gi tr ca thng tin
B. Dng ngn t n gin, r rng, d hiu
C. To cm gic gn gi vi bnh nhn
D. C B, C u ng
11. Cho mt ngun thng tin: Bi bo Kho st sinh kh dng v tng
ng sinh hc ca ba ch phm amoxicilin ca tc gi Bi Tng Hip
ng trong tp ch dc hc s 12 nm 2004. Theo anh (ch), y l
ngun thng tin:
A. Loi I
B. Loi II
C. Loi III
D. Khng phn loi c
12. Cho mt ngun thng tin: Chng Tng tc thuc trong sch Dc
lm sng i cng ca B mn Dc lm sng Trng H Dc HN,
Nh xut bn Y hc, 2004. Theo anh (ch), y l ngun thng tin:
A. Loi I
B. Loi II
C. Loi III
D. Khng phn loi c
S
13. Ngun thng tin loi I thng bao gm cc thng tin do tc gi
cng b kt qu nghin cu ca mnh m khng c s can thip,
nh gi ca bn th hai.
66
S
14. Khi s dng ngun thng tin loi II, ngi s dng thng tin c
th xc nh c phng php nghin cu, kt qu nghin cu
v cc kt lun c th m tc gi t c.
15. Hin nay, ngun thng tin loi I ang pht trin rt yu, trn
th gii ch c khong 200 tp ch y sinh hc c tn tui c
xut bn hng nm.
16. Nhc im ca ngun thng tin loi III l tnh cp nht km,
tin cy ph thuc vo nng lc ca tc gi.
17. Hin nay, c cc ngun thng tin loi II c lu tr trong
CD-ROM hoc a ln mng Internet, gip ngi s dng tm
tin d dng v nhanh chng hn
18. Ni dung thng tin thuc cho cn b y t ging nh thng tin
thuc cho bnh nhn
19. Yu cu ni dung thng tin thuc cho bnh nhn phi c c
tnh dc ng hc ca thuc: Hp thu, phn b, chuyn ho,
thi tr.
20. Yu cu ni dung thng tin thuc cho bnh nhn phi nu tng
tc thuc (thuc - thuc, thuc - thc n , thuc - nc ung)
21. Khi thng tin thuc cho bnh nhn cn chn ngn t n gin,
r rng, dn d, d hiu
22. Khi thng tin thuc cho bnh nhn khng nn tip xc thn
mt, cn to c mt khong cch vi bnh nhn
67
Bi 6
Xt nghim lm sng v nhn nh kt qu
Mc tiu
1. Trnh by c c im v ngha ca cc xt nghim sinh ho mu:
Creatinin, ur, acid uric, glucose, bilirubin, cc enzym (ASAT; ALAT; CK).
2. Trnh by c c im v ngha ca cc xt nghim huyt hc: Hng
cu, bch cu, tiu cu.
M u
Xt nghim lm sng bao gm cc lnh vc sinh ho, huyt hc, min
dch, vi trng, k sinh trng, virus l nhng cng c ngy cng phong ph
hin i khng th thiu c gip ch cho ngi thy thuc trong chn
on, iu tr v theo di tin trin ca bnh. Bn cnh , kt qu mt s
xt nghim lm sng cn c s dng gip cho vic s dng thuc hp
l, an ton, pht hin kp thi nhng tc dng khng mong mun trong qu
trnh iu tr.
V xt nghim lm sng l mt lnh vc rt rng, trong chng ny ch
cp n mt s xt nghim sinh ho v huyt hc thng c s dng
trong lm sng.
1. h thng si trong y hc
Mu, nc tiu v mt s dch sinh hc thng c s dng phn
tch. Cc kt qu thu c ngi kho mnh nm trong mt gii hn nht
nh gi l "tr s bnh thng" hoc "tr s quy chiu". Nhng kt qu ra
ngoi gii hn trn gi l "bt thng". Mi xt nghim c th phn tch
bng nhiu phng php khc nhau, do c th cho kt qu hi khc nhau.
V vy khi bin lun nn s dng tr s quy chiu lm ti c s mnh.
thng nht cch biu th kt qu, trong vi thp k qua ngi ta
chuyn dn sang dng h thng n v quc t SI (systme international).
H thng SI da trn 7 n v c s: mt ( di), kilogam (trng lng), giy
(thi gian), mol (lng cht), Kelvin (nhit ), ampe (cng dng in) v
candela (cng nh sng). T 7 n v c s ny, m rng ra cc n v
dn xut khc nh: m2 - din tch, m3 - th tch, Newton (N)- lc, Pascal (Pa) -
68
p sut, Joule (J) - cng hoc nng lng, Hertz (Hz) - tn s. Khi nhng n
v c s v n v dn xut c ln khng thch hp trong cc hng s sinh
hc, ngi ta dng nhng bi s v c s thp phn ca cc n v bng
cch ghp nhng tip u ng tng ng vo tn cc n v .
Bng 6.1. Nhng tip u ng thng dng trong xt nghim lm sng
Tip u ng K hiu H s
kilo k 103
mega M 106
giga G 109
mili m 10-3
micro 10-6
nano n 10-9
pico p 10-12
femto f 10-15
T nm 1977, Hi ngh Y t Th gii ln th 30 quyt nh chp

nhn s dng h thng SI trong y hc, tuy nhin nhiu ti liu sch bo vn
s dng c hai cch biu th kt qu c v mi. Do vy, trong nhiu trng
hp, mun bin lun c kt qu, cn phi chuyn i kt qu t n v c
sang n v mi v ngc li. lm c iu ny, c th trc tip tnh
ton (v d: bin lun kt qu mt lng cht, ngi ta s dng n v SI
l mol, nu mun chuyn i t n v c (g/l, mg/dl...) sang n v SI th c
th tnh ton da vo phn t lng ca cht ). Tuy nhin vic tnh ton
trc tip thng phc tp, do vy trong thc t ngi ta hay s dng h s
chuyn i theo cng thc:
X (n v c) x h s chuyn i = Y (n v SI)
Bng 6.2 l tr s quy chiu v h s chuyn i ca mt s xt nghim
sinh ho mu thng dng thng dng trong lm sng.
Bng 6.2. Tr s quy chiu v sinh ho ca mu
Tr s quy chiu H s
Xt nghim n v c n v mi chuyn i
Acid uric 2,0-7,0 mg/dl 120-420 mol/l 59,48

Alanin amino transferase
0-35 U/l 0-0,58 kat/l 0,01667
(ALAT, GPT)
Albumin 4,0-5,0 g/dl 40-50 g/l 10
69
Tr s quy chiu H s
Xt nghim n v c n v mi chuyn i
Aspartat amino transferase

0-35 U/l 0-0,58 kat/l 0,01667
(ASAT, GOT)
Bilirubin ton phn 0,1-1,0 mg/dl 2-18 mol/l 17,10
Bilirubin trc tip 0-0,2 mg/dl 0-4 mol/l 17,10
Calci 8,8 - 10,3 mg/dl 2,20-2,58 mmol/l 0,2495

Cholesterol ton phn 160-180 mg/dl 4,1-4,6 mmol/l 0,02586
Cholesterol LDL 50-130 mg/dl 1,30-3,30 mmol/l 0,02586
Cholesterol HDL 30-70 mg/dl 0,80-1,80 mmol/l 0,02586
CO2 ton phn 22-28 mEq/l 22-28 mmol/l 1
Clorua 95-105 mEq/l 95-105 mmol/l 1
Creatinin kinase (CK) 0-130 U/l 0-2,16 kat/l 0,01667
Creatinin 0,6-1,2 mg/dl 50-110 mol/l 88,40
H s thanh thi creatinin 75-125 ml/pht 1,24-2,08 ml/s 0,01667

Globulin 2,3-3,5 g/dl 23-35 g/l 10
Glucose 70-110 mg/dl 3,9-6,1 mmol/l 0,05551
Kali 3,5-5,0 mEq/l 3,5-5,0 mmol/l 1
Lactat dehydrogenase 50-150 U/l 0,82-2,66 kat/l 0,01667
Natri 135-147 mEq/l 135-147 mmol/l 1

Osmol* (p sut thm thu ca
huyt tng) 280-300 mOsm/kg
Phosphat 2,5-5,0 mg/dl 0,80-1,60 mmol/l 0,3229

Phosphatase acid 0-5,5 U/l 0-90 nkat/l 16,67
Phosphatase kim 30-120 U/l 0,5-2,0 kat/l 0,01667
Protein ton phn 6,0-8,0 g/dl 60-80 g/l 10

Transaminase (GOT) xem ASAT
Transaminase (GPT) xem ALAT
Triglycerid < 160 mg/dl < 1,80 mmol/l 0,01129
Ur 20-40 mg/dl 3,3-6,6 mmol/l 0,165
Osmol* : osmolalit plasmatique- p sut thm thu ca huyt tng do natri, glucose v
ur/mu to ra.
70
2. Mt s xt nghim sinh ho MU
2.1. Creatinin huyt tng

c im
Creatin (acid methylguanidin acetic), c tng hp gan ri c mu
vn chuyn n c. Ti t bo c, creatin gn phosphat to thnh
phosphocreatin - mt dng d tr nng lng s dng cho vic co c.
y l mt phn ng thun nghch, khi t bo c cn nng lng, di
tc dng xc tc ca creatinkinase, phosphocreatin li c chuyn
thnh creatin, gii phng phosphat giu nng lng. Trong qu trnh
trao i ny, mt phn creatin b mt nc, ng vng to thnh
creatinin. y l mt sn phm cn b, khng c s dng, ra khi c,
vo mu ri o thi qua thn.
Mi ngy c khong 1,6 - 1,7% creatin chuyn thnh creatinin. S to
thnh creatinin tng i hng nh, ph thuc ch yu vo khi lng
c ca mi ngi. Do nam gii c creatinin huyt tng cao hn n
gii. Hm lng creatinin trong huyt tng t thay i, khng ph
thuc vo cc yu t ngoi lai (v d ch n, ch vn ng hoc
cc thay i sinh l khc).
Creatinin o thi ch yu do lc cu thn, bi tit ng thn hoc
ti hp thu rt t, coi nh khng ng k.
ngha
Tr s bnh thng: 0,6 - 1,2 mg/dl; SI = 50 - 110 mol/l.
Tng: Do s to thnh tng i hng nh v gn nh thi tr hon
ton qua lc cu thn, tr s creatinin huyt thng c s dng
nh gi chc nng lc cu thn. Khi chc nng lc ca cu thn gim,
nng creatinin huyt tng tng. nh gi chnh xc hn chc
nng lc cu thn, ngi ta cn c th cn c vo h s thanh thi
creatinin.
c coi l suy thn khi nng creatinin huyt tng ln hn 130
mol/l hoc khi h s thanh thi creatinin di 80 ml/pht. Suy thn c
coi l nh nu h s thanh thi creatinin 50 - 80 ml/pht, l trung bnh vi
tr s t 15 - 50 ml/pht v l nng vi tr s thp di 15 ml/pht.
Nhiu thuc c o thi hon ton hoc mt phn bi thn. H s
thanh thi creatinin l cn c gip cho vic iu chnh liu lng thuc
thch hp.
71
2.2. Ur
c im
Ur l sn phm thoi ho chnh ca protein, c to thnh gan
thng qua chu trnh ur. Ur c th khuch tn d dng qua phn ln cc
mng t bo v phn tn rng khp cc dch ni v ngoi bo trong c th.
Ur c o thi ch yu qua thn, nhng khc vi creatinin, sau khi lc
qua cu thn, mt phn ur c ti hp thu ng thn. Ngoi ra n cn
c thi tr mt phn nh qua m hi v qua rut.
ngha
Tr s bnh thng: 20 - 40 mg/dl; SI = 3,3 - 6,6 mmol/l.

Gim: Gim ur mu him gp, thng gp giai on cui ca thiu
nng gan do suy gim tng hp ur.
Tng: Ur huyt cao c th do nguyn nhn trc thn, sau thn, hoc
ti thn.
+ Nguyn nhn trc thn nh mt nc, nn ma, a chy, gim lu
lng mu, sc, suy tim.
+ Nguyn nhn sau thn nh tc ng tit niu (si).
+ Nguyn nhn ti thn nh vim cu thn cp hoc mn, vim ng
thn cp do nhim c.
2.3. Glucose
c im
Glucose c to thnh t 3 ngun chnh: Thc n, do phn hu
glycogen, do qu trnh tn to ng t cc thnh phn khc. Glucose
l ngun nng lng ch yu ca no, c.
Glucose huyt lun hng nh do c ch iu ho thn kinh - ni tit.
Cc hormon iu ha glucose huyt c phn thnh hai nhm i lp:
Mt bn l insulin lm gim, mt bn l nhng hormon lm tng
glucose huyt (adrenalin, glucagon, glucocorticoid, somatostatin).
ngha
Tr s bnh thng: Lc i 70 - 110 mg/dl; SI = 3,9 - 6,1 mmol/l.
Tng: Hay gp nht l tng ng huyt do i tho ng. Nng
glucose huyt lc i cao hn 126 mg/dl (7,0 mmol/l) c coi l bnh l.
ng huyt cao ti 290 - 310 mg/dl (16 17 mmol) c nguy c gy hn
m i tho ng. Tuy nhin khng th nu ln mt gii hn c th v
tr s ny thay i kh nhiu vi tng ca bnh.
72
Ngoi i tho ng, tng ng huyt cn do mt s bnh ni tit khc:
Hi chng Cushing (cng nng v thng thn), tng nng tuyn gip.
Tng ng huyt cng c th do dng mt s loi thuc:
Glucocorticoid, thuc li tiu thiazid, phenytoin...
Gim: H ng huyt di 45 mg/dl (2,5 mmol/l) cng rt nguy him.
Nguyn nhn thng lin quan n dng qu liu insulin v cc thuc
ung trong iu tr i tho ng.
H ng huyt cn do mt s nguyn nhn khc nh u tu tng, suy
gan, thiu nng tuyn yn, thiu nng tuyn gip, thiu nng v thng thn.
2.4. Acid uric

c im
Acid uric l sn phm thoi ho cui cng ca nhn purin trong
nucleoprotein. Acid uric khng c vai tr g trong c th, sau khi c
to thnh, khong 2/3 c o thi qua thn (lc qua cu thn, nhng
sau mt phn c ti hp thu ng thn) v khong 1/3 c o
thi qua rut.
Nng bo ho ca acid uric trong huyt thanh l 7 mg/dl (420
mol/l), nu vt qu ngng ny th cc tinh th urat c th tch ng
trong sn, khp, thn. l nguyn nhn gy bnh Gout.
pH nc tiu tng s lm tng ho tan ca acid uric, nhng ngc
li nu pH nc tiu h, ho tan ca acid uric gim, c th dn n
to si, c bit trn cc bnh nhn c nng acid uric trong nc
tiu cao.
ngha
Tr s bnh thng: 2 - 7 mg/dl; SI = 120 - 420 mol/l
Tng: Tng acid uric trong mu c th do tng sn xut (tng ph hu
nucleoprotein, n ch n giu protid) hoc do o thi km (suy
gim chc nng thn). Nhng tc nhn c tc dng c t bo c th
lm tng acid uric mu (cc cht khng chuyn ho, mt s thuc iu
tr ung th nh methotrexat, busulfan, vincristin, prednison,
azathioprin). Cc tc nhn lm gim bi tit acid uric ng thn cng
lm tng acid uric mu (thuc li tiu thiazid, furosemid, acid
ethacrinic).
Gim: Gim acid uric mu t gp, thng do gim qu trnh ti hp thu
acid uric ng thn. Mt s thuc nh probenecid, cc salicylat,
phenylbutazon c th gy c ch thi tr acid uric khi dng vi liu
thp, nhng khi dng vi liu cao li lm gim ti hp thu, dn n
gim acid uric mu. Gim acid uric cn gp trong mt s trng hp c
tn thng ng thn nh trong bnh Wilson, hi chng Fanconi.
73
2.5. Enzym
Enzym khu tr trong cc m lm nhim v xc tc cc phn ng
chuyn ho cc cht trong t bo. Khi t bo b ph hu, mt lng ln
enzym c gii phng vo huyt thanh. o hot nhng enzym ny gip
nh gi tn thng ca m: Tn thng cng rng v cp tnh th lng
enzym gii phng vo mu cng nhiu. Tn thng mn tnh m thng
ch gii phng enzym vi lng va phi.
Isoenzym hoc isozym l nhng enzym xc tc cng mt phn ng ho
hc nhng chng khc nhau v mt s tnh cht l ho. S phn b isozym
c khc nhau tu tng m. Do isoenzym cng c s dng nhm xc
nh v tr tn thng.
Hot enzym c biu th bng n v quc t (U) hoc theo h
thng SI bng n v katal (kat). Mt microkatal (kat) bng 60 U.
2.5.1. Creatinkinase (CK hoc creatin phosphokinase CPK)

c im
Creatinkinase xc tc chuyn phosphocreatin thnh creatin, gii phng
phosphat giu nng lng ch yu cho c tim v c xng. CK l mt dime
gm 2 tiu n v l M (Muscle) v B (Brain). Nh vy s c 3 loi CK: CK -
BB, CK - MM v CK - BM. Ba isozym ny c c tnh phn b khc nhau:
M no c khong 90% BB v 10% MM.
M c tim c 40% MB v 60% MM.
M c xng gn nh 100% MM.
Huyt thanh bnh thng c 100% l MM nh c xng.
Cc trng hp lm sng gy tng CK trong huyt thanh thng l t
c xng hoc c tim. Cn loi BB no khng bao gi thy xut hin trong
huyt thanh, k c khi b tai bin mch mu no, v enzym ny khng i qua
c hng ro mu - no.
ngha
Tr s bnh thng: 0 - 130 U/l, SI = 0 - 2,16 kat/l.
Tng:
+ Tn thng c xng: Mi tn thng m c xng u gy tng
CK huyt thanh. Phn hu c xng cp do chn thng, do hn m
ko di, cc trng hp tn thng c xng khc nh lon dng c,
vim nhiu c hoc thiu nng tuyn gip u c th gy tng CK
ng k. Tim bp cng c th lm tng CK huyt thanh t 2 - 6 ln
v tr v bnh thng sau 48 gi k t khi ngng tim. Nhiu thuc
74
dng liu iu tr hoc qu liu c th gy ra tn thng c xng,
lm tng CK: Ch phm c thuc phin, cocain, amphetamin,
theophylin, khng histamin, cc fibrat, barbiturat, mt s khng
sinh, chloroquin, corticoid, vincristin. c bit lu vi cc thuc
nhm statin, nht l khi kt hp vi mt s thuc khc nh fibrat,
niacin, cyclosporin, erythromycin v c th gy ra tiu c nng, thm
ch dn n t vong.
+ Tn thng c tim: CK l enzym tng sm nht trong nhi mu c
tim. Sau khi b cn khong 4 gi, CK trong huyt thanh bt u tng
v t nh cao khong 24 gi ri tr v bnh thng sau ngy th
hai n ngy th t. V lng c tim nh hn nhiu so vi lng c
xng nn trong nhi mu c tim, hot CK thng ch tng nh.
chn on phn bit chnh xc, cn da vo xt nghim isozym,
phn CK - MB cao trn 6% hot CK ton phn c coi l mt
du hiu ca nhi mu c tim.
2.5.2. Aspartat amino transferase (ASAT)

c im
Enzym ny cn c tn khc l glutamat oxaloacetat transaminase
(GOT). y l enzym c vai tr chuyn vn nhm amin. Enzym ny c nhiu
nht m tim v gan, m khc t gp.
ngha
Tr s bnh thng: 0 - 35 U/l; SI = 0 - 0,58 kat/l.
Tng:
+ Nhi mu c tim: Sau CK, ASAT l enzym th hai tng sm trong
huyt thanh sau nhi mu c tim, tng bt u sau 6 - 8 gi, t
nh cao sau 24 gi ri tr v bnh thng sau 4 - 6 ngy.
+ Tn thng t bo gan: ASAT tng trong cc bnh c tn thng t
bo gan, c bit trong vim gan virus hoc do nhim c. Trng
hp ny ASAT v ALAT huyt thanh tng sm trc cc biu hin
lm sng gp hng chc ln bnh thng. Trng hp vim gan mn,
x gan, hoc mt, hot ASAT tng va phi tu theo mc
tiu hu t bo.
Nhiu thuc c th gy tng ASAT v gy thng tn t bo gan, th d
isoniazid, c bit khi phi hp vi rifampicin. Khi tip tc ung thuc m
enzym vn tip tc tng, v d gp hn ba ln gii hn cao ca bnh thng
th cn ngng tm thi hoc vnh vin thuc .
75
2.5.3. Alanin amino transferase (ALAT)
c im
Enzym ny cn c tn khc l glutamat pyruvat transaminase (GPT).
y cng l enzym c vai tr chuyn vn nhm amin. Enzym ny ch yu
tp trung t bo nhu m gan.
ngha
Tr s bnh thng: 0 - 35 U/l; SI = 0 - 0,58 kat/l.
Tng:
Tn thng t bo gan: ALAT tng ch yu trong cc bnh c tn
thng t bo gan. Mc d c hai enzym ASAT v ALAT u tng trong cc
bnh v gan nhng ALAT c coi l enzym c hiu vi gan hn v thng
t khi tng trong cc bnh khc ngoi nhu m gan.
2.6. Bilirubin
c im
Bilirubin l sc t c nhn pyrol v l sn phm thoi ha ca nhn
porphyrin ca hem. Mi ngy c th to khong 50 mol (hoc 50 x 0,585 =
29 mg) bilirubin t do (cn gi l bilirubin gin tip hoc bilirubin trc gan)
vi c im khng tan trong nc, tan trong m. Bilirubin t do vo huyt
tng c vn chuyn di dng gn vi albumin. Ti gan, bilirubin lin
hp vi hai phn t acid glucuronic v tr thnh bilirubin diglucuronic (cn
gi l bilirubin lin hp hoc bilirubin trc tip) vi c im tan trong nc,
qua ng mt do c ch vn chuyn tch cc v c tch ti mt. Khi mt
vo rut trong qu trnh tiu ho, bilirubin c thu phn bi vi khun
ng rut ri b kh thnh urobilinogen v stercobilinogen. Nhng sn
phm ny khng mu v tip tc c chuyn ho theo 3 con ng:
Oxy ho thnh urobilin v stercobilin c mu, phn ln o thi qua
phn.
Qua chu k gan - rut tr v gan v o thi li qua mt.
Mt phn nh o thi qua nc tiu.
Khi nng bilirubin huyt thanh > 34 mol/l th xut hin vng da.
ngha
Tr s bnh thng: Ton phn <1,5 mg/dl, trc tip <0,5 mg/dl,
(SI: Ton phn <26 mol/l, trc tip <8,6 mol/l).
76
Tng:
Cc nguyn nhn gy tng bilirubin huyt c th phn thnh 3 loi:
+ Trc gan: Tan mu
Nguyn nhn gy tng bilirubin trc gan l do ph hu hng cu
nhiu vt qu kh nng lin hp ca gan. Nh vy trong cc bnh
l thiu mu tan mu, bilirubin tng v ch yu tng loi gin tip.
Mt s thuc c th gy thiu mu tan mu do c ch min dch
(methyldopa, penicilin, cephalosporin, quinidin, ibuprophen,
triamteren) hoc do c ch gy oxy ho hemoglobin (dapson, mt s
thuc chng st rt, sulfonamid...).
+ Ti gan: C 3 ngun gc
. Ngun gc t bo gan: Do tn thng t bo gan, bilirubin tng ch
yu l loi trc tip, km theo transaminase tng rt cao (ALAT
thng cao hn ASAT). Cc nguyn nhn gy tn thng t bo
thng gp: Do virus, do thuc (acetaminophen, halothan,
tetracyclin, acid valproic, INH, rifampicin, methyldopa...), do ru.
. Ngun gc tc mt: Do tc ng dn mt trong gan.
. Ngun gc hn hp.
+ Sau gan: Do tc ng dn mt ngoi gan, ch yu do si mt, ung th
u tu. Mt s thuc gy vng da mt: Estrogen, chlopromazin,
erythromycin estolat... Bnh nhn vng da tc mt thng c phn
trng bch mu t st v nc tiu sm mu v c s o thi nhiu
sc t mt qua nc tiu cn phn th khng c. Thiu acid mt
trong ng tiu ho do tc mt gy chng phn m. Transaminase
thng tng t.
3. Mt s xt nghim huyt hc
Trong mu c ba loi huyt cu: hng cu, bch cu v tiu cu. Xt
nghim t bo mu gip cho chn on v theo di tin trin ca bnh, mt
khc gip cho vic theo di tc dng ca thuc v c nhng tc dng khng
mong mun ca thuc.
3.1. Hng cu
Hng cu l mt trong nhng thnh phn hu hnh ca mu vi vai tr
ch yu l vn chuyn hemoglobin (huyt sc t) ri hemoglobin s vn
chuyn oxy t phi n cc m. Hng cu c hnh a lm hai mt nn t l
gia din tch ca mng bao bc t bo so vi cc thnh phn cha bn trong
t bo l rt ln. Hng cu cng c th thay i hnh dng khi i qua cc
mao mch. Xt nghim v hng cu rt phong ph, y ch trnh by mt
s xt nghim c bn sau:
77
S lng hng cu
Bnh thng nam c 4.200.000 200.000/1 mm3 (SI: 4,2 0,2 x 1012/L).
n 3.850.000 150.000/1 mm3 (SI: 3,85 0,15 x 1012/L).
Hng cu gim: Thiu mu do nhiu nguyn nhn - c th do gim tng
hp (suy tu, ri lon tng hp porphyrin, ..), tng ph hu (thiu mu
tan mu), hoc do mt mu.
Hng cu tng (a hng cu): Trong trng hp m b thiu oxy, s c
qu trnh iu ho kch thch to hng cu tu xng. Nguyn nhn
gy thiu oxy m c th do sng vng cao, suy tim, cc bnh ng
h hp... v nhng nguyn nhn ny c th gy tng hng cu th pht
v s lng hng cu c th tng n 6 - 8 triu/1 mm3. Bn cnh ,
cn c cc trng hp tng hng cu do bnh l, v mt nguyn nhn
no , tu xng sn xut ra qu nhiu hng cu, trong trng hp
ny s lng bch cu v tiu cu u tng.
Nng hemoglobin
Nng huyt sc t ngi Vit Nam bnh thng l: Nam 14,6 0,6
g/dl (SI: 2,26 0,09 mmol/L); n 13,2 0,5 g/dl (SI: 2,04 0,08 mmol/L).
c coi l thiu mu khi nng huyt sc t thp hn 13g/dl nam v
12g/dl n; nhng cng c trng hp thiu mu gi to do mu b ho
long tng th tch huyt tng.
Hematocrit
Nu ly tm mu ton phn chng ng trong mt ng mao qun, s
tch c 2 phn: Phn trn lng l huyt tng, phn di c l cc
huyt cu. So snh t l phn trm gia th tch huyt cu vi mu
ton phn c gi l hematocrit. Trn thc t, d dng tnh ton
ngi ta s dng mt loi ng ly tm ring c khc cc vch t 0 n
100 gi l ng hematocrit. Sau khi ly tm, khng cn tnh th tch cc
lp m thng tnh hematocrit bng cch so snh chiu cao ca 2 lp.
ngi bnh thng, hematocrit c gi tr 39 - 45% hoc 0,39 - 0,45
nam; 35 - 42% hoc 0,35 - 0,42 n.
Hematocrit gim trong chy mu, tan mu v tng trong mt nc do
a chy, nn ma, st ko di.
Tc lng mu
Tc lng mu (huyt trm) l tc lng ca hng cu trong mu
c chng ng v c ht vo mt ng mao qun c ng knh
nht nh t th thng ng. Thng ly kt qu chiu cao ca ct
huyt tng sau 1 hay 2 gi u.
78
ngi bnh thng: tc lng mu l 3-7 mm/gi i vi nam v
5 - 10 mm/gi i vi n.
Tc lng mu tng trong cc bnh c vim nhim nh thp khp, lao
ang tin trin, ung th (gi u c th ti 30 - 60mm). Xt nghim ny
tuy khng c hiu nhng n gin nn thng c dng theo di
tin trin ca bnh.
3.2. Bch cu (3200 - 9800/mm3; SI: 3,2 - 9,8 x 109/L)

Bch cu gip c th chng li tc nhn gy bnh bng qu trnh thc
bo hoc bng qu trnh min dch. Cn c vo hnh dng v cu trc, ngi
ta chia bch cu thnh 5 loi: Bch cu a nhn trung tnh, bch cu a
nhn a acid, bch cu a nhn a base, bch cu mono v bch cu
lympho. C 3 loi bch cu a nhn u c rt nhiu ht c trng trong
bo tng nn ngi ta cn gi chung l bch cu ht.
Cng thc bch cu c t l % nh sau:
Bch cu ht trung tnh 50 - 70%
Bch cu ht a base 0-1%
Bch cu ht a acid 1-4%
Bch cu lympho 20 - 25 %
Bch cu mono 5-7%
S lng bch cu trn 10.000/mm3 c coi l tng bch cu. Khi c s
lng xung di 3000/mm3 coi l gim bch cu.
Tng bch cu gp trong cc trng hp:
Trong i a s cc bnh nhim khun gy m.
Trong cc bnh nhim c.
Khi c sang chn, thng tn t bo, sau phu thut.
c bit, bch cu tng rt cao trong bnh ung th dng bch cu.
Gim bch cu gp trong cc trng hp:
St rt.
Thng hn.
Bnh do virus.
Chng mt bch cu ht, gim sn hoc suy tu xng.
3.3. Tiu cu (150.000 - 300.000/mm3; SI: 0,15-0,3 x 1012/L)

L nhng t bo khng nhn, tham gia vo qu trnh cm mu. Khi
thnh mch b tn thng, tiu cu s tp kt ti cho n khi hnh thnh
79
nt tiu cu bt kn ch b tn thng. Gim tiu cu xung di
100.000/mm3 d sinh chy mu. Gim tiu cu c th do suy tu, do ung th,
do nhim c asen, benzen, nhim khun v virus. Nhiu thuc c th gy
gim tiu cu (chloramphenicol, quinidin, heparin, nhiu thuc chng ung
th). Nhiu thuc khc c kh nng c ch s kt dnh tiu cu (aspirin).
Kt lun
Trn y l mt s kin thc c bn v cc xt nghim sinh ho v
huyt hc thng hay s dng trong lm sng. Cc kin thc ny cng ch
ch yu tp trung vo nhng vn c lin quan n s dng thuc, c
bit l nhm nh gi hiu qu ca thuc v theo di ADR trong qu trnh
iu tr. c c nh gi chnh xc, t khi ch theo di mt xt nghim
n l m cn nhn nh tng hp nhiu kt qu xt nghim khc nhau.
ng thi cng phi ty tng trng hp c th cn nhc cc thi im
cn thit phi tin hnh theo di nh gi cc xt nghim lm sng: Trc
khi c quyt nh dng thuc, trong sut qu trnh iu tr v c bit c
nhng trng hp ngay c sau khi ngng thuc.
T lng gi

1. Creatinin o thi ch yu do(A), bi tit ng thn hoc ti hp thu
rt t, coi nh khng ng k. Do , tr s creatinin huyt thng c
s dng nh gi ....B.
2. Cc hormon iu ha ng huyt c phn thnh hai nhm i lp:
Mt bn l hormon lm gim ng huyt nh (A), mt bn l nhng
hormon lm tng ng huyt nh (B), (C)
3. Khi nng acid uric trong huyt thanh vt qu mc bo ho th cc
tinh th urat c th tch ng trong sn, khp, thn. l nguyn nhn
gy bnh (A)
4. ALAT trong huyt thanh thng tng trong cc bnh l c tn thng
(A)
5. Cc nguyn nhn gy gim thi tr dn n lm tng ur mu c th
phn thnh 3 nhm:
Nguyn nhn ...(A)... : Vim cu thn cp hoc mn, vim ng thn cp
do nhim c.
Nguyn nhn ...(B)... : tc ng tit niu (si).
80
Nguyn nhn ...(C)...: mt nc, nn ma, a chy, gim lu lng mu,
sc, suy tim.
6. Nguyn nhn gy tng bilirubin mu c th phn thnh 3 nhm:
Nguyn nhn ...(A)... : V d nh si mt, ung th u tu
Nguyn nhn ...(B)... : V d nh tn thng t bo gan (do virus, do
thuc, do ru), tc ng dn mt trong gan
Nguyn nhn ...(C)... : V d nh thiu mu tan mu
7. Cng thc bch cu c t l % nh sau:
Bch cu (A) 50 - 70%
Bch cu ht a base 0-1%
Bch cu ht a acid 1-4%
Bch cu (B) 20 - 25 %
Bch cu mono 5-7%
8. S lng bch cu (A) trong cc trng hp nhim khun, ung th
bch cuv (B). trong cc trng hp st rt, suy tu
9. S lng hng cu c th gim do cc nguyn nhn:
Gim tng hp: V d nh(A)
Tng ph hu: V d nh(B)
Mt mu
10. Tc lng mu tng trong cc bnh ....(A)..... nh thp khp, lao ang
tin trin, ung th....

11. Khi bnh nhn suy thn, kt qu xt nghim sinh ho mu thng
cho thy:
A. Creatinin v ur khng thay i
B. Creatinin khng thay i, ur tng
C. Creatinin tng, ur khng thay i
D. C creatinin v ur u tng
12. Glucose mu tng:
A. Trong bnh l i tho ng
B. Trong hi chng Cushing (cng nng v thng thn)
81
C. Khi s dng di ngy cc thuc nhm glucocorticoid
D. A, B v C u ng
13. H glucose huyt qu mc thng do qu liu:
A. Insulin
B. Probenecid
C Cc thuc h ng huyt dng ung
D C A v C u ng.
14. Khi bnh nhn s dng mt thuc c c tnh trn t bo gan, cn theo
di xt nghim no trong cc xt nghim sinh ho mu sau:
A. ASAT
B. ALAT
C. CK
D C A v B u ng
.
15. Enzym no c trng nht cho tn thng t bo gan:
A. ASAT
B. ALAT
C. CK
D C A, B v C u sai
.
16. Khi bnh nhn b nhi mu c tim, trong cc xt nghim mu sau, xt
nghim no cho kt qu tng:
A. ASAT
B. ALAT
C. CK
D C A v C u ng
.
17. Khi bnh nhn s dng mt thuc c c tnh trn t bo c xng (v d
nh dng cc statin), cn theo di xt nghim no trong cc xt nghim
sinh ho mu sau:
A. ASAT
B ALAT
82
C. CK
D C A v B u ng
.
18. Trong bnh l vim gan virus B, cc xt nghim mu no cho kt qu tng:
A. Transaminase
B. Bilirubin
C. C A v B u ng
D C A v B u sai
.
19. Bilirubin mu c th tng do cc nguyn nhn:
A. Thiu mu tan mu
B. Suy gim chc nng thn
C. Vim gan virus
D A v C u ng
.
20. Khi bnh nhn b thiu mu, kt qu xt nghim huyt hc cho thy:
A. S lng hng cu gim
B. Nng hemoglobin gim
C. Hematocrit gim
D C A, B, C u ng
.
S
21. Trong h thng n v quc t, biu th kt qu mt lng
cht, ngi ta s dng n v mol.
22. S to thnh creatinin trong c th tng i hng nh, ph
thuc ch yu vo khi lng c ca mi ngi
23. Creatinin o thi ch yu do lc cu thn, bi tit ng
thn hoc ti hp thu coi nh khng ng k.
24. Glucose mu lun hng nh do c ch iu ho thn kinh -
ni tit.
83
25. Khi t bo gan b tn thng c th lm tng CK trong huyt
thanh
26. Hai enzym ASAT v ALAT u tng trong cc bnh v gan
27. Bilirubin t do tan tt trong nc, c o thi ra ngoi
qua mt
28. Nng huyt sc t tng khi bnh nhn thiu mu
29. Tc mu lng l mt trong cc xt nghim c hiu
theo di tin trin ca bnh.
30. Trong phn ln cc trng hp nhim khun gy m, s
lng bch cu tng
31. Khi suy tu, s lng hng cu tng bt thng
32. Cc thuc c kh nng c ch kt tp tiu cu nh aspirrin
s c tc dng cm mu
84
Bi 7
S dng thuc cho cc i tng c bit
Mc tiu
1. Phn tch c nhng nh hng ca thuc khi dng cho ph n c thai
i vi thai nhi v nguyn tc s dng thuc cho ph n c thai.
2. Trnh by c cch phn loi thuc dng cho ph n c thai.
3. Phn tch c nhng nh hng ca thuc dng cho ph n cho con b
i vi tr b m v nguyn tc s dng thuc ph n cho con b.
4. Lit k c nhng thay i v dc ng hc v dc lc hc ca thuc
khi dng cho tr em, ngi cao tui.
5. Trnh by c nhng vn cn lu khi s dng thuc cho tr em v
ngi cao tui.
M u
m bo mc tiu dng thuc an ton hp l hiu qu, cn phi c
th ho vic s dng thuc cho bnh nhn. iu c ngha l khi ngi
thy thuc k n cho bnh nhn, khng ch n gin l suy xt n iu tr
bnh mc phi, m phi tnh n c tnh trng sinh l, bnh l ca ngi
bnh la chn c thuc, liu lng dng, nhp a thuc v ng
dng ph hp. Cc thng tin chung v tng thuc c th c cung cp
trong cc ti liu chuyn kho u l kt qu ca cc th nghim, nghin
cu trn ngi tnh nguyn, khng c nhng bt thng v sinh l (c thai,
ngi cao tui, tr nh) hoc bnh l (suy gan, suy thn). nhng i tng
c s khc bit v sinh l v bnh l, s phn ca thuc trong c th b thay
i ng k, ng thi p ng i vi tc dng ca thuc ca c th cng c
85
nhng khc bit nht nh. Do vy, vi cc i tng c bit ny, khng
phi lc no cng c th s dng cc thuc c ch nh cho nhng trng
hp tng t ngi bnh thng hoc p dng mc liu v nhp a thuc
nh khi iu tr cho bnh nhn thng.
Nhng thng tin trong chuyn ny tp trung vo cc kin thc lin
quan n s dng thuc mt s nhm bnh nhn c bit, l: Ph n c
thai, ph n ang thi k cho con b, tr em v ngi cao tui. Nhng i
tng bt thng v bnh l, c bit l bnh l c quan thi tr thuc l
gan v thn c trnh by phn dc ng hc.
Nhim v ca ngi dc s (trung cp) trong nhng trng hp ny l
hiu c nhng thay i c nhng t vn thch hp cho bnh nhn.
1. s dng thuc cho Ph n c thai
1.1. nh hng ca thuc i vi thai nhi

Khi ngi m mang thai dng thuc, hu ht cc thuc u qua c
rau thai mc khc nhau v xm nhp vo vng tun hon ca thai nhi.
Cc cht c vn chuyn theo 2 chiu, nhng ch yu l t m sang thai
nhi. Li dng iu ny, i khi thuc c th c dng cho ngi m iu
tr nhng ri lon ca thai nhi. V d: Flecainid dng cho m x tr nhp
tim nhanh ca thai.
Tuy nhin vn ng quan tm khi dng thuc ph n c thai l
thuc vo c vng tun hon ca thai v gy hi cho thai nhi. Thuc dng
cho m c th gy tc dng trc tip hoc gin tip trn thai nhi. V d ngi
m dng liu cao corticoid (prednisolon trn 10mg/ngy) c th trc tip gy c
ch tuyn thng thn ca thai. Thai nhi cng c th chu nh hng ca thuc
mt cch gin tip nh khi ngi m dng thuc chng tng huyt p, nu
huyt p ca m gim qu mnh s gy thiu oxy cho thai nhi. Cc tc dng
loi ny thng ph thuc liu v c th d on trc.
Trong nhiu trng hp, nh hng ca thuc ln thai nhi khng ph
thuc vo liu, khng th d on trc v thng lin quan n c im di
truyn ca thai nhi.
Tc dng c hi ca thuc i vi thai nhi khi dng cho ngi m ph
thuc vo cc yu t nh: Bn cht v c ch gy tc dng c hi ca thuc;
liu lng v thi gian dng thuc ca ngi m; kh nng vn chuyn
thuc t m vo thai nhi; kh nng thi tr thuc ra khi c th m v thai
nhi; c im di truyn ca thai nhi v giai on pht trin ca thai khi
ngi m dng thuc.
nh hng ca thuc ln thai nhi tu thuc thi im dng thuc trong
thi k mang thai.
86
1.1.1. Thi im dng thuc trong thai k v nh hng ca thuc
Cc cht c kh nng gy qui thai t khi gy ra mt d tt duy nht.
Thng thng, mt lot cc d tt s xy ra, tng ng vi nhng b phn c
th thai nhi ang pht trin mnh vo thi im ngi m dng thuc.
K t lc trng c th tinh, thai k s ko di trong 38 tun, v c
chia ra lm 3 giai on: Tin phi, phi v thai.
Thi k tin phi (hay pha phn on)
Ko di 17 ngy sau khi trng c th tinh, thng khng nhy cm
vi cc yu t c hi v cc t bo cha bt u bit ho. c tnh ca thuc
i vi thai nhi tun theo qui lut tt c hoc khng c g, tc l phi bo
cht hoc tip tc pht trin hon ton bnh thng. Chnh v vy cc bt
thng v hnh thi ca thai him khi xy ra tr trng hp thi gian bn
thi ca thuc ko di v thuc cn tip tc nh hng ti thi k phi.
Thi k phi
T ngy th 18 n ngy th 56, hu ht cc c quan ca c th c
hnh thnh trong thi k ny. S to hnh xy ra rt nhanh, cc t bo ang
nhn ln rt mnh, nn nhy cm vi c tnh ca thuc l ln nht.
Dng thuc trong giai on ny c th gy ra nhng bt thng nng n v
hnh thi cho a tr. Mi c quan c mt giai on nht nh nhy cm
nht vi c tnh ca thuc.
Bng 7.1. Cc thi k nhy cm trong qu trnh pht trin ca thai nhi
C quan Thi k nhy cm cao Thi k t nhy cm hn

(tun tui ca phi) (tun tui ca thai)
TKT 3-5 6 - lc sinh
Tim 3-6 6-8
Tay 4-7 8
Chn 4-7 8
Mt 4-8 8 - lc sinh
Rng 6-8 9 - 16
Vm ming 6-9 9 - 12
Tai 4 - 10 10 - 17
B phn sinh dc ngoi 7 - 12 12 - lc sinh
Thi k thai
T tun 8 - 9 tr i, ko di ti lc sinh. Trong thi k ny, cc b phn
trong c th tip tc pht trin v hon thin. Thai t nhy cm hn vi cc
87
cht c. Cc cht c hi cho thai nhi thng ch lm gim tnh hon thin
v cu trc v chc nng ca cc c quan. Cc b phn ca c th thai nhi
cn nguy c cao l h thn kinh trung ng, mt, rng, tai v b phn sinh
dc ngoi. V d c quan sinh dc ngoi hnh thnh t tun th 7 v hon
thin cho ti lc sinh, nu ngi m dng danazol, mt thuc c hot tnh
androgen yu vo bt c lc no trong khi mang thai cng c th gy nam
ho thai nhi n.
1.1.2. nh hng ca thuc dng cho ph n c thai i vi tr sau

khi sinh
Tr s sinh c th phi chu tc dng bt li ca thuc dng cho ngi
m khi mang thai. Do kh nng thi tr thuc ca tr s sinh rt km, mt
s thuc c th b tch lu ng k v gy c cho tr. V vy cn c bit ch
ti mt s thuc khi dng cho ph n c thai gn ngy sinh. V d thuc
chng trm cm v thuc an thn dng cho m phi c gim liu t t cho
ti lc gn sinh hn ch ri lon thn kinh do c tnh trc tip ca thuc
trn tr s sinh, ng thi hn ch tc dng cai thuc.
1.2. Phn loi mc an ton ca thuc i vi ph n c thai

C quan Qun l thuc v thc phm M (FDA) xp thuc thnh
5 loi:
Loi A
Cc nghin cu c kim sot cho thy khng c nguy c i vi bo thai.
Cc nghin cu c kim sot vi s lng ln trn ph n c thai chng
minh l khng lm tng nguy c thai bt thng khi dng cho ngi m
mang thai ti bt c thi im no ca thai k.
Loi B
Khng c bng chng v nguy c i vi bo thai ngi. Thuc c nguy
c gy tc hi cho bo thai trn ng vt nhng cc nghin cu c kim sot
v ln khng chng minh c nguy c khi dng trn ngi; hoc thuc
khng c nguy c trn ng vt nhng cha nghin cu tin cy chng
minh an ton cho ngi.
Loi C
C nguy c cho bo thai. Nghin cu trn ngi cha nhng nghin
cu trn ng vt chng minh c nguy c gy tn hi hoc khuyt tt cho
bo thai; hoc cha c nghin cu trn ng vt v nghin cu trn ngi
cng cha y .
88
Loi D
Chc chn c nguy c cho bo thai. Cc d liu nghin cu hoc d liu
sau khi thuc c lu hnh trn th trng cho thy thuc c nguy c
gy tc hi cho bo thai, tuy nhin li ch iu tr vt tri nguy c ri ro.
Thuc c chp nhn iu tr trong nhng trng hp bnh nng e do
tnh mng ngi m v khng th tm c thuc thay th an ton hn.
Loi X
Chng ch nh cho ph n c thai. Tt c mi nghin cu trn ng
vt, trn ngi, cc d liu thu thp sau khi thuc lu hnh trn th trng
u khng nh tc hi cho bo thai ca thuc v li ch iu tr khng vt
tri nguy c ri ro.
V d: Cng mt nhm thuc tr lot d dy t trng nhng cc antacid
c xp loi A, cimetidin, famotidin c xp loi B, pantoprazol c xp
loi C cn misoprostol c xp loi X.
1.3. Nguyn tc trong s dng thuc cho ph n c thai

Hn ch ti a dng thuc, nn la chn cc phng php iu tr
khng dng thuc.
Trnh khng dng thuc trong 3 thng u thai k.
Dng thuc vi liu thp nht c hiu qu, thi gian ngn nht.
La chn thuc c chng minh l an ton, trnh dng nhng
thuc cha c s dng rng ri cho ph n c thai.
2. s dng thuc Ph n thi k cho con b

Cng ngy ngi ta cng nhn thc r li ch ca vic cho tr b sa
m. Cho tr b sa m, tr s kho mnh, tng sc khng, thng minh
hn, ng thi ngi m chng tr li vc dng c, gim nguy c ung th v,
c t cung. Tuy nhin, khi dng thuc cho ph n cho con b, thuc c th
c bi tit vo sa v gy hi cho a tr b m. Chnh v vy, vic dng
thuc ph n cho con b cng cn c quan tm ng mc lm sao t
c mc tiu iu tr bnh cho m, ng thi trnh cho a tr b dng v
chu tc dng bt li ca thuc m vn m bo duy tr cho tr b m.
2.1. Nhng yu t quyt nh lng thuc vo a tr khi s dng

thuc cho ph n cho con b
Khi dng thuc cho ph n cho con b, c mt s yu t cn cn nhc
89
m bo vic iu tr l hp l v an ton cho c ngi m v a tr.
Cn phi lu tm ti lng thuc tit vo sa m v lng thuc a tr
n vo bng. iu ny lin quan n 4 loi yu t.
2.1.1. Yu t lin quan n vic dng thuc ca ngi m

Bao gm thuc c dng (thuc dng, liu, ng dng) v c im
dc ng hc ca m (kh nng hp thu, phn b, chuyn ho v thi tr
thuc). Cc yu t ny s quyt nh lng thuc tim tng c th c thi
tr vo sa.
2.1.2. Yu t lin quan n bi tit sa

Lng sa cho a tr b s ph thuc vo lng sa m sn xut ra
v s t l vi lng thuc a tr tiu th vo bng.
Thnh phn v pH ca sa s nh hng n mc bi tit ca thuc
vo sa. Thnh phn sa m c nc, lipid, protid, lactose... thay i
gia cc c th v ngay trong tng c th nhng thi im khc nhau.
Sa non t lipid, giu protid, pH t kim hn sa chnh thc. Trong mt
ngy, sa tit vo bui sng giu lipid hn bui chiu.
2.1.3. Tnh cht ho l ca thuc

Thuc vo sa ch yu theo c ch khuch tn th ng qua nhng l
trn mng biu m tuyn v. Ngoi ra c mt phn theo c ch vn chuyn
tch cc nh cht mang. Sa c pH thp hn, kh nng lin kt protein yu
hn, thnh phn lipid nhiu hn huyt tng. Cc yu t nh hng n s
khuch tn ca thuc vo sa l kh nng lin kt protein huyt tng, tnh
tan trong lipid, phn t lng v mc ion ho ca thuc (pKa). Nhng
thuc c phn t lng nh, tan trong lipid, khng ion ho s d khuch tn
vo sa.
2.1.4. Lng sa thc t c a tr b

Lng thuc vo a tr khi dng cho ngi m khng ch ph thuc
vo cc yu t trn m cn c quyt nh bi lng sa a tr thc b.
V vy thi im cho tr b m cng cn c xem xt. Nu tr b m vo
thi im thuc ang t nng ti a trong mu m th lng thuc vo
tr s cao hn khi nu cho tr b ngay trc khi ngi m dng liu thuc
tip theo.
2.2. Nhng thuc nh hng n kh nng bi tit sa khi dng cho

ph n ang cho con b
Vic tit sa c iu ho bng prolactin, gim lng prolactin trong
mu hoc gim s lng th th lm gim bi tit sa. Hai loi thuc nh
90
hng sn xut sa l: Cc hormon v thuc c hot tnh dopamin.
Estrogen l hormon hay c s dng v c nh hng ti bi tit sa.
Khi dng cho ph n cho con b, thuc vo sa rt t nhng c tc dng c
ch th th prolactin giai on sm lm gim bi tit sa. V vy ph n
cho con b nn dng thuc trnh thai cha progesteron n c.
Mt s thuc c tc dng lm gim sn xut sa c lit k trong
bng 7.2.
Bng 7.2. Cc thuc km hm bi tit sa
Androgen Bromocriptin
Clomiphen citrat Li tiu thiazid
IMAO Levodopa
Dn cht ca lo mch Vitamin B6 liu cao
Ngoi ra, cc thuc nh metoclopramid, domperidon c tc dng kch

thch bi tit sa, c s dng trong lm sng vi tc dng ny.
2.3. Nguyn tc chung trong s dng thuc ph n cho con b

Hn ch ti a dng thuc.
Chn thuc an ton cho tr b m, thuc c t l nng sa/huyt
tng thp, c thi gian bn thi ngn.
Trnh dng liu cao, nn dng thi gian ngn nht c hiu qu.
Nn cho tr b ngay trc khi dng thuc.
Cn vt sa b i nu khng cho tr b trong thi gian dng thuc. Sau
khi ngng thuc cn ch thm mt thi gian thch hp (4 ln t1/2) ri
mi cho tr b m.
Cn nhc li ch v nguy c.
V nguyn tc, nn la chn nhng thuc an ton cho tr. Ni chung
nhng thuc dng c cho tr s sinh v tr nh th c th dng ph n cho
con b. Nhng thuc khng hp thu khi dng ng ung ngi ln cng
s khng hp thu tr b m. V vy nhng thuc nh aminoglycosid,
vancomycin, heparin, insulin c coi l an ton khi dng cho ph n cho
con b.
3. s dng thuc trong nhi khoa
3.1. Phn loi tr em theo lp tui
91
C th tr em pht trin nhanh, trong , ln v trng thnh l hai
qu trnh sinh hc c bn. Cc c quan, h thng v cc enzym trong c th
cn cha hon thin v ang pht trin cc mc khc nhau, gy kh
khn trong vic s dng thuc v liu lng, dng ch phm, p ng i vi
thuc v tc dng khng mong mun ca thuc rt khc nhau so vi ngi
ln v trong tng giai on pht trin ca tr.
Trong Nhi khoa, tr em c phn loi theo cc lp tui nh bng 7.3.
Bng 7.3. Cc lp tui trong nhi khoa
Loi tr em Tui
Tr thiu thng (Premature) Cha y 38 tun thai
Tr s sinh (Newborn, Neonate) Di 1 thng tui
Tr 1 nm (Infant, Baby) T 1 thng n 12 thng tui
Tr nh (Young child) T > 1 n 6 tui
Tr ln (Older child) T > 6 n 12 tui
Thiu nin (Adolescent) T > 12 n 18 tui
Cch phn loi ny phn nh s thay i v mt sinh hc. Vi mc ch

tnh ton liu lng thuc, tr em trn 12 tui c coi nh ngi ln.
3.2. Nhng khc bit v dc ng hc tr em

Nhng khc bit v dc ng hc ca thuc ch yu gp tr s sinh
v tr di 1 nm tui.
3.2.1. Hp thu thuc

Thuc dng ng ung
Thuc thng c dng cho tr theo ng ung. Tr s sinh c s
khc bit rt nhiu v kh nng hp thu thuc do s bi tit t acid
hydrocloric v s chm rng ca d dy. Thi gian lu d dy ko di, ch
t mc nh ngi ln khi tr c 6 thng, do nhng thuc hp thu ti
d dy s c thi gian lu li lu hn, hp thu nhiu hn v tng tc dng
hn so vi ngi ln. Nhu ng rut ca tr tht thng, nim mc rut
cha pht trin nn hp thu thuc ng tiu ho ca tr s sinh v tr
nh rt km. iu ny cng nh hng ti hp thu ca mt s thuc v dng
ch phm c bit. V d dng ch phm gii phng chm (nh vin
Theodur- theophyllin) gim hp thu ti 50% tr di 5 tui.
Thuc dng ng tim
92
Tr s sinh khi c vn cn nh, co bp c km, lu lng ti mu
khng u, lng nc nhiu nn hp thu thuc theo ng tim bp chm
v tht thng. V vy vi tr s sinh, nu cn tim thuc nn chn tim
tnh mch. Vi tr ln hn, kh nng hp thu khi tim bp tt hn, nhng
cng nn la chn tim bp i hn l tim mng v tay. Trong thc t
ng tim bp gy au cho tr nn nu c th th trnh dng ng ny.
Thuc dng ng trc trng
t c s khc bit v sinh l nh hng ti hp thu thuc ng trc
trng tr em.
Thuc dng ngoi
Tr s sinh v tr nh c kh nng hp thu thuc qua da rt ln, c
bit l vng bn hoc mt. Nguyn nhn l do t l din tch da trn cn
nng tr ln, da tr b hydrat ho mnh, lp sng mng, hng ro biu m
cha trng thnh. V vy bi thuc d b kch ng hoc d ng, thm ch c
trng hp ng c ton thn. V d sn phm dng ngoi da cha lignocain
khng c dng cho tr di 1 tui do tng hp thu gy methemoglobin.
Khi bi thuc v bng li, kh nng hp thu thuc qua da tng v c th
gy c.
Thuc dng qua ng h hp
Nim mc mi tr mng, nhiu mch mu, thuc hp thu rt nhanh c
nguy c ng c, cn thn trng khi dng cc thuc co mch nh mi cho tr
s sinh v tr nh v nhng thuc ny rt hay c phn x co mch ton thn
v ngng h hp.
3.2.2. Phn b thuc

Tr s sinh c t l nc trong c th ln. V vy cc thuc tan nhiu
trong nc, c phm vi iu tr hp nh aminosid, theophyllin... liu tnh
theo cn nng cao hn ngi ln thu c nng tng t trong huyt
thanh. V d liu 1 ln gentamicin cho ngi ln l 1 - 1,5 mg/kg, tr ln l
2,5 mg/kg v tr s sinh l 3 mg/kg.
3.2.3. Chuyn ho thuc

a s cc h thng enzym cn cho chuyn ho thuc tr s sinh hoc
cha c, hoc cha hon thin so vi ngi ln. Thm vo , lu lng mu
gan yu nn tc chuyn ho thuc chm hn r rt so vi ngi ln. Tuy
nhin, kh nng ny cc lp tui khc, v d tr 1 - 9 tui i vi mt s
thuc li nhanh hn ngi ln. Do tnh tht thng ny, liu dng tr em
phi tnh theo tng lp tui. Vi nhng thuc c phm vi iu tr hp th
tnh theo din tch b mt da ca c th.
93
3.2.4. Thi tr thuc qua thn
Trc 3 - 6 thng tui, tc lc cu thn vn cha t c bng nh
ngi ln. Chc nng ca ng thn t bng ngi ln khi tr c 8 - 12
thng. Do vy, cc thuc thi tr nhiu qua c ch bi tit ng thn cn
gim liu cho tr s sinh (v d penicillin).
T 9 thng tui tr ln, thn ca tr hot ng bnh thng nh ca tr
ln v ngi ln nn khng c s iu chnh liu theo chc nng thn nh
vi tr s sinh na.
3.3. Nhng thay i trong p ng thuc tr em

Tr s sinh v tr nh nhy cm hn vi thuc do cc c quan trong c
th cn cha hon chnh. Nhng im khc bit c th l:
H thng thn kinh trung ng ca tr hon thin chm, n 8 tui
mi c nh ca ngi ln. Tnh thm ca hng ro mu no tr cao
hn so vi ngi ln. V vy, tr em c bit nhy cm vi tc dng c
ch thn kinh ca phenobarbital, morphin, meprobamat...
H thng iu ho thn nhit ca tr cha hon thin v khng n
nh. Nhiu thuc lm thn nhit tr dao ng rt nhiu; v d: Liu
thng thng ca aspirin v paracetamol dng h st nhng liu
cao li c th gy tng thn nhit.
Da ca tr mng, tnh thm cao nn tr d b d ng, hoc ng c khi
dng thuc bi trn da. Cc thuc hay gy da phn ng trn da tr l
sulfonamid, tetracyclin, penicillin...
Sau y l mt s tc dng ph cn lu ca mt s thuc khi dng
cho tr em:
+ Chm ln do tetracyclin v corticoid.
+ Dy th sm do androgen.
+ c thn kinh do hexachloraphen.
+ Tng p lc ni s do corticoid v acid nalidixic, vitamin A, vitamin
D v nitrofuratoin.
+ Vng da do novobiocin, sulfonamid v vitamin K.
+ Phng thp v hng rng vi tetracyclin.
3.4. Mt s im cn lu khi dng thuc cho tr em

3.4.1. Liu lng thuc dng cho tr em
Khng c coi tr em l ngi ln thu nh. Liu lng thuc dng cho
tr cn phi tnh ti tui, cn nng v din tch b mt c th, cn c vo
94
kh nng hon thin ca chc nng gan, thn. Thuc thng tnh liu cho
tr theo mg/kg. Nhng thuc rt c nh ho tr liu chng ung th tt nht
l nn tnh theo mg/m2 din tch c th. Cch tt nht l tra cu trong ti
liu c ghi liu ca tr em c kim nh bng thc t lm sng.
3.4.2. La chn ch phm thuc dng cho tr em

Thuc dng ng ung
Thuc dng ng ung l an ton v tin li nht. Thuc nn c mu
sc v mi v hp dn gip d cho tr ung, lm cho tr cm thy thch v
t nguyn ung thuc, c nh vy mi gip cho vic iu tr thnh cng. Tuy
nhin phi ch trnh trng hp tr t dng thuc hay dng nhm thuc
c mu sc mi v hp dn, gy ng c.
Vi tr di 5 tui, nn dng thuc dng lng. Tr ln hn c th
dng thuc dng rn. Nhiu trng hp, thuc vin nn c nghin bng
tha sau trn vi mt s th nh mt ong, nc qu... cho tr ung.
Khng khuyn khch cha m trn ln thuc vo thc n ca tr v c th gy
gim hoc mt tc dng, hn na nu tr b d thc n th thuc s khng
c dng liu.
Thuc dng ng tim
Nh phn tch phn trn, nn trnh tim bp cho tr nh. Vi
ng tim - truyn tnh mch cn ch tim - truyn vi tc chm v
th tch dch cho php dng cho tr.
Thuc t trc trng
y l ng dng thun tin v tr thng khng chu ung thuc.
ng dng ny c th t c tc dng nhanh, thch hp khi tr b nn
nhiu, hn m hoc b tc rut, cha m a tr d dng can thip c. Tuy
nhin, khng lm dng ng a thuc ny v c th gy kch ng ti ch.
Thuc dng kh dung
Tr di 5 tui kh dng bnh xt th nh liu v cha bit phi hp ht
vo v th ra khi phun thuc, do my kh dung hoc bung phun (vi tr
di 3 tui cn c mt n) thch hp hn.
4. s dng thuc cho Ngi cao tui

4.1. c im dc ng hc ngi cao tui
Tui tc nh hng nhiu n sinh l ca c th, v nh vy s nh
hng n qu trnh hp thu, chuyn ho qua gan ln u, lin kt thuc -
protein huyt tng, phn b v thi tr ca thuc.
4.1.1. Hp thu thuc
95
Thuc dng theo ng ung
ngi cao tui, c s gim tc tho rng d dy, gim tit acid,
gim lu lng mu rut, gim din tch b mt hp thu. Do s chm rng
ca d dy, mt s vin thuc d tan r, tng hp thu, nhng c th lm
hng dng bo ch c bit (thuc bao tan rut) hoc lm tng tc dng
khng mong mun ca thuc nh b lot d dy khi dng thuc chng vim
khng steroid. pH d dy tng c th lm gim hp thu mt s thuc acid
c hp thu d dy nh barbituric, salicylat...
Thuc dng ngoi
Da ngi cao tui kh, thnh phn lipid gim, kh thm cc thuc thn
nc nn hp thu thuc qua da gim.
Thuc tim bp
Khi c gim, ti mu gim, hp thu thuc theo ng ny gim v
khng n nh.
4.1.2. Chuyn ho thuc qua gan ln u

Cc thuc b chuyn ho qua gan gim ngi cao tui do hot tnh
men gan gim, kch thc gan gim, lu lng mu qua gan gim. Hu qu
lm tng ng k tc dng lm sng ca mt s thuc ngi gi, v d nh
nifedipin.
4.1.3. Phn b thuc

Do c s gim lng nc ton b c th, nhng thuc tan trong nc
nh digoxin, morphin, lithi b gim th tch phn b (Vd), tng nng trong
mu v trong m. Cc thuc gn mnh vo m nh digoxin s ko di thi
gian tc dng.
T l m trong c th tng lm tng kh nng phn b ca cc thuc
tan trong m nh barbiturat, thiopental, diazepam... dn n ko di thi
gian tc dng, tch lu nhiu m m.
Gim protein huyt tng, ch yu l albumin, nn cc thuc acid c xu
hng gn vi albumin huyt tng (cimetidin, furosemid, wafarin) s tng
lng thuc dng t do, tng tc dng.
4.1.4. Chuyn ho thuc ti gan
Khi lng gan v lu lng mu qua gan ngi cao tui gim nn
mt s thuc b chuyn ho qua gan s b ko di thi gian tc dng, d tch
lu v ng c. Thng thng, thuc chuyn ho nhiu qua gan khi dng cho
ngi cao tui nn gim 1/2 - 1/3 liu v theo di cht ch.
4.1.5. Thi tr thuc qua thn
96
Do khi lng thn, s lng nephron v lu lng mu qua thn gim,
kh nng lc ca cu thn v ng thn gim nn thi gian bn thi ca
nhiu thuc, c bit l nhng thuc thi tr ch yu di dng cn hot
tnh nh thn tng ln, lm tng tc dng v c tnh. Do cn gim liu
cc thuc c phm vi iu tr hp nh digoxin, aminosid ngi cao tui.
Thay i chc nng thn rt khc nhau gia cc c th ngi cao tui
nn cn c s iu chnh liu thch hp cho tng bnh nhn c th, da vo
thanh thi creatinin.
4.2. Thay i v dc lc hc ngi cao tui
4.2.1. D b tt huyt p th ng
Mt s thuc nh thuc h huyt p, thuc c tc dng chn giao
cm, thuc c ch giao cm ca thn kinh trung ng, thuc chng
Parkinson... d gy tt huyt p th ng ngi cao tui.
4.2.2. D b ng do mt thng bng t th

C th c th thng bng c l nh kh nng iu chnh thng bng.
Cng vi tui tc, kh nng gi thng bng ca c th b gim; chnh v th
khi dng mt s thuc nh thuc ng, thuc an thn... t l ng ngi cao
tui cao hn thanh nin.
4.2.3. Kh nng iu ha thn nhit gim

Kh nng iu ho thn nhit gim ngi cao tui. H nhit bt
thng c th gp khi dng cc thuc an thn gy ng, chng trm cm 3
vng, ch phm thuc phin v ru...
4.2.4. Gim chc nng nhn thc

H thng thn kinh trung ng c s thay i ln v cu trc v cht
trung gian ho hc ngi cao tui. V vy mt s thuc hay gy l ln
ngi cao tui nh thuc khng cholin, thuc ng, khng th th H2, chn
th th beta 2.
4.3. c im bnh l lin quan n s dng thuc

Tnh trng a bnh l: Ngi cao tui mc nhiu bnh mt lc, do
phi dng nhiu thuc ng thi. iu ny dn n tng nguy c gp
tng tc thuc - thuc v tc dng khng mong mun ca thuc (t l
ADR gp la tui 60 - 70 gp i la tui 30 - 40).
S suy gim chc nng gan - thn gy gim thi tr thuc. Cc tai bin
v thuc ngi cao tui thng l lin quan n qu liu hn l do c
tnh ca thuc.
97
Thay i p ng vi thuc lin quan n tui tc do cc tn thng
lu cu ca nhng qu trnh bnh l ko di sut c cuc i. Ngi
cao tui cng nhy cm hn vi mt s tc dng bt li, v d: D b tt
huyt p hn, d b trm cm hn...
4.4. Nhng vn cn ch khi s dng thuc cho ngi cao tui

Ngi cao tui l nhm bnh nhn c c im sinh l khc bit vi
thanh nin. S lo ho khng ging nhau tng lp tui cng dn n
nhng khc bit gia cc c th trong p ng vi thuc v trong qu trnh
tun hon ca thuc trong c th.
Nhng vn cn ch khi s dng thuc cho ngi cao tui bao gm:
Ri lon tiu ho (to bn), do ngi cao tui hay dng thuc nhun
trng, iu ny lm gim hp thu thuc.
Gim tr nh: Hay qun dng thuc, nhm ln liu.
Mt km: Kh c hng dn, phi ghi ch to, d c.
Run tay: Khng nn cho ung thuc theo git, lu cc chai thuc kh m.
Thch lm dng thuc, dng ko di qu quy nh.
Long xng nn vn ng t, hay ung thuc khi nm: Lu vi thuc
gy lot thc qun.
t kht nn t ung nc: Phi nhc ung nhiu nc khi dng cc
thuc d lng ng thn nh Co-trimoxazol, cc sulfamid.
Nh vy, iu tr cho ngi cao tui, cn phi hiu tui tc v cc
bnh mc km nh hng nh th no n dc ng hc v dc lc hc
ca thuc, trn tng c th, v cn phi lu tm n mong mun ca h
trong vn iu tr.
Kt lun
Nh vy, cc i tng c bit, c nhng vn khc bit cn phi
c tnh n khi dng thuc. Thng thng cc thng tin v an ton,
cch hiu chnh liu, cc theo di cn thit khi s dng mt thuc cho bnh
nhn thuc i tng c bit c nu trong cc chuyn mc thng tin v
thuc cc ti liu tra cu chuyn mn. V vy trc khi s dng bt c
thuc no, cn xem xt k hng dn s dng. Nu trong chuyn lun thng
tin ca mt thuc, thng tin v mt i tng c bit no khng c
cp n th tt nht khng nn dng thuc ny cho i tng trn.
T lng gi
98
1. Thuc c th c dng cho ngi m (A) nhng ri lon ca thai
nhi. Tuy nhin vn ng quan tm khi dng thuc ph n c thai l
thuc vo c vng tun hon ca thai v (B) cho thai nhi.
2. Thi k tin phi, c tnh ca thuc i vi thai nhi tun theo qui lut.
(A), tc l. (B) hoc.. (C).
3. Giai on thai nhy cm nht vi c tnh ca thuc l (A)... (tnh
t...(B)... n (C)....ca tui thai).
4. Cc thuc c phn loi A cho ph n c thai l nhng thuc m cc
nghin cu c kim sot cho thy ...(A).... i vi bo thai.
5. Cc thuc phn loi X ...(A)... dng cho ph n c thai.
6. Bn c tnh ca thuc nh hng n kh nng khuch tn thuc vo
sa l:
A. ..
B. ...
C. Mc ion ho ca thuc (pKa)
D. ..
7. Liu lng thuc dng cho tr em cn phi tnh ti (A), v cn c vo
kh nng (B)
8. Thuc dng ng trc trng cho tr em c th t c tc dng nhanh,
thch hp khi tr b (A), (B) hoc (C)
9. Liu lng cc thuc thi tr nhiu qua thn khi dng cho ngi cao tui
cn c hiu chnh da vo(A)
10. Ngi cao tui mc nhiu bnh, phi dng nhiu thuc ng thi, dn
n tng nguy c gp (A) v (B)
11. Cc nhm thuc hay gy l ln ngi cao tui l: thuc khng cholin,
thuc ng, . (A) ., . (B)
12. Cc thuc an thn gy ng lm gim (A) do vy lm t l ng
ngi cao tui cao hn thanh nin.
13. H nhit bt thng ngi cao tui c th gp khi dng cc thuc an
thn gy ng, (A), . (B). v ru.
14. Cc thuc chuyn ho nhiu qua gan khi dng cho ngi cao tui thng
thng nn gim (A) liu v theo di cht ch.

15. Giai on pht trin m thai nhi nhy cm nht vi c tnh ca thuc,
99
c th dn ti nhng bt thng nng n v hnh thi l:
A. Thi k tin phi
B. Thi k phi.
C. Thi k thai.
D Thi k phi v thai.
.
16. Hp thu thuc theo ng tim bp tr s sinh chm v tht thng do:
A. Khi c vn t, co bp c vn km
B. Lu lng ti mu khng u
C. T l nc nhiu
D. Tt c cc yu t trn
17. Nhng khc bit v dc ng hc ca thuc tr em ch yu gp la tui:
A. Tr s sinh
B. Tr di 1 nm tui.
C. Tr nh 1 - 6 tui
D. A v B ng
E. B v C ng
18. Nhng vn cn ch khi s dng thuc cho ngi cao tui bao gm:
ANgi cao tui gim tr nh, hay qun dng thuc, nhm ln liu.
.
BMt ngi cao tui km nn kh c hng dn dng thuc.
.
CNgi cao tui thng t ung nc nn d gy lng ng thuc thn.
.
DC 3 trn u ng.
.
Phn bit ng /sai (t cu 19 n cu 30)
S
19. Mt s thuc khi dng cho ph n c thai gn ngy sinh c th
b tch lu ng k tr s sinh v gy tc dng bt li cho tr.
100
S
20. Nhm thuc c phn loi A l nhng thuc an ton nht khi
dng cho ph n c thai.
21. Nhng thuc an ton cho tr s sinh v tr nh th dng cho
ph n cho con b cng an ton cho tr b m.
22. Nhng thuc khng hp thu khi dng ng ung nh
aminoglycosid, vancomycin nu dng cho ph n cho con b
s khng an ton cho tr b m v c c tnh cao.
23. Ph n cho con b nn dng thuc trnh thai cha progesteron
n c.
24. Khi dng thuc cho ph n cho con b, nn chn thuc c t l
nng sa/huyt tng thp, c thi gian bn thi ngn
25. Nn cho tr b ngay trc khi ngi m dng thuc v nng
thuc trong mu m l thp nht
26. Khi dng thuc cho ph n c thai hoc ph n cho con b,
nn trnh dng liu cao v dng thi gian ngn nht c hiu
qu
27. Hp thu thuc qua da ca tr s sinh v tr nh km hn so
vi ngi ln.
28. Tr nh c bit nhy cm vi tc dng c ch thn kinh ca
phenobarbital v cc thuc gim au trung ng nh morphin
29. Dng thuc dng ng ung ph hp nht cho tr nh l
dng lng
30. Thuc ung dng cho tr nh khng nn c mu sc v mi v
hp dn v d lm tr ung nhm gy ng c.
101
Bi 8
nguyn tc S dng thuc

khng sinh v khng khun
Mc tiu
1. Trnh by c nh ngha v khng sinh v p dng ca khng sinh
trong s dng khng sinh.
2. Nu c nh ngha ca s khng khng sinh v bin php hn ch s
khng khng sinh.
3. Trnh by c tc dng khng mong mun (ADR), chng ch nh (CC)
ca 9 nhm thuc khng sinh v khng khun thng dng.
4. Lit k v phn tch c 3 nguyn tc s dng thuc khng sinh v
khng khun hp l trong iu tr.
M u
Lch s ra i ca khng sinh cho n nay gn 1 th k. Vi s pht
trin nhanh chng ca k thut tng hp ho dc, nhiu cht trc y ch
c th sn xut bng con ng nui cy vi sinh vt th nay c th tng
hp ton phn nh cc khng sinh nhm phenicol, tetracyclin...; bn cnh
cc cht khng khun tng hp ra i vi hot lc mnh khng thua km
cc khng sinh c ngun gc t nhin lm cho danh mc cc cht khng sinh
v khng khun (KS&KK) ngy mt nhiu. S ra i hng lot ch phm
mi gy khng t kh khn cho c ngi k n v ngi s dng. y l
mt nhm thuc c bn theo n nhiu nc nhng Vit Nam cha
lm c iu ny.
Chuyn ny s gip cc hc vin h thng ho li cc kin thc
hc chng trnh ho dc - dc l, lm c s hiu cc nguyn tc s
dng KS&KK (sau y chng ti gi chung l khng sinh) an ton - hp l.
1. Nhc li mt s khi nim c bn lin quan n s dng

khng sinh
Vic nh gi hot tnh ca ca khng sinh trn vi khun n gin
nht c thc hin ngoi c th, trn cc mi trng nui cy vi khun (in
vitro) iu kin nhit thch hp (thng khong 280C n 370C).
102
Sau y l mt s khi nim lin quan n hot tnh khng khun ca
khng sinh in vitro.
1.1. Nng km khun ti thiu

Gi tt theo ting Anh l MIC (Minimum Inhibitory Concentration): L
mc nng thp nht lm cho vi khun khng nhn ln c, s lng t
bo vi khun khng thay i k t khi tip xc vi khng sinh nhng vi
khun khng cht; vi khun cht cn phi tng nng (nu c th) hoc
c s tham gia ca c th (in vivo nu c th c sc khng).
1.2. Nng dit khun ti thiu

Gi tt theo ting Anh l MBC (Minimum Bactericid Concentration):
L nng thp nht c kh nng tiu dit vi khun. S lng t bo vi
khun s gim dn theo thi gian tip xc gia khng sinh vi vi khun.
T cc gi tr MIC v MBC, nh sn xut s a ra cc mc liu v
khong cch a thuc ph hp (liu khuyn co) sao cho nng khng
sinh t c trong huyt tng sau khi s dng phi t mc ln hn
MIC v khong thi gian duy tr mc trn MIC l bao nhiu tu thuc
loi khng sinh.
1.3. Khng sinh km khun v khng sinh dit khun

Khi t l MBC/MIC > 4, khng sinh c tc dng km khun, cn khi t
l ny bng 1, khng sinh c tc dng dit khun.
Khng sinh km khun thng c s dng trong nhng trng hp
nhim khun nh v trung bnh, trn c a bnh nhn c sc khng.
Cc nhm khng sinh c tc dng km khun l: Macrolid, tetracyclin,
phenicol, lincosamid.
Khng sinh dit khun c dng cho cc nhim khun nng, trn
nhng bnh nhn yu, suy gim min dch. Cc nhm khng sinh c tc
dng dit khun l: Beta-lactamin, aminosid, fluoroquinolon, 5-nitro
imidazol, Co-trimoxazol.
1.4. Khng sinh

Khng sinh l phng php nh gi nhy cm ca vi khun i
vi khng sinh trn th nghim in vitro.
Khng sinh thng c lm khi iu tr nhng trng hp nhim
khun nng, vi tc nhn gy bnh c khng khng sinh cao, khng
vi nhiu loi khng sinh thng dng. Khng sinh gip ta la chn c
khng sinh ph hp vi vi khun gy bnh trn mt bnh nhn c th.
103
1.5. S khng khng sinh
Nhng trng hp s dng khng sinh mc liu khuyn co thng
thng khng em li kt qu c gi l khng khng sinh.
C 2 loi khng thuc:
Khng gi: y l trng hp thng gp khi dng khng sinh c tc
dng km khun. Vi khng sinh loi ny, nhim v tiu dit vi khun
thuc v c th vt ch (ngi) nhng do c th b suy yu (gi yu, do dng
thuc iu tr ung th, thuc c ch min dch ko di...). Khng gi cng
gp trong trng hp nng khng sinh ti nhim khun khng do
khng sinh thm nhp km vo nhim khun (do bn cht ca phn t, do
t chc nhim khun kh thm thuc...). Nhng trng hp ny nn
thay bng khng sinh dit khun, khng sinh c c tnh dc ng hc
thch hp.
Khng tht: Do vi khun to ra men ph hu khng sinh hoc to ra
gen khng khng sinh. Khng tht xut hin do s dng khng sinh khng
hp l (khng liu, khng thi gian quy nh...). khng sinh c tc
dng trong trng hp ny, cn phi hp khng sinh, chn khng sinh theo
khng sinh .
2. Tc dng khng mong mun v chng ch nh
Cc nhm khng sinh v khng sinh c th c trnh by trong hc

phn Ho dc - Dc l I v II. Hc phn ny (Ho dc - Dc l III tc
Dc lm sng) gii thiu tp trung vo cc kin thc lin quan n s dng
thuc hp l. S dng thuc hp l khng ch ni n hiu qu m phi bo
m c an ton. t mc tiu ny, vic tn trng chng ch nh
(CC) v phng nga phn ng c hi (ADR) do thuc gy ra l rt quan
trng.
Phn ny nhm tm tt mt s CC v ADR ca mt s nhm khng
sinh v khng khun thng dng. Cc khng sinh nu trong ct 2 c nu
theo tn quc t v ch l nhng v d v khng th k ht cc i din vi
mi nhm.
104
Bng 8.1. Tc dng khng mong mun v chng ch nh
Thuc thng gp ADR v CC
Cc penicilin Pen. G, pen. V, - D ng: Ban da, sc qu mn

Ampicilin, Amoxicilin CC: Tin s d ng vi beta-lactam
Cc cephalosporin C1G: Cephalexin,

Cephalothin - D ng: Ban da, sc qu mn (t l t hn
C2G: Cefaclor, penicilin)
Cefuroxim - c vi thn
C3G: Cefotaxim, CC: Tin s d ng vi cephalosporin
Ceftriaxon
Aminosid Streptomycin, - Suy thn
Kanamycin, - Gim thnh lc, ic
Gentamicin, Amikacin CC: Tin s d ng vi aminosid, nhc c
Fluoroquinolon Nofloxacin, - Mn cm vi nh sng
Ciprofloxacin, - Co git
Pefloxacin, Ofloxacin - Tn thng m sn
- Vim gn, t gn
CC: Tr em < 15 tui, c thai, cho con b,
suy gan, suy thn nng, ng kinh
- D ng
TMP/SMZ Co-trimoxazol - Mu: Thiu mu, gim bch cu, suy tu
- Si ng niu
CC: Mn cm, c thai, cho con b, tr s
sinh, bnh v mu
Metronidazol, - Bun nn, chn n, a lng
5-nitro imidazol Tinidazol - Vim a dy thn kinh, co git
CC: C thai, cho con b, ri lon TKT
Macrolid Erythromycin, - Ri lon tiu ho: Bun nn, a lng
Clarythromycin, - Vim gan, vng da do mt
Spiramycin, CC: Mn cm, suy gan nng
Azithromycin
Lincosamid Lincomycin, - Vim rut kt mng gi
Clindamycin CC: Suy gan, nhc c
- Suy tu
Phenicol Cloramphenicol, - Hi chng xm tr s sinh
Thiamphenicol CC: Mn cm, tr s sinh, c thai, ang
cho con b, suy tu
Tetracyclin Tetracyclin, - Tn hi xng v rng
Oxytetracyclin, - Ri lon tiu ho
Doxycyclin CC: Tr em di 9 tui, c thai, cho con b
Ghi ch: C1G, C2G, C3G l cephalosporin th h 1, 2, 3

TMP/SMZ l Trimethoprim v Sulfamethoxazol
105
3. nguyn tc s dng khng sinh trong iu tr
Trong phn ny chng ta s cp n 3 nguyn tc sau:
Ch s dng khng sinh khi c nhim khun
Phi bit la chn khng sinh hp l.
Phi s dng khng sinh ng thi gian qui nh.
3.1. Ch s dng khng sinh khi c nhim khun

Cc tc nhn gy bnh cho ngi c th l virus, vi khun, nm, sinh
vt n bo (amip, trichomonas...) hoc k sinh vt (giun, sn...). Cc khng
sinh cp phn ny ch c tc dng vi vi khun, do trc khi ch nh
khng sinh, phi tin hnh nhng bc sau y xc nh ng l bnh do
nhim vi khun trc khi quyt nh s dng khng sinh:
Thm khm lm sng: Bao gm vic o nhit bnh nhn, phng
vn v khm bnh. y l bc quan trng nht v phi lm trong mi
trng hp.
V st l du hiu in hnh khi c nhim khun nn vic o nhit
gp phn quan trng khng nh nhim khun. St do vi khun
thng gy tng thn nhit trn 390C trong khi st do virus ch c
nhit khong 380C - 38,50C.
Nhng trng hp ngoi l:
+ Nhim khun bnh nhn suy gim min dch, bnh nhn qu gi
yu... c th ch st nh.
+ Tri li, nhim virus nh bnh quai b, thy u, st xut huyt, bi
lit... c th tng thn nhit ti trn 390C.
Thm khm lm sng v phng vn bnh nhn gip thy thuc d
on tc nhn gy bnh qua ng thm nhp ca vi khun, qua cc
du hiu c trng...
Cc xt nghim lm sng thng qui: Bao gm cng thc bch cu,
X quang v cc ch s sinh ha s gp phn khng nh chn on ca
thy thuc.
Tm vi khun gy bnh: L bin php chnh xc nht tm ra tc
nhn gy bnh nhng khng phi mi trng hp u cn. Ch trong
trng hp nhim khun rt nng nh nhim khun huyt, vim mng
no, thng hn... khi m thm khm lm sng khng tm thy du
hiu c trng hoc nhim khun mc phi bnh vin, bnh nhn
suy gim min dch khng c st hay ch st nh.
106
Vic phn lp vi khun gy bnh khng phi u cng lm c, li
phi mt thi gian v tn km nn mc du chnh xc nhng khng phi l
u tin hng u. Hn na nc ta vic bn khng sinh trn lan khng
cn n cng lm kh khn cho vic pht hin vi khun khi nui cy.
3.2. Phi bit la chn khng sinh hp l

La chn khng sinh ph thuc 3 yu t:
Vi khun gy bnh
V tr nhim khun
C a bnh nhn
3.2.1. La chn khng sinh phi ph hp vi vi khun gy bnh

Mi khng sinh ch c tc dng ln mt s loi vi khun nht nh, cho
d khng sinh c coi l ph rng. V vy mun ch nh khng sinh hp l
th phi chn c khng sinh ph hp vi tc nhn gy bnh. Vic nh
danh vi khun nh phn trn ni l rt tn km, mt thi gian v khng
phi lc no, ni no cng lm c; do ch yu da vo kinh nghim lm
sng l chnh.
V d:
Trn b mt da hay gp cc vi khun Gram (+) nh lin cu
(Streptococcus), t cu (Staphylococcus).
Vng khoang ming, hu, hng hay gp lin cu nhm A (Streptococcus
pyogenes).
Trong i trng c nhiu E. coli.
Tuy nhin, nhiu khi ti nhng v tr trn vn gp nhng vi khun
khc do s di chuyn ca vi khun t v tr ny sang v tr khc; do
vic kt hp thm cc xt nghim l khng th thiu c khi la chn
khng sinh.
3.2.2. La chn khng sinh theo v tr nhim khun

Mun iu tr thnh cng, khng sinh phi thm c vo nhim
khun, nh vy ngi thy thuc phi nm vng cc c tnh dc ng hc
ca thuc mi c th chn c khng sinh thch hp.
iu ny rt quan trng khi iu tr nhim khun ti cc t chc kh
thm thuc nh mng no, tuyn tin lit, xng - khp, mt.
107
Bng 8.2. Kh nng thm u tin ca mt s khng sinh
vo cc c quan v t chc
C quan, t chc Khng sinh

Tuyn tin lit Erythromycin, Co-trimoxazol, FQ, C3G
Xng - khp Lincomycin, clindamycin, rifampicin, FQ, C1G...
Dch no ty Cloramphenicol, rifampicin, metronidazol, C3G...
Ghi ch: C1G, C2G, C3G l cephalosporin th h 1, 2 v 3;
FQ l fluoroquinolon.
Cc khng sinh bi ti ch, nh hoc tra mt, nh vo tai... cng c ch
nhm tng nng ti nhim khun. Khng sinh dng ngoi rt a dng
v thng l nhng khng sinh c c tnh cao khi dng ton thn nh
colistin, framycetin, polymycin-B.
Vi cc v tr cho php bi thuc nh nhim khun da v m mm, nn
tn dng li th ca thuc st khun (cn 700, chlorohexidin, iod hu c, bc
sulfadiazin... ).
3.2.3. La chn khng sinh theo c a bnh nhn
Nhng i tng cn lu khi la chn khng sinh bao gm:
Tr em (c bit l tr s sinh), ngi cao tui, ngi suy gim chc
nng gan thn l nhng i tng d b tch lu thuc do chc nng
thi tr thuc km.
Ph n c thai, ang cho con b l nhng i tng m vic dng thuc
c th nh hng n thai nhi hoc tr b m.
Ngi c c a d ng l nhng i tng m vic dng thuc d gp d
ng, c bit l sc qu mn.
Bng 8.3 trnh by v d v c tnh trn gan v thn ca mt s khng
sinh. Bng 8.4. trnh by khuyn co la chn khng sinh cho ph n c
thai minh ha cho nguyn tc la chn khng sinh theo c th.
Bng 8.3. Kh nng gy c vi thn ca mt s khng sinh
Khng sinh Mc c vi thn

Aminosid ++
Cc penicilin 0
Cc cephalosporin +
Tetracyclin +
Doxycyclin 0
Phenicol 0
Ghi ch: K hiu (0): khng gp hoc cha c bo co
(+): thnh thong, (++): gp thng xuyn
108
Bng 8.4. S dng khng sinh ph n c thai
Khng sinh 3 thng u 3 thng gia 3 thng cui

Pen. G + + +
Pen. M + + 0
Pen. A + + +
Cephalosporin + + +
Macrolid + + +
Aminosid 0 0 0
Tetracyclin 0 0 0
Phenicol 0 0 0
Lincosamid 0 0 0
Co-trimoxazol 0 0 0
Quinolon 0 0 0
Ghi ch: K hiu (0): khng c s dng, (+) s dng c (Theo Mouton Y 1994)
3.3. Phi s dng khng sinh ng thi gian qui nh

Khng c qui nh c th v di ca t iu tr vi mi loi nhim
khun nhng nguyn tc chung l s dng khng sinh n khi ht vi khun
trong c th cng thm 2 - 3 ngy ngi bnh thng v 5 - 7 ngy bnh
nhn suy gim min dch.
Thc t t khi c iu kin cy vi khun sau khi iu tr, do coi l
ht vi khun khi bnh nhn gim st, trng thi c th ci thin: n ng tt
hn, tnh to...
Vi nhim khun nh, t iu tr thng ko di khong 7 n 10 ngy,
nhng vi nhim khun nng, nhim khun nhng t chc m khng sinh
kh thm nhp (mng tim, mng no, xng...) th t iu tr ko di hn;
ring vi bnh lao, phc ngn ngy cng phi ko di ti 8 thng.
Ngy nay, vi s xut hin nhiu khng sinh hoc cc dng ch phm c
thi gian bn thi ko di cho php gim c ng k s ln dng thuc
trong t iu tr, lm d dng hn cho vic tun th iu tr ca bnh nhn.
V d:
Dng doxycyclin trong iu tr nhim khun ng h hp do
Rickettsia, Mycoplasma v cc vi khun ni bo khc ch cn mt t
iu tr ko di 3 ngy trong khi nu dng cc tetracyclin c in phi
mt t nht 7 - 10 ngy.
Dng ceftriaxon iu tr bnh thng hn, liu 1 - 2 g/ln, t 5 ngy
thay cho dng cloramphenicol 30 - 50 mg/kg mi ngy, ko di 14 ngy.
109
Kt lun
Mi lin h tam gic "khng sinh vi khun ngi bnh" rt khng
kht. Chn c khng sinh ph hp vi loi vi khun gy bnh kh
nhng ng thi li phi ph hp vi ngi bnh li cng kh hn. Trong
khun kh chng trnh trung hc, chng ti ch ch trng n nhng nt
lin quan n s dng khng sinh trong iu tr, cn phn s dng khng
sinh cho d phng s hc trong chng trnh i hc. Nhng ni dung lin
quan n s dng khng sinh trong iu tr cng ch trnh by tm tt, tp
trung vo mt s nhm khng sinh thng dng. Cc kin thc rng hn s
c hc chng trnh i hc.
T lng gi
1. Khng sinh l phng php nh gi ...(A)... ca vi khun i vi
...(B)... trn th nghim ...(C)..
2. Khng khng sinh l nhng trng hp s dng khng sinh mc liu
...(A)..nhng ...(B)... kt qu
3. Xp tn khng sinh ph hp vi tn nhm bng cch in s vo vung:
1. Beta-lactam Metronidazol Cefotaxim
2. Aminosid Doxycyclin Cefurozim
3. Quinolon Ampicilin Tinidazol
4. Tetracyclin Cephalexin Gentamicin
5. Macrolid Ciprofloxacin Ofloxacin
6. Phenicol Cloramphenicol Erythromycin
7. Nitro-imidazol Clindamycin Pefloxacin
8. Lincosamid Pen. G Spiramycin
9. TMP/SMZ Lincomycin Kanamycin
4. Mun xc nh l bnh nhn c nhim khun, cn phi:
A. Thm khm lm sng
B. ..
C. .
5. Cc khng sinh c th thm tt vo dch no tu l:
A. Cloramphenicol
110
B. .
C.
D .
6. Cc khng sinh c xuyn tt vo xng l:
A. Clindamycin
B. .
C. Ciprofloxacin
D. .
7. Nng km khun ti thiu (MIC) l .... (A)... c ch s nhn ln ca vi
khun. Ti mc nng ny, s lng t bo vi khun ...(B)... nhng vi
khun khng cht.
8. Nng dit khun ti thiu (MBC) l ...(A)... c kh nng tiu dit vi
khun. S lng t bo vi khun ...(B) ... theo thi gian tip xc gia
khng sinh vi vi khun.
9. Chn nhm khng sinh v khng khun thng dng l:
1. Beta-lactam 4. TMP/SMZ 7. Phenicol
2 5. 8
3. 6. Macrolid 9

10 . Khng sinh c tc dng km khun khi:
A. T l MBC/MIC > 4.
B. T l MBC/MIC < 4.
C. T l MBC/MIC = 4.
11. Cc khng sinh sau y u c th s dng cho ph n c thai, tr:
A. Pen. G
B. Erythromycin
C. Amoxicilin
D. Cephalexin
E. Gentamicin
12. Cc cu sau y v "Khng gi" i vi khng sinh u ng, tr:
A. Thng gp khi dng khng sinh c tc dng km khun.
B. Thng gp khi dng khng sinh c tc dng dit khun.
111
C. Nng khng sinh ti nhim khun khng
D. Thng gp khi dng khng sinh km khun ngi suy gim min
dch
13. Cc cu sau y v "Khng tht" i vi khng sinh u ng, tr:
A. Khng tht l do vi khun to ra men ph hu khng sinh hoc to
ra gen khng khng sinh
B. Khng tht xut hin do s dng khng sinh khng liu
C. Khng tht xut hin do s dng khng sinh khng thi gian
quy nh
D. Khng nn phi hp khng sinh trong trng hp ny.
E. Nn lm khng sinh khi iu tr cho nhng trng hp ny.
14. Cc nhm khng sinh sau y c tc dng km khun, tr:
A. Macrolid
B. Tetracyclin
C. Aminosid
D. Phenicol
E. Lincosamid

V tc dng khng mong mun (ADR) ca thuc khng sinh v khng khun:
S
15. D ng l ADR ni bt ca nhm beta-lactam
16. Sc qu mn gp nhiu khi s dng nhm cephalosporin hn
nhm penicilin
17. Gy suy tu l ADR thng gp khi dng nhm quinolon
18. ic c th gp khi dng nhm aminosid
19. Nhc c khng bao gi gp khi dng nhm lincosamid
20. Gy tn hi xng v rng thng gp khi dng nhm phenicol
21. Quinolon c th gy co git
22. Tetracyclin c th gy t gn
23. Si tit niu l ADR c th gp khi s dng TMP/SMZ
24. Bun nn, chn n thng gp khi s dng metronidazol
112
V di ca t iu tr bng khng sinh:
S
25. t iu tr khng sinh thng ko di khong 3 ngy
26. Nn ngng ngay khng sinh khi triu chng lm sng c ci
thin
27. iu tr lao thng ko di 8 thng
28. iu tr vim mng no do vi khun ko di khong 1 tun
29. Khi dng cc khng sinh c thi gian bn thi di, t iu tr
c rt ngn li
113
Bi 9
nguyn tc s dng Vitamin v cht khong
Mc tiu
1. Trnh by c lng cn b sung khi thiu ca mt s vitamin v cht
khong sau y: A, C, B1, B6, B12, calci, st, iod.
2. Trnh by c cc nguyn nhn gy thiu vitamin v cht khong v
nu c bin php khc phc.
3. Trnh by c cc nguyn nhn gy tha vitamin v cht khong v
nu c bin php hn ch nguy c ny.
M u
Vitamin l cc cht hu c c sn trong thc phm, ng cc, rt cn
thit cho cuc sng hng ngy. Vitamin lun tn ti cng vi cc cht
khong (Ca, Mg, Fe, Cu, Zn...). Nhm cc cht ny khng to ra nng lng
cho c th hot ng nh glucid, lipid, cng khng tham gia vo vic to cc
t bo cho c th nh protid, lng cn a hng ngy rt nh (thng ch
tnh bng miligam) nhng li v cng quan trng cho s sng. Vitamin v
cht khong tham gia to nn cc enzym cn cho chuyn ha cc cht hoc
bn thn l nhng cht sinh hc c hot tnh mnh nn khi thiu hoc tha
so vi nhu cu hng ngy th u c th gy bnh.
Cc vitamin v cht khong thng c bn nh nhng thuc khng
k n di nhiu dng n l hoc phi hp, vi cc hm lng khc nhau
v ch nh cng rt a dng gy khng t lng tng cho ngi s dng.
Cng do c bn t do trn lan v tuyn truyn khng chnh xc v
tc dng nn trong thc t to ra s lm dng, gy nhng tai bin
nghim trng.
Xut pht t cc c im trn, chuyn ny nhm cung cp mt s
thng tin cn thit trong vic la chn v s dng vitamin v cht khong,
gp phn vo vic nng cao hiu qu iu tr t mc tiu "an ton - hp
l" trong s dng nhm thuc ny.
114
1. nhu cu hng ngy v vitamin v cht khong
Nhu cu hng ngy v vitamin v cht khong i vi ngi bnh
thng khng nhiu. B sung vitamin v cht khong ch cn thit khi
thiu. Bng 9.1. l lng vitamin v cht khong cn b sung hng ngy khi
thiu hon ton di dng thuc.
Bng 9.1. Liu khuyn co b sung vitamin v cht khong hng ngy
Vitamin v Di 1 T 1- 4 Trn 4 tui v C thai v

n v
cht khong tui tui ngi ln cho con b
Vitamin A vqt 1.500 2.500 5.000 8.000
- D vqt 400 400 400 400
- E vqt 5 10 30 30
- C mg 35 40 60 60
- B1 mg 0,5 0,7 1,5 1,7
- B2 mg 0,6 0,8 1,7 2
- PP (B3) mg 8 9 20 20
- B6 mg 0,4 0,7 2 2,5
- B12 g 2,0 3 6 8
A. folic (B9) mg 0,1 0,2 0,4 0,8
Biotin (B8) mg 0,5 0,15 0,3 0,3
A.pantothenic (B5) mg 3 5 10 10
Calci (Ca) mg 600 800 1.000 1.300
St (Fe) mg 15 10 18 18
Phospho (P) mg 500 800 1.000 1.300
Iod (I2 ) g 45 70 150 150
Magnesi (Mg ) mg 70 200 400 450
Km (Zn) mg 5 8 15 15
ng (Cu) mg 0,6 1 2 2
S liu trong bng 9.1 da theo tiu chun ca Vin hn lm khoa hc

M v c "Cc Thc phm v Thuc" (FDA) ca M ly lm thng tin
la chn b sung vitamin v cc cht khong, v vy lng ghi trong bng l
tiu chun b sung trong trng hp thiu ht vitamin.
Bnh thng, liu dng ca cc vitamin v cht khong ch nn trong
phm vi t 3 n 5 ln lng ghi trong bng. Dng ko di nhng lng ln
hn 10 ln nhu cu thc t c th dn n nhng trng thi bnh l do tha
vitamin v cht khong.
115
Hai vitamin c phm vi an ton hp nht l vitamin A v D. Liu ti a
cho php ch gp 10 ln nhu cu trong bng. Viatmin A c bit nguy him
khi dng liu cao cho ph n c thai v c nguy c gy qui thai hoc tng p
lc ni s thai nhi. Ph n c thai nu cn b sung ch c dng nhng
liu bng lng ghi trong bng.
Trong bng khng trnh by nhu cu vitamin K v thc t lng
vitamin K cn cho nhu cu hng ngy c th bo m nh h vi khun rut.
B sung vitamin ny ch cn thit i vi tr s sinh v i tng ny h vi
khun rut cha pht trin y hoc vi bnh nhn s dng ko di
khng sinh ng ung do h vi khun rut b khng sinh hy hoi. Do
vitamin K c d tr trong gan nn vic b sung cng n gin: Dng 1
liu 0,5 - 1 mg qua ng tim bp hoc ung.
Nhn vo bng 9.1 c th thy lng cn b sung vitamin v cht
khong hng ngy tu thuc la tui, trng thi sinh l,....
Nhu cu tng c th gp trong cc trng hp sau:
Trng thi sinh l: Nhu cu hng ngy s tng khng ch theo la tui,
khi c thai... m c theo hot ng th lc (lao ng nng, hot ng
th thao...).
Trng thi bnh l: Khi b bnh ko di, c bit l nhng trng thi
bnh l lin quan n h tiu ho - ni hp thu vitamin (tc mt, ct
on d dy, a chy ko di...), khi gp stress (st cao, sau m, nhim
khun nng...). Cc s liu trong bng 9.2 l v d v mt s trng hp
cn b sung vitamin v lng cn b sung.
Bng 9.2. Lng vitamin cn b sung khi gp stress
(st cao, sau m, bng nng, nhim khun nng...)
Vitamin % US RDA Lng cn b sung

Vitamin C 500 300 mg
Vitamin B1 667 10 mg
Vitamin B12 61 1,8 mcg
Acid folic 375 1,5 mg
2. Thiu vitamin v cht khong
2.1. Nguyn nhn gy thiu

Cc vitamin v cht khong lun c sn trong ng cc v thc phm
(go, m, tht, c, trng, sa, rau...), v vy i vi nhng ngi khng c qu
116
trnh ri lon hp thu ng tiu ha (a chy, tc mt, vim ty, lot d
dy- t trng...) v khng n king, c ch n cn i vi thc phm m
bo cht lng th khng bao gi thiu v khng cn b sung. Ni chung, cc
vitamin tan trong nc d b hng hn cc vitamin tan trong du v khng
c d tr nn d gp hin tng thiu hn.
Nn nh rng vitamin lun tn ti song song vi cht khong v cc
nguyn t vi lng (st, ng, km, calci, phospho...) nn nhng trng hp
thiu vitamin cng thng km theo thiu c cht khong v do khi b
sung cng cn tnh n c cht khong. Tuy nhin, cht khong kh bn v
t hao ht nn nguy c thiu cng t hn; vic b sung cht khong cn thn
trng v phm vi an ton hp, d dn n ng c do qu liu.
Thiu cc cht ny c th do nhng nguyn nhn sau:
2.1.1. Do cung cp thiu

Cht lng thc phm khng bo m: Ng cc lu ngy hoc b
mc s gim lng cc vitamin nhm B c trong lp v o ca ht (go,
m...). Rau qu a, ho hoc bo qun lnh lu ngy lm gim hm
lng vitamin C.
Khu ch bin khng ng cng c th lm gim lng vitamin mc d
cht lng thc phm ban u tt. V d cc vitamin nhm B v C u
d hng trong mi trng kim, khi tip xc vi kim loi, vi nhit
cao hoc vi cc cht oxy ha.
Nghin ru: Nghin ru gy x gan dn n gim kh nng d tr
vitamin ca gan, gy tc mt lm gim hp thu vitamin tan trong du,
thiu albumin lm gim hp thu vitamin A...
Do cht t v ngun nc tng a phng: Cht t v nc mt
s vng c hm lng iod hoc fluorid thp gy bnh bu c a
phng, hng rng...
2.1.2. Do ri lon hp thu

Suy dinh dng, a chy ko di, nghin ru,... u lm gim hp thu
cc cht, trong c vitamin v cht khong.
ngi cao tui, s thiu vitamin v cht khong l do s gim chc
nng ca h tiu ha: gim s tit dch v, dch mt, dch ty... v s
hot ng km hiu qu ca cc c ch hp thu tch cc qua nim mc
rut. Thm vo , do nhu ng rut yu, hay b to bn nn vic dng
thuc nhun trng ko di cng l mt nguyn nhn cn tr hp thu
cc cht, trong c vitamin v cht khong.
Ri lon hp thu c th do mt s bnh ng tiu ha nh vim ty,
tc mt, lot d dy - t trng...
117
2.1.3. Do nhu cu c th tng nhng cung cp khng
Ph n c thai, cho con b, thiu nin tui dy th hoc bnh nhn sau
m dy, sau m, nhim khun ko di... u c nhu cu v vitamin v cht
khong tng hn bnh thng. Nhng trng hp ny nu c b sung tt
bng ch n ung th khng cn dng thm vitamin v cht khong dng
thuc. Ung hoc tim vitamin v cht khong ch cn khi khng n c do
ri lon tiu ha hoc n khng (do mt mi, chn n...).
2.2. X tr khi thiu vitamin

Pht hin nguyn nhn gy thiu v loi b n l vic phi lm
u tin.
V d:
+ Nu thiu do ri lon hp thu th phi iu tr cc bnh lin quan (a
chy, suy gan, tc mt...).
+ Thiu do cung cp khng cho nhu cu th phi tng cng thm
khu phn n hoc s dng thm vitamin v cht khong nu thiu
trm trng...
B sung vitamin v cht khong:
+ B sung hp l nht l t thc phm v l ngun cung cp y
v cn i nht.
+ B sung di dng thuc ch khi thiu trm trng hoc trong trng
hp cha c iu kin sa i li ch n, v d thiu vitamin A,
thiu st bnh nhn ngho, nhng ngi m hp phn dinh dng
ch yu l ng cc v rau.
Chn ch phm:
Tt c cc yu t gy thiu vitamin v cht khong nu trn gy ra
nhng ri lon chuyn ha cc cht. Thng th t c hin tng thiu n
c mt cht tr nguyn nhn thiu do khuyt tt di truyn hoc do tng
tc thuc, v vy vic b sung vitamin hoc cht khong di dng hn hp
c hiu qu hn dng cc cht n l. T l phi hp ca cc cng thc khc
nhau nn khi la chn phi cn c vo nguyn nhn gy thiu b sung
cho ph hp. Ch phm vitamin c km cht khong t ph bin hn. Dng
n l ca vitamin v cht khong thng r hn. V vy nu bit chc chn
thiu cht no th ch b cht t c nguy c tha cht khc m li tit
kim. Tuy nhin cc dng n l thng c hm lng cao hn nn d dn
n nguy c tha hn dng phi hp.
118
Ch :
Mt s trng hp ch nh vitamin khng h lin quan n tc dng
sinh l ca chng v thng dng liu rt cao :
Hn hp vitamin nhm B (B1, B6, B12) vi hm lng vitamin gp hng
trm, hng nghn ln nhu cu sinh l dng gim au trong cc
chng au thn kinh khng r nguyn nhn. Ch nh ny hon ton
theo kinh nghim ch khng h c chng minh thc nghim. Nn nh
rng vitamin B12 tuy thuc nhm tan trong nc nhng c d tr gan
v liu cao cng gy tch ly, dn n tha nh i vi cc vitamin tan
trong du, do cn tnh n hu qu ny khi s dng.
Vitamin B12 di dng hydroxocobalamin vi liu rt cao (0,1 g/kg, tim
tnh mch) c dng gii c cyanua.
3. Tha vitamin V cht khong
3.1. Nguyn nhn gy tha v hu qu
3.1.1. Do lm dng vitamin v cht khong di dng thuc

y l nguyn nhn hng u hay gp nht. Cn nhc li rng nhng
ngi khe mnh, khng c ri lon hp thu v n vi ch n cc cht
th khng bao gi phi dng thm vitamin hoc cht khong di dng
thuc. Nu nhng i tng ny thng xuyn ung vitamin, c bit l
vitamin tan trong du (A, D) th d gp cc ri lon do tha. B sung iod
di dng thuc (tim du Lipiodol) hin ti khng p dng b khi thiu
iod na cng do d gy tha. Bin php b sung iod bng cch trn vo mui
n an ton hn. St v calci cng hay b lm dng liu cao.
Hu qu:
Tr em di 4 tui thng xuyn ung vitamin A c hm lng 5.000
vqt/ ngy c th b ng c mn tnh vi triu chng au xng, ban
, vim da trc vy, vim ming...
Liu vitamin A 100.000 vqt/ngy c th gy phng thp, co git,
tng p lc s no tr nh.
Ph n c thai dng ko di > 5.000 vqt/ngy trong khi vn n ung
y v hp thu tt s c nguy c tha vitamin A, gy qui thai.
Vitamin C tuy thuc nhm tan trong nc nhng khi dng thng
xuyn, c bit liu cao cng gy khng t tai bin: a chy, lot
ng tiu ha, vim ng tit niu, v c bit l si thn (t l gp
cao bnh nhn c tin s bnh ny). Dng tim tnh mch gy gim
sc bn hng cu, rt ngn thi gian ng mu...
119
Cc ch phm vitamin B (hn hp 3B) liu cao gy tha vitamin B6 vi
cc biu hin ri lon thn kinh cm gic, tha vitamin B12 vi triu
chng tha cobalt gy tng sn tuyn gip, bnh c tim v tng hng
cu qu mc.
3.1.2. Tha do n ung

C mt s ti liu m t hin tng tha vitamin A, thm ch c ng
c ca th dn phng bc (gn Bc cc) do n gan gu trng.
Tha beta-caroten do n ko di nhng thc phm giu cht ny th
hin bng hin tng nhum vng da, nh nhng trng hp ny t nguy
him v ngi s dng t ng b thc n .
Ni chung, tha vitamin do n ung t gp v c th c c ch t iu
chnh trong qu trnh hp thu qua ng tiu ha.
3.2. Bin php trnh tha vitamin v cht khong

V hin tng tha a phn do s dng cc cht ny di dng thuc
khng hp l, do nhng kin thc v s dng nhm thuc ny s gp
phn nng cao tnh an ton trong iu tr.
Thn trng khi s dng cc ch phm c hm lng ln hn 5 ln nhu
cu hng ngy. Loi ny thng gp vi hn hp vitamin nhm B (B1,
B6 v B12) hoc cc cng thc dng vi tc dng chng lo ho (anti-
oxidant).
Nu bit ch xc thiu vitamin hoc cht khong no th tt nht nn
dng dng n l trnh hin tng tha cc cht khc, c bit cc
vitamin tan trong du v cht khong. Cc cng thc phi hp nn
dnh cho cc trng hp thiu do ri lon hp thu, do m ko di (v d
ung th)..
Chn la thuc dng hn hp vitamin v cht khong phi phn
bit cc cng thc dnh cho tr di 1 tui, cho tr di 4 tui v cho
ngi ln.
Trong nui dng nhn to hon ton ngoi ng tiu ha, vic b
sung vitamin l bt buc duy tr kh nng chuyn ha cc cht
nhng liu lng cht cn a phi c tnh ton da trn tnh trng
bnh l ca tng bnh nhn. C th dng nhng ng hn hp vitamin
ng sn hoc ly ring l tng cht ri phi hp theo t l mong mun.
Bnh nhn thm tch mu ch nn b sung hn hp vitamin tan trong
nc v trong trng hp ny vitamin tan trong du khng b mt trong
qu trnh thm tch.
120
ng a thuc u tin trong mi trng hp l ng ung v trnh
c nguy c tha nh qu trnh t iu chnh khi hp thu. ng
tim ch dng trong trng hp c ch hp thu qua ng tiu ha b tn
thng (nn nhiu, a chy...) hoc khi cn b sung gp vi cht, trong
nui dng nhn to ngoi ng tiu ha (TPN).
Kt lun
Chuyn lun ny nhm gip cc dc s c c nhng kin thc khi s
dng mt nhm thuc c bn rt rng ri khng cn n. C c hiu
bit tt s gip ngi bnh trong chn la ch phm v gip h pht hin
sm nhng trng hp thiu b kp thi. Mt khc hin nay vic lm
dng vitamin v cht khong rt ph bin nn vic t vn nhm ngn chn
nguy c tha cng rt quan trng. chnh l mc tiu ca s dng vitamin
an ton hp l dnh cho dc s.
T lng gi
1. Tui dy th, ph n c thai, ph n cho con b... nu c b sung
tt bng ... (A)... th khng cn dng thm vitamin v cht khong dng
thuc.
2. Vitamin v cht khong ...(A)... nng lng cho c th hot ng nh ...
(B)...
3. Lng cn a hng ngy ca vitamin v cht khong ...(A)... nhng li
v cng quan trng cho ..(B)...
4. Vitamin v cht khong tham gia to nn cc ... (A)... cn cho chuyn ha
cc cht hoc bn thn l nhng cht sinh hc ... (B)...
Chn cu tr li ng (t cu 5 n cu 6)
5. Trng hp no l ng vi nhu cu hng ngy dnh cho ngi ln ca
vitamin v cht khong sau (nh du x vo phng n la chn)
C: 35 mg C: 60 mg C: 40 mg
A: 5.000 vqt A: 50.000 vqt A: 2.500 vqt
B1: 2 mg B1: 1,7 mg B1: 1,5 mg
B12: 2 mg B12: 2 mcg B12: 6 mcg
Ca: 1.000 mg Ca: 800 mg Ca: 1.300 mg
121
Fe: 180 mg Fe: 18 mg Fe: 15 mg
Iod: 150 mg Iod: 150 mcg Iod: 1.500 mcg

6. Trong thnh phn ca polyvitamin thng khng c vitamin no?
A. Vitamin K
B. Vitamin B1
C. Vitamin C
D. Vitamin A
E. Vitamin B12
7. B sung iod vo mui n trnh thiu c ch li:
A. Iod d hp thu hn khi dng thuc
B. Trnh c tha iod
C. C 2 phng n trn
8. Nguyn nhn gy thiu vitamin v cht khong l:
A. Do cung cp thiu
B. Do ri lon hp thu
C. Do nhu cu tng nhng cung cp khng
D. C 3 nguyn nhn trn
9. Khi nguyn nhn gy thiu vitamin v cht khong l do cht lng thc
phm, nn:
A. Sa i li cch ch bin
B. Chn thc phm ti
C. C 2 cch trn
10. Nhng nguyn nhn sau y gy thiu vitamin v cht khong u lin
quan n ri lon hp thu, tr:
A. Tc mt
B. Ct d dy
C. n king
D. I chy
E. Vim tu
122
11. Cc bin php x tr khi thiu vitamin v cht khong sau y u
ng, tr:
A. Loi tr nguyn nhn gy thiu
B. B sung ngay vitamin v cht khong c hm lng cao
C. iu chnh li ch n
D. Thc phm trong khu phn n nn a dng
12. Cc bin php b sung vitamin v cht khong sau y u hp l, tr:
A. Nn thn trng vi cc ch phm c hm lng trn 5 ln nhu cu
hng ngy
B. Nn s dng vitamin n l liu cao
C. Nn chn loi n l nu bit chc chn thiu cht no
D. Nn chn dng phi hp nu nguyn nhn thiu do cht lng
thc phm

S
13. Vitamin l nhng cht cung cp nng lng cho c th hot ng.
14. Mt s cht khong l thnh phn ca cc enzym trong chuyn
ho cc cht ca c th.
15. Nn ung vitamin u n hng ngy.
16. Nhu cu v vitamin v cht khong tng ph n c thai
17. Tr em di 4 tui cn nhiu vitamin hn ngi ln.
18. Tr s sinh hay thiu vitamin K v h vi sinh vt rut cha c
19. Cc vitamin tan trong du d b tha do c d tr ti gan.
20. Cc vitamin tan trong nc khi dng liu cao cng khng c
cho c th.
21. Rt t khi gp ch thiu n c 1 loi vitamin.
22. Thiu iod c th do ri lon hp thu
23. S dng khu phn n cn i v lng v cht tt hn s dng
vitamin
24. Tha vitamin ch yu do n qu nhiu.
25. Nn thng xuyn b sung vitamin D cho tr nh
26. Vitamin A liu cao c th gy phng thp, tng p lc ni s cho
tr nh
27. Ph n c thai nn b sung vitamin A liu cao (trn 5.000 vqt
mi ngy)
123
Bi 10
Nguyn tc s dng Thuc chng vim

cu trc steroid v khng steroid
Mc tiu
1. Lit k c cc tc dng khng mong mun ca mi nhm.
2. Trnh by c cch khc phc tng tc dng khng mong mun.
3. Nu c cc chng ch nh vi mi nhm thuc.
M u
Vim l mt tnh trng bnh l kh ph bin gp trong nhiu bnh v
do nhiu nguyn nhn gy ra. Nhn chung, vim l phn ng t v ca c
th, tuy nhin khi qu trnh vim tr nn trm trng, ko di s dn n
hng lot ri lon chc nng ca nhiu c quan trong c th, lm gim st
sc kho ca ngi bnh, thm ch gy e do tnh mng. Cc thuc
chng vim ra i nhm gip c th khng ch bt cc tc hi do qu trnh
ny gy ra.
C nhiu nhm thuc chng vim c s dng trong iu tr hin nay
nhng 2 nhm thng dng nht l: Nhm cc cht c cu trc steroid (cc
glucocoticoid) v nhm cc cht khng c cu trc steroid (cc cht chng
vim khng steroid, vit tt l NSAID).
Chng ny nhm cung cp nhng thng tin lin quan n tc dng
khng mong mun nhm bo m s dng hp l - an ton hai nhm thuc
ny. Nhng kin thc i su v c ch tc dng, ch nh c hc hc
phn Ho dc - Dc l I v II.
1. glucocorticoid
1.1. i cng
Glucocorticoid (GC) l mt nhm thuc c ngun gc ban u t v
thng thn, c cu trc chung l nhn steroid; cht do tuyn thng thn
tit ra l hydrocortison (cortisol). Do tc dng chng vim mnh v ton
din (c ch tt c cc giai on ca qu trnh vim) nn tc dng ny dc
s dng nhiu trong iu tr v c tn l thuc chng vim steroid. Mt lot
124
ch phm tng hp ra i c tc dng chng vim mnh hn nhiu so vi
hydrocotison m li gim c tc dng khng mong mun l gi mui -
nc lm cho v tr ca nhm thuc ny tr nn quan trng. Tuy nhin, vic
s dng nhm thuc ny trong iu tr gp phi kh khn lin quan n tc
dng ph, trong c nhng tc dng ph nghim trng nh hng n
cht lng sng ca bnh nhn. Cc ni dung ca bi ny cp n cch
hn ch mt s tc dng ph gp vi tn sut cao trong iu tr; mt s tc
dng ph t gp hn hoc cch khc phc phc tp hn s c cp n
trong chng trnh i hc.
Bng 10.1. So snh hot lc ca mt s glucocorticoid thng dng
DTD Chng Tng Mc sinh l Liu chng

Tn quc t Gi Na+
(h) vim glucose (mg) vim (mg)
Hydrocortison 8- 12 1 1 1 15 - 30 80
Cortison 8- 12 0.8 0.8 0.8 20- 35 100
Prednison 12- 18 3.5 3.5 <1 7.5- 10 20
Prednisolon 12 - 18 4.5 4,5 <1 7,5 - 10 16
Triamcinolon 12 - 18 5.0 4,5 0 7,5 - 10 16
Dexamethason 18 - 56 30 4,5 0 1 - 1,5 3
Ghi ch: DTD: di tc dng; Mc sinh l: Ngha l lng c sn trong c th.
1.2. Tc dng ph v cch khc phc
1.2.1. Gy xp xng
C ti 50% bnh nhn cao tui b gy xng khng c chn thng do
dng GC liu cao ko di. C ch gy xp xng l do GC tng cng s hu
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. Cc tc dng ny cng thm vi
125
vic ngn cn hp thu calci t rut v tng thi calci qua nc tiu lm
xng xp nhanh hn, c bit ph n sau mn kinh v ngi cao tui.
Tng cng vn ng, bo m ch n giu cht m v calci, s
dng mt liu hp l calci v vitamin D (bng nhu cu hng ngy, xem Bi 9
Nguyn tc s dng vitamin v cht khong) l nhng bin php hu hiu
nhm chng xp xng do corticoid. Cc ch phm fluorid hoc calcitonin rt
c ch cho nhng trng hp ny. Ngoi ra alendronat - mt biphosphat
cng c k n nhiu phng v iu tr long xng do s dng
corticoid.
1.2.2. Tng kh nng b nhim trng
Tc dng c ch min dch ca glucocorticoid dn ti hu qu gim kh
nng chng ca c th vi tc nhn gy bnh. Bnh nhn s dng
glucocorticoid d b nhim vi khun, virus, nm.
Bin php hn ch tc dng ph ny l khng s dng corticoid trong
trng hp nhim khun nng khng khng ch c bng khng sinh. Vi
nhng trng hp nhim virus hoc nhim nm th nn chng ch nh.
Trong trng hp bt buc phi s dng (v d bnh nhn mc cc bnh
lin quan n ri lon h min dch) th phi theo di st sao v s dng
thuc chng virus hoc chng nm khi cn thit. C nhiu ch phm bi
ngoi phi hp corticoid vi khng sinh v thuc chng nm u vi mc
ch ny.
Khng dng corticoid khi tim chng bng vaccin sng v virus to
vaccin tuy b lm yu nhng vi c a suy gim min dch bnh nhn
dng corticoid c th li tr nn gy bnh. Vi tim chng ni chung cng
nn trnh dng nhm thuc ny v s ngn cn kh nng to khng th.
1.2.3. Chm lin so

GC c ch hnh thnh t bo si, gim to collagen, gim s hnh
thnh m lin kt. Tc dng ny cng l hu qu ca s c ch tng hp
protein. Hu qu ca qu trnh ny l lm chm lin so, lm mng da v
mt collagen trong t chc xng. V hu qu ny, nn trnh s dng GC
sau phu thut.
1.2.4. Lot d dy - t trng
Cc tai bin loi ny thng gp nhiu bnh nhn cao tui v tai bin
d dy nhiu hn rut. Tc dng ph ny khng ph thuc loi corticoid
v liu. Tuy nhin hin tng thng d dy gp nhiu hn bnh nhn
dng liu cao. Lot v thng xy ra c khi dng thuc ngoi ng tiu ho
(tim, vin t...). C th dng thuc trung ho dch v (antacid) nhng
khng c ung ng thi vi GC. Mt s tc gi ngh dng cc cht
khng th th H2 (ranitidin, famotidin) gim bt lng acid dch v. Theo
126
di bnh nhn cht ch v x l sm hoc ngng thuc kp thi l bin php
quan trng gim t l tai bin.
1.2.5. Suy thng thn cp
Suy thng thn cp l mt tai bin ng ngi khi dng corticoid,
thng xy ra khi dng liu cao, ko di. Cng thng gp suy thng thn
khi s dng dng ch phm c tc dng ko di (K-cort). trnh suy
thng thn cp, cn lu :
Theo di cht ch bnh nhn.
Khng ngng thuc t ngt m phi gim liu t t.
Nn dng ch ung 1 ln mi ngy, vo bui sng khong 6 - 8 gi.
Khi cn iu tr ko di nhiu thng, nn p dng li iu tr cch ngy
khi bnh n nh v xc nh c mc liu duy tr.
1.2.6. Hi chng Cushing do thuc

Biu hin d nhn thy nht l hin tng bo khng cn i do ri
lon phn b m: Khun mt mt trng, gy tru, bo na thn trn
nhng 2 chn li teo c. Cc ri lon sinh dc, tm thn, tng huyt p,
long xng... cng l nhng triu chng ca bnh Cushing. Nguyn nhn
gy Cushing l do s dng corticoid liu cao ko di (lm dng thuc hoc
bt buc phi dng trong mt trng thi bnh l no ).
Vic ngng thuc trong trng hp ny vn phi tun theo qui tc
gim liu tng bc ch khng c ngng t ngt. Sau khi ngng thuc,
nu bnh ti pht th nn s dng cc thuc c hiu iu tr triu chng tt
hn l quay li dng corticoid; v d gii quyt hen bng thuc gin ph
qun, gim au khp bng thuc chng vim khng steroid...
1.2.7. Tc dng ph do dng corticoid ti ch

Cc dng bi ngoi hoc nh mt - mi c cha corticoid rt nhiu. Tai
bin thng gp bao gm: Teo da, x cng b, vim da ng , mn trng c
hoc bi nhim nm v vi khun, virus. Hin tng chm lin so khng ch
gp vi dng bi ngoi m c khi dng ng ton thn. c thu tinh th
(cataract) hoc tng nhn p (glaucom) hay gp khi dng dng nh mt v
do trn nhn thuc c cha corticid phi ghi chng ch nh cho nhng
trng hp ny.
Cc bin php gim tc dng ph trong trng hp ny l:
Khng c nh mt cc ch phm cha GC khi nhim virus hoc nm.
Hn ch bi ko di v khm k bnh nhn trc khi k n.
Sc ming sau khi xng hng bng corticoid trnh nm ming.
Khng t dng thuc l bin php tt nht gim tc dng ph ny.
127
1.3. Chng ch nh
Lot d dy t trng tin trin.
Cc trng hp nhim nm
Cc trng hp nhim virus.
Tim chng bng vaccin sng.
2. Thuc chng vim khng steroid (NSAID)

2.1. i cng
Thuc chng vim khng steroid c vit tt bng ting Anh l
NSAIDs (Non Steroidal Anti Inflammatory Drugs) l mt nhm c cu trc
ho hc rt a dng. V cng chng vim th nhm ny km cc cht
glucocorticoid nhng tc dng khng mong mun t hn, c bit l khng c
cc tc dng ph nghim trng nh ri lon tm thn, sinh dc, tng
glucose - mu. Tr ngi ln nht ca nhm ny gy lot d dy t trng
nng hn nhm glucocorticoid, trong lot d dy gp nhiu hn t trng.
y l nhm thuc chng vim c dng rt rng ri, c ch nh vi mi
th vim v cc trng hp au khng c vim. Ba tc dng c s dng
rng ri trong iu tr ca nhm thuc ny l chng vim, gim au v h
st. Phn ny c hc hc phn Ho dc - dc l I v II. Hc phn
ny s cp n gii quyt tc dng khng mong mun nhm phc v cho
mc tiu s dng thuc an ton.
Bng 10.2. Mt s cht chng vim khng steroid
t 1/2 Liu ti a/1 ln Liu ti a/24h

Tn quc t
(h) (mg*) (mg*)
Aspirin 3-9 500 3900
Diclofenac 1-2 25 - 50 150
Indometacin 4,5 25 - 50 150
Sulindac 16,4 100 - 200 400
Ibuprofen 1-2 200 - 400 1.200
Naproxen 13 550 1.375
Meloxicam 20 7,5 15
Piroxicam 50 10 - 20 40
Tenoxicam 70 20 20
Celecoxib 11,2 100-200 800
Rofecoxib** 17 12,5 25
Ghi ch: * Liu dnh cho ngi ln ** rt khi th trng 9/2004.
128
2.2. Tc dng khng mong mun v cch khc phc
2.2.1. Lot d dy - t trng

Tt c cc NSAID u c tc dng ph lin quan n chnh c ch tc
dng ca thuc: Do c ch men cyclo-oxygenase (COX), lm gim s to
prostaglandin nn c th gy lot d dy t trng. Cc tc dng ph ny gp
c khi dng bng ng tim, t hu mn hoc bi ngoi trn din rng.
Lot d dy km xut huyt gp nhiu hn nu s dng thuc bng ng
ung.
Ngoi c ch tc dng thng qua c ch COX-1, tc dng gy lot cn
do tan thp trong mi trng dch v to kh nng kch ng cao ln nim
mc d dy t trng, c bit l d dy.
gim bt cc tc dng ph trn ng trn tiu ha c th c cc cch
x l sau:
To vin bao tan trong rut, loi vin ny phi ung xa ba n nu l
bao c vin (v d vin Aspirin pH 8).
To vin si bt hoc cc dng ung c th ha tan thnh dung dch
trc khi ung (v d gi bt Aspegic).
Lng nc ung phi ln (200 ml - 250 ml).
Hin nay, xu hng khuyn dng phi hp thm vi cc cht chn bm
proton (omeprazol, lanzoprazol...) c ng h. Tr ngi l gi thnh ca
cc cht chn bm proton t, v vy ch dng vi ngi c nguy c cao.
Tn trng mc liu ti a cho php (bng 10.2) cng s gim bt nguy
c gy lot.
Khng c dng cc antacid v cc cht bao bc nim mc v hiu qu
km v gy tng tc do cn tr hp thu. Nu dng th phi ung 2
thuc cch nhau ti thiu 2 gi.
Nhng nm gn y, do pht hin c COX-1 lin quan n vic tng
hp prostaglandin, to cht nhy bo v d dy, cn COX-2 chu trch
nhim v cc phn ng vim - au - st nn nhng hp cht mi c tc
dng chn lc trn COX-2 ra i nh celecocib (Celebrex), rofecocib
(Vioxx)... cng gim c ng k (khong 50%) t l lot d dy
nhng tnh u vit ca nhm ny cn cn c thi gian kim chng v
thy c nhng ADR khc cng nguy him khng km cho bnh
nhn; v d in hnh nht l vic ngng lu hnh rofecoxib gn y do
tai bin trm trng gy nhi mu c tim v t qu.
129
2.2.2. Chy mu
Tc dng gy chy mu, mt mu ko di xy ra khng ph thuc vo
liu. Tc dng ny c p dng trong iu tr nga ng mu nhm
trnh cc tai bin mch vnh, nhi mu c tim. Thuc thng s dng vi
mc ch ny l aspirin v aspirin c tc dng c ch chc nng tiu cu
khng hi phc v ch cn dng mc liu thp hn nhiu so vi liu cn
gim au - h st - chng vim.
Tc dng ph ny c th dn n thiu mu khi dng NSAID ko di
do mt mu thng xuyn tng t mt qua ng tiu ho.
Cng do lm gim kh nng ng mu nn khng c dng trong
nhng trng hp st c xut huyt v tng chy mu.
2.2.3. Mn cm
Mt tc dng ph khc cng hay gp vi cc NSAID, l hin tng
mn cm vi thuc, hay gp nht khi dng aspirin: Ban da, hen, sc
qu mn. Cc tc dng ny c th gp cc bnh nhn c tin s d ng, c
bnh hen, polyp mi, st (c bit hay gp bnh nhn b st do virus), v
vy phi thn trng khi dng cho nhng bnh nhn c c a d ng hoc
c tin s d ng, hen do dng aspirin.
Hi chng Reye bnh nhn nhi (gp nhiu tr di 12 tui) do dng
aspirin h st khi nhim virus dn n t vong c xc nhn, chnh
v vy hn ch dng cc ch phm NSAID h st cho tr em; nhng
trng hp ny paracetamol l thuc c la chn.
2.3. Tng tc thuc cn trnh

Khng phi hp cc NSAID vi nhau v tc dng ph lot ng tiu
ho v chy mu s tng. Vi mc ch tng tc dng gim au khi
dng n mc liu ti a cho php (bng 10.2) th nn phi hp NSAID
vi paracetamol v nu cn vi c cc thuc gim au trung ng nh
codein, dextropropoxyphen.
Khng dng cc thuc antacid hoc thuc bao nim mc ng thi vi
NSAID v s lm gim nng NSAID trong mu. Nu cn dng, phi
ung 2 thuc cch nhau 2 gi.
NSAID c th lm gim hiu qu iu tr ca cc thuc chng tng
huyt p, c bit l ca nhm c ch men chuyn (ACE), gim tc
dng bi niu ca thuc li tiu.
NSAID lm tng nguy c chy mu trm trng khi dng ng thi vi
cc thuc chng ng mu khc. Gim st thi gian ng mu hiu
chnh li liu thuc chng ng mu, theo di cht ch cc du hiu
xut huyt (mu trong phn), nh lng hematocrit l nhng vic cn
phi lm thng xuyn trong qu trnh iu tr ko di.
130
S dng cc NSAID, c bit l cc salicylat cng vi ru lm tng
nguy c xut huyt tiu ho.
Cc salicylat lm gim bi xut acid uric qua nc tiu, do khng
dng gim au khi b bnh Gout.
2.4. Chng ch nh
Mn cm.
Lot d dy t trng.
Cc bnh c nguy c chy mu (nh st xut huyt).
C thai 3 thng u v 3 thng cui.
Kt lun
Hai nhm thuc chng vim steroid v khng steroid c nhng c
im ring v tc dng ph. Vic mong mun khc phc hon ton tc dng
ph l khng th c v tc dng ph c 2 nhm u lin quan n c ch
tc dng v tc dng ca chnh bn thn nhm thuc . La chn thuc
theo c a bnh nhn v ph hp vi trng thi ca bnh, chn mc liu
thp nht c tc dng, tn trng cc chng ch nh, theo di st trong qu
trnh iu tr l nhng bin php hu hiu hn c.
T lng gi
Thuc chng vim cu trc steroid

1. Bnh nhn s dng GC d b nhim ...(A)..., virus, nm. Nguyn nhn do
...(B)... sc khng ca c th vi ...(C)...
2. GC gy chm lin so l do ...(A)... to collagen. Tc dng ny cng l hu
qu ca s c ch tng hp ...(B)...
3. Suy thng thn cp thng gp khi dng GC ...(A)..., ko di hoc s
dng dng ch phm c tc dng ...(B)...
Chn nhng cu tr li ng (t cu 4 n cu 6)
4. Trong s cc bnh sau y, bnh no cn s dng glucocorticoid (GC):
A. Nhim khun D. Sc qu mn
B. Nhim nm E. Vim khp
C. Hen G. Suy gim min dch
131
5. Nhng CC no l ca GC
A. Lot d dy t trng tin trin. D. Tim chng bng vaccin sng.
B. Nhim virus E. X gan c trng do ru.
C. Nhim nm G. Suy tim
6. trnh suy thng thn cp cn lu :
A. Theo di cht ch bnh nhn.
B. Nn ngng thuc ngay, khng nn gim liu t t.
C. Nn chia liu dng trong ngy thnh nhiu ln.
D. Khi cn iu tr ko di nn dng ch iu tr cch ngy.

7. Trong s cc bnh sau y, bnh no khng c s dng GC:
A. Nhim nm D. Vim khp
B. Hen E. Thn h nhim m
C. Sc qu mn
8. Cht c tc dng gi mui nc mnh nht trong cc GC l:
A. Dexamethason D. Triamcinolon
B. Hydrocortison E. Prednison
C. Prednisolon
9. Cht khng c tc dng gi mui nc trong cc GC l:
A. Prednisolon
B. Dexamethason
C. Hydrocortison
D. Prednison
10. Chng ch nh no khng ng vi GC:
A. Lot d dy t trng tin trin. D. Tim chng bng vaccin sng.
B. Cc trng hp nhim nm E. S dng cho tr em
C. Cc trng hp nhim virus.
11. Nhng i tng c nguy c xp xng cao khi s dng GC l:
A. Thanh nin D. B v C
B. Ph n sau mn kinh E. C A, B, C
C. Ngi cao tui
132
Cc cu sau y u ng tr (t cu 12 n cu 19)
12. gim nguy c xp xng do GC, nn:
A. Tng cng khu phn n giu calci
B. B sung liu tht cao calci v vitamin D
C. Tng cng cht m trong khu phn n
D. Tng cng vn ng
E. S dng calcitonin
13. Khi gp Cushing do thuc, nn:
A. Ngng GC ngay
B. Gim liu t t
C. Hn ch vic a li GC nu bnh ti pht
D. Dng thuc iu tr triu chng nu bnh ti pht
14. Khi dng GC cn thit phi:
A. Ngng thuc t t sau khi iu tr di ngy
B. Nn chia thuc ung lm nhiu ln trong ngy
C. Nn dng mc liu thp nht c hiu qu
D. Tng lng m, gim lng ng v mui trong ch n
E. Dng li iu tr cch ngy khi cn duy tr nhiu thng
15. Cc bin php gim tc dng ph do dng GC ti ch l:
A. Khng c nh mt cc ch phm cha GC khi nhim virus hoc nm.
B. Hn ch bi ko di
C. Khng c sc ming sau khi xng hng bng GC
D Khng bi thuc ko di khi khng c hng dn ca thy thuc.
.
16. Tc dng ph hay gp khi dng GC dng nh mt l:
A c thu tinh th (cataract)
.
B Tng nhn p (glaucom)
.
C Nga mt
.
17. Tc dng ph ca GC:
133
A. Gy xp xng
B. Lm chm lin so
C. Gy lot d dy t trng
D. Tng kh nng nhim khun
E. Tng sc khng ca c th
18. Cc bin php chng long xng do GC gy ra:
A. B sung calci v vitamin D theo nhu cu hng ngy
B. Gim vn ng
C. Dng calcitonin
D Tng khu phn n giu cht m v calci
.
19. Cc bin php sau y c th dng gim tc dng ph gy lot d dy
t trng ca GC
A. Ung GC cng mt lc vi antacid
B. Dng thuc khng th th H2
C. Dng antacid sau khi ung GC 2 gi
D. Ung khi n
Thuc chng vim khng steroid (NSAID)
Chn nhng cu tr li ng (t cu 1 n cu 4)
1. Cc bin php c th s dng gim kch ng ca NSAID vi d dy:
A. Ung ng thi vi antacid
B. Dng thuc bao bc trc khi ung NSAID
C. Dng thuc chn bm proton
D. Ung khi n
E. Ung nhiu nc
2. Chng ch nh no ng vi NSAID
A. C thai
B. D ng vi ch phm
C. Lot d dy
D Cc trng thi xut huyt
.
134
E. Ngi cao tui
G Ngi b bnh tm thn
.
3. Khi dng cc antacid ng thi vi NSAID s:
A. Gp tng tc do cn tr hp thu.
B. Antacid lm gim nng NSAID trong mu
C. NSAID lm gim nng antacid trong mu
D. Nu dng phi ung 2 thuc cch nhau ti thiu 2 gi.

4. Ch nh chnh ca aspirin l:
A. H st tr em
B. Chng ng mu
C. Chng vim
D. Gim au trong cc bnh au xng khp
5. Tc dng no khng phi ca NSAID:
A. H st
B. Gim au
C. Chng vim
D. Chng nhim khun
6. C ch gy lot d dy ca NSAID
A. Do gim cht nhy ca nim mc d dy
B. Do tc dng kch ng ti ch
C. Do tng tit dch v
D. A v B u ng
7. Tc dng ph ca NSAID l :
A. Tng nguy c xut huyt
B. C th gy cn hen.
C. Lot d dy
D. C 3 tc dng trn u ng
8. Thuc h st an ton nht cho tr em l
135
A. Paracetamol
B. Aspirin
C. Ibuprofen
D. Meloxicam
9. Tc dng ph sau no sau y khng phi l hin tng mn cm vi

NSAID:
A. Ban da
B. Hen
C. Xut huyt d dy
D. Sc qu mn.
10. gim t l gy lot d dy ca NSAID, nn:
A. Dng vin bao tan trong rut
B. Dng vin si bt
C. Lng nc ung phi ln (200 ml - 250 ml).
D. C 3 trn u ng
11. Cc thng tin sau y u ng vi hi chng Reye, tr:
A. T l cao gp vi aspirin
B. Hay gp khi dng NSAID h st bnh nhn nhi (< 12 tui)
C. Hay gp khi dng paracetamol h st cho tr em
D. C th gy t vong
136
Bi 11
S dng thuc trong iu tr Hen Ph Qun
Mc tiu
1. Nu c c ch v tc dng ca 4 nhm thuc thng dng trong iu tr
hen ph qun.
2. Lit k c cc bin php iu tr h tr hen bng thuc v khng
dng thuc.
M u
1. vi nt v bnh Hen ph qun
1.1. nh ngha
"Hen ph qun (HPQ) l trng thi lm sng ca s phn ng cao
ph qun do nhiu kch thch khc nhau, biu hin c trng l cn kh th
vi ting c c hu qu ca co tht c trn ph qun, ph n nim mc ph
qun v tng tit dch nhy ph qun. Cn kh th c th hi phc.
(Bi ging Bnh hc ni khoa - Nh xut bn Y hc).
1.2. Nguyn nhn v iu tr

Nguyn nhn
Hen ph qun c th do d ng khi tip xc vi mt d nguyn, gy nn
mn cm, c bit vi ngi c c a d ng nh b my ay, vim mi, ph
Quincke... Cc d nguyn thng l bi nh, cc loi lng, b cht, phn hoa,
nm mc, ho cht, thuc, c bit l aspirin, cc hng liu, kh hu v
ma, thc n v ung, vi khun...
Hen c th do ni ti, do cc bnh h hp khc nh vim ph qun,
gng sc (th dc th thao), ni tit, do tm l...
Ngi ta chia thnh 4 mc hen:
Mc 1: Cn hen ngn, khng lin tc, cn hen xut hin < 2
ln/tun.
Mc 2: Cn hen xut hin > 2 ln/tun nhng < 1 ln/ngy.
137
Mc 3: Cn hen xut hin hng ngy, hot ng th lc v gic ng
b nh hng.
Mc 4: Cn hen lin tc, hot ng th lc b hn ch, cn thng
trm trng.
iu tr hen ph qun
Cn c vo hiu qu iu tr ngi ta chia thnh 3 mc l cha khi
hon ton, iu tr cc cn hen nguy kch phi cp cu v iu tr ko di
sut i.
iu tr tn gc: C rt nhiu nguyn nhn bnh sinh ca hen ph
qun, v vy vic iu tr tn gc l rt kh khn, ngi ta ch c th ct cn
c mt thi gian ngn.
iu tr nhng cn nguy kch: Tu thuc vo tng tnh trng c th,
tuy nhin phi s dng nhng thuc c hiu, l corticosteroid, cc thuc
cng giao cm beta 2 gy gin ph qun ... Cc thuc nhm xanthin cng
thng c s dng, tuy nhin cn lu tng tc ca nhm ny vi cc
thuc dng cng khc.
2. cc thuc iu tr hen ph qun
2.1. Thuc gin ph qun

2.1.1. Thuc kch thch th th beta - adrenergic
Cc cht kch thch th th beta khng chn lc
Cht thng dng l adrenalin (epinephrine). Adrenalin kch thch c
th th alpha v beta - adrenergic. Trong trng hp khn cp, adrenaline
c tim, hiu qu gin ph qun rt nhanh, nhng c nhiu nguy c tai
bin do tc dng ph vi h tim mch v h thn kinh, nht l c th gy ra
nhng tai bin nguy him vi tim. C th tim di da 0,3 mg (1/3 ng loi
0,1%), nhng ch c bc s chuyn khoa mi c ch nh. Hin nay t dng.
Cc cht kch thch chn lc th th beta - 2 adrenergic
Cc cht kch thch chn lc th th beta - 2 adrenergic nh salbutamol

hoc terbutalin, metoproterenol... t tc dng ph hn cc thuc kch thch
beta - 2 khng chn lc nh isoprenalin hoc adrenalin. Cc cht ny t nh
hng n tim. Phn ln cc cn hen t nh n va u p ng nhanh vi
cc thuc kch thch chn lc beta - 2 adrenergic dng kh dung (dng xt)
nh salbutamol hoc terbutalin.
138
Bng 11.1. Cc thuc kch thch beta dng iu tr hen ph qun
Tn hot cht Tn bit dc
Adrenalin (Epinephrin) Primatene

Bitolterol Tornalate
Ephedrin Coderin
Fenoterol Berodual, Berotec
Isoetharin Bronkometer, Bronkosol
Isoprenalin (Isoproterenol) Medihaler-Iso, Duo-Medihaler, Mistometer
Metaproterenol Alupent, Metaprel
Noradrenalin (Norepinephrine) Bronkephrine
Pirbuterol Maxair
Procaterol Pro - air
Salbutamol (albuterol) Asthalin, Apo-Salvent, Combivent, Durasal-CR,
Ventolin, Proventil
Salmeterol xinafoat Seretide accuhaler, Serevent inhaler
Terbutalin Brethaire, Brethine, Bricanyl
2.1.2. Thuc gin ph qun theo c ch khng cholinergic

Cc thuc nhm ny c hiu qu tt trong vim ph qun mn do gim
co tht ph qun. Thuc thng dng l ipratropium (Atrovent). Oxitropium
cng c tc dng tng t nh ipratropium. Dng bo ch thng dng l
kh dung di dng bnh xt nh liu hoc dch phun kh dung; tc dng ti
a t c sau khi phun 30 - 60 pht v ko di t 3 n 6 gi, c th duy
tr gin ph qun vi cch dng 3 ln mi ngy.
Hiu qu gin ph qun ca ipratropium khng bng cc thuc thuc
nhm kch thch beta - 2 v adrenalin. Hiu qu s tt hn nu dng
ipratropium kt hp vi cc cht kch thch beta - 2. Dng hai th cng mt
lc c hiu qu hn dng xen k tng th mt. Hin ti c dng bo ch phi
hp sn 2 thuc to hn hp ht cng mt lc (ipratropium v
salbutamol). Ni chung, cc thuc khng cholinergic c li trong iu tr
bnh phi tc nghn mn tnh (coPd - Chronic Obstructive Pulmonary
Disease) hn l i vi hen. Cc thuc khng cholinergic dng theo dng
ung gy nhiu tc dng ph hn dng kh dung, trong s quan trng
nht l lm gim tit dch ng h hp, v vy m mc d chng c pht
hin trc cc thuc thuc loi kch thch beta - 2 v adrenalin nhng n
nay rt t s dng trong iu tr hen.
139
2.1.3. Thuc gin ph qun nhm xanthin
L nhm thuc c s dng trong c cn hen cp tnh v mn tnh, c
tc dng gin c trn kh ph qun, ng thi c ch gii phng histamin.
Thuc in hnh ca nhm ny l theophyllin, c dng di hai dng:
tim v ung. Dn cht ca theophylin l aminophylin c dng theo
ng tim tnh mch, c ch nh trong nhng cn hen cp, khi ngi
bnh kh dng thuc qua ng ung. Dng tnh mch ct cn nhanh nhng
nguy him v d qu liu, v vy sau khi ct cn nn chuyn sang ng
ung ngay.
Triu chng ng c theophylin do qu liu bao gm: Nhc u, kh
ng, bn chn, kch ng, mch nhanh, bun nn, nn; nu trm trng c
th m sng, co git, thm ch c th t vong.
Theophylin l thuc c phm vi iu tr hp, v vy cn phi theo di
st, ch nh ng liu v trnh tng tc thuc. Vic xc nh nng
thuc trong mu s bo m cho iu tr an ton hn (nht l i vi tr nh
b hen) nhng hin ti nc ta cha lm c.
Theophylin tc dng ko di (loi 12 gi hoc 24 gi) gi nng
iu tr n nh, c dng c trong iu tr v d phng ngn chn cc
cn hen.
Lu khi s dng theophylin:
Cc tng tc thuc giai on chuyn ho (hay gp khi dng ng
thi vi erythromycin hoc cc khng sinh h macrolid) dn n tng
nng theophylin trong huyt tng.
Khi s dng theophyllin, tc dng kch thch thn kinh trung ng
tng nu ngi bnh ung ung c cha cafein (c ph, tr c,
Coca-cola) hoc n scla.
2.2. Corticoid
Ngoi cc loi thuc gin ph qun, cc corticoid ng vai tr quan
trng trong vic iu tr bnh hen ph qun vi c ch chng vim. Thuc c
th dng dng ung, tim hoc kh dung.
S dng thuc kh dung l bin php a thuc n thng cc vng b
vim bn trong ng h hp, nh gim bt liu lng v v vy gim
c tc dng khng mong mun ca corticoid.
Khi phi dng ko di, nn dng thuc cch nht gim tc dng suy
thng thn khi ngng thuc (xem Bi 10 Nguyn tc s dng thuc chng
vim cu trc steroid v khng steroid").
140
Bng 11.2. Mt s corticoid dng kh dung
Tn khoa hc Tn thng mi
Beclometason dipropionat Beclate-50, Becotide, Becloforte, Vanceril
Beclometason monopropionat Beclovent
Budesonid Inflammide
Flunisolid
Fluticason propionat Flixotide, Seretide
Flunicason Aerobid, Aerobid-M
Fluticason Flovent
Triamcinolon Azmacost
2.3. Thuc khng histamin H1

Cc khng histamin ngn chn s tip xc ca histamin vi th th
m hu qu ca s tip xc ny gy ra phn ng co tht ph qun, tc l cc
khng histamin chn ngay t mt xch u tin ca phn ng.
Tuy nhin histamin ch l mt trong cc yu t gy co tht ph qun,
do cc khng histamin ch ngn chn c cn hen ph qun trong mt s
trng hp nht nh.
Vi ngi hen, cc khng histamin gy mt tc dng kh chu l lm
gim tit dch, khin cho cc dch nhy trong ph qun ngi hen qunh c
li, gim thi m. khc phc tc dng ph ny ngi ta dng ng thi
ung nhiu nc trong ngy b tr tc dng kh qunh do thuc gy ra.
2.4. Thuc bo v t bo mast (Dng bo) (cromolyn, nedocromil)

Do c ch bo v t bo mast khi phn ng khng nguyn - khng th,
cc cht ny ngn cn s gii phng cht trung gian ho hc. C 2 cht u
c tc dng tng t nhau: Tc dng chng vim nh, tc dng gin ph
qun l khng ng k. Cc thuc ny ch c tc dng d phng, t c tc
dng trong iu tr.
Ph bin l cromolyn; dng bo ch mi dng ht, cha mt liu
lng nh sn cho mt ln ht, ging nh nhng loi thuc kh dung khc
dng cho ngi hen, mi liu cho mt ln l 800 microgam. Mt dng khc
c tn l Tilade (kh dung nedocromil sodium) hiu lc hn cromolyn nhng
ch dng c cho tr trn 12 tui v ngi ln.
141
3. Cc bin php iu tr h tr hen bng thuc v khng
dng thuc
3.1. Thuc long m

Loi thuc ny c mc ch lm lng, lm long cc dch tit ng h
hp, nh d tng m di ra ngoi.
3.2. Oxy
Oxy liu php thng khng dng nh ring, ch dng trong bnh
vin. Trong iu kin bnh thng, khng kh trong phng cha khong 20%
oxy. Vi ngi hen ko di v mc nng, cn mt nng oxy gp i nh
th. Du hiu tm ti mi, tai, mt, di cc mng tay chng t phi
khng a oxy vo mu, cn a ngay vo bnh vin cho th oxy v
thc hin cc bin php iu tr tch cc.
3.3. B nc
Mt nc l mt bin chng do hen gy ra v trong qu trnh hen
suyn, nhp th ca ngi bnh c th nhiu gp 5 ln hoc hn na so vi
ngi thng, do lng nc mt cng gp nhiu ln nh th. Khng b
lng nc y th s xy ra bin chng mt nc. ng lu rng vi
nhng ngi ang cn hen, rt kh cho ung nc qua ming v h khng
mun ung, s ung nc v nut nc vo rt kh, v vy cng lm tng
nguy c mt nc nhanh hn. Vn khc phc ch yu vn l lm sao cho
ngi bnh ung c, bn thn ngi bnh phi tp ung, ung tng
ngm nh vi chc ml mi ln, thm ch 10ml cng c v c 5 n 10 pht
nhp mt ln, la nhng thi im tt c th ung.
kt lun
Hen ph qun l mt bnh mn tnh. Nguyn nhn gy hen khng phi
lc no cng c th bit, v vy iu tr hen ch yu l cc thuc gin ph
qun ct cn hen. Vic dng thuc d phng cng rt quan trng v s
lm gim c s cn. Cc bin php iu tr h tr gip cho bnh nhn d
chu hn, kh nng vt qua cc cn hen d dng hn, c bit trong nhng
trng hp nng. Phi hp thuc, s dng thuc ng cch, ng lc,
phi hp cc bin php iu tr h tr s lm tng t l iu tr thnh cng
bnh ny
142
T lng gi
Chn mt cu tr li ng nht (t cu 1 n cu 6)
1. Cc nhm thuc gin ph qun c s dng trong iu tr hen ph qun:
A. Kch thch th th beta
B. Nhm beta - lactam
C. Nhm khng cholinergic
D. Nhm xanthin
2. Adrenalin:
A. Adrenalin kch thch c th th alpha v beta - adrenergic.
B. Adrenalin c dng c ng ung v ng tim.
C. Tc dng gin ph qun rt nhanh.
D. C nhiu tc dng ph vi h tim mch v h thn kinh.
3. Theophylin:
A. Tc dng ph ca theophylin l nhc u, kh ng, bn chn, kch
ng, mch nhanh, bun nn, nn...
B. Tc dng ca theophylin khng b nh hng khi dng ng thi
vi erythromycin hoc cc ung c cha cafein.
C. Theophylin l thuc c phm vi iu tr hp.
4. Cc khng histamin H1:
A. Cc khng histamin ngn chn s tip xc ca histamin vi th th
ca histamin v th m ngn chn co tht ph qun
B. Cc khng histamin gy mt tc dng kh chu l lm gim tit
dch, khin cho dch nhy trong ph qun ngi hen qunh c li,
gim thi m.
C. Trong tt c cc trng hp hen cc khng histamin u c tc
dng tt.
5. Ngi ta thng s dng cc nhm thuc sau h tr iu tr hen:
A. Cc thuc long m
B. Dch truyn
C. Khng histamin H2
D. Oxy
143
6. Cc thuc sau, thuc nhm kch thch chn lc th th beta 2- adrenergic:
A. Salbutamol
B. Adrenalin
C. Terbutalin
D. Metoproterenol
Phn bit ng sai (t cu 7 n cu 16)

S
7. Hen ph qun (HPQ) l mt bnh thuc h h hp
8. HPQ c c trng bi s tc nghn ng th khng hi phc
9. HPQ l tnh trng vim mn tnh v tng p ng ca ng
th vi nhiu tc nhn kch thch.
10. Cc cht kch thch chn lc th th beta - 2 adrenergic nhiu
tc dng ph hn cc thuc kch thch khng chn lc beta - 2.
11. Cc cht kch thch chn lc th th beta - 2 adrenergic t nh
hng n tim mch.
12. Cc cn hen u p ng nhanh vi cc thuc kch thch chn
lc th th beta - 2 adrenergic
13. Cc thuc bo v t bo mast c tc dng chng vim nh, tc
dng gin ph qun l khng ng k.
14. Cc thuc bo v t bo mast ch yu c tc dng trong iu tr,
t c tc dng d phng hen ph qun.
144
Bi 12
S dng thuc trong iu tr

to bn v tiu chy
Mc tiu
1. Trnh by c nguyn tc iu tr bnh to bn v tiu chy.
2. Trnh by c cc thuc c s dng, cch s dng hp l cc thuc
trong iu tr to bn - tiu chy.
m u
To bn v tiu chy l nhng ri lon tiu ho m hu ht mi ngi
trong cuc i u c lc mc phi. Thng thng, cc triu chng ny t
ht, tuy nhin i khi cng cn s dng thuc iu chnh nhng ri lon
ny. Trn th trng c rt nhiu loi thuc khng cn k n iu tr cc
triu chng to bn v tiu chy, v li khuyn ca cc dc s trong s
dng cc thuc ny l v cng quan trng m bo vic s dng thuc
hp l cho bnh nhn.
1. To bn
1.1. Vi nt v bnh
To bn l hin tng i ngoi t hn 3 ln mt tun v/hoc lng phn
trung bnh t hn 30 g/ngy (bnh thng l 150 g/ngy i vi ngi ln).
Ngi cao tui l i tng d b to bn nht, ngoi ra cn k n tr
em, ph n c thai, bnh nhn b bnh phi nm lu.
C rt nhiu nguyn nhn gy to bn. a s trng hp l do khng
cung cp thnh phn cht x trong thc n. Cc trng hp mt nc
(ung t, ra qu nhiu m hi), t vn ng (ngi gi, b bnh nm lu) u
dn n to bn. Nhng ngi c thi quen khng i tin ng gi gic
hoc qun i tin (tr nh, ngi cao tui, ngi b bnh tr, nt hu mn s
au) cng gy to bn. To bn cng c th l th pht do mt s bnh l
ng tiu ho hay ton thn; hoc do thuc (chn knh calci, chng trm
cm 3 vng, li tiu...).
145
Triu chng ca to bn bao gm: i tin kh khn, nhiu ngy mi
i mt ln, i ngoi au hay i ngoi khng ht, phn rn, ln nhn, c th
c au bng, cng bng, au u v chn n nh. Nu to bn mn tnh
hoc trong trng hp to bn nng, phn c th c mu hoc cht nhy.
1.2. iu tr
1.2.1. Nguyn tc iu tr
Mc ch iu tr l lm tng thnh phn nc trong phn, nh
lm mm v tng khi lng phn, v kch thch lm tng cng nhu
ng rut.
To bn d do bt k nguyn nhn no cng bt u iu tr bng bin
php khng dng thuc thay i ch n v li sng.
Cc trng hp xc nh c to bn l th pht do mt bnh no
th cn iu tr c hiu theo nguyn nhn; hoc nu xc nh c l
do thuc cn cn nhc vic ngng thuc hoc gim liu.
Ch dng thuc nhun trng khi p dng cc bin php trn khng .
Ch trnh tnh trng lm dng thuc nhun trng v lu di s
lm cho bnh nng thm, kh cha; thuc gy mt in gii v km
hp thu.
1.2.2. Bin php iu tr khng dng thuc

Tng lng x trong khu phn n hng ngy ti t nht l 14 g cht x
trong mt ngy. Khng nn tng thnh phn x ln qu nhiu v c th
lm chng bng kh tiu. Cn b sung nc trnh tc rut. Cc
thc n cha nhiu x l rau qu, ng cc, trnh thc n d gy to
bn (i, sim).
Ung nhiu nc: t nht 1,5 lt /ngy.
Tng cng vn ng nh chy b, i b (c bit l ngi cao tui, sc
yu, ngi t vn ng).
Luyn tp: Xoa bng kt hp vi i b, to thi quen i ngoi ng gi.
Cn p dng bin php iu tr khng dng thuc ny lin tc trong t
nht 1 thng trc khi nh gi hiu qu v cn nhc vic dng thuc.
1.2.3. Thuc iu tr to bn
Cc thuc iu tr to bn thng c phn loi theo c ch tc dng.
146
Bng 12.1. Mt s thuc iu tr to bn
Nhm thuc Hot cht ng Thi gian bt Liu dng

dng u tc dng
Thuc lm tng khi Methylcellulose U
lng phn Cm U 12 - 72 gi 4 - 6g/ngy
Thuc nhun trng Lactulose U, TTT 15 - 30ml

thm thu Glycerin TTT, TT 15 - 30 pht
Sorbitol U 30 - 50g/ngy
Mui magnesi U 30 pht - 6 gi -
Mui phosphat U, TTT -
Thuc kch thch Bisacodyl U 6 - 12 gi 10mg
TT 15 pht - 2 gi
Thuc lm mm phn Docusat U, TTT 12 - 72 gi 50-300mg/ngy
Thuc bi trn Du parafin U, TTT 6 - 8 gi 15 - 30ml
Ghi ch: U: ung TTT: tht trc trng TT: t trc trng
Cc thuc lm tng khi lng phn

L cc dn cht cellulose v polysaccharid khng tiu ho c v
khng hp thu. Chng ht nc, trng n, lm tng khi lng phn, nh
kch thch nhu ng rut v lm gim thi gian lu chuyn cc cht trong
ng tiu ho. Tc dng xut hin sau khi ung 12 - 24 gi, c tc dng ti a
sau 2 - 3 ngy. Mi liu thuc cn ung cng khong 500 ml nc cho
thuc trng n ht, trnh gy tc rut, thc qun.
Thuc kh an ton, t tc dng ph. L thuc la chn hng u trong
trng hp to bn n thun. Thuc dng c cho ph n c thai, ph n
ang cho con b v khng hp thu. Khng dng thuc lm tng khi lng
phn cho bnh nhn b hp, lot, dnh rut; mt trng lc i trng.
Thuc nhun trng thm thu

Gm hai nhm : + Glycerin, lactulose, sorbitol
+ Cc mui v c (magnesi sulfat, natri sulfat)
Thuc nhun trng thm thu lm tng p sut thm thu trong lng
rut, gi nc trong lng rut, nh vy lm mm phn. Ngoi ra, thuc cn
c tc dng kch thch nhu ng rut.
Glycerin c tc dng sau 15 - 30 pht, lactulose cn 24 - 48 gi, cc
mui magnesi v natri tc dng sau 15 pht - 6 gi (thuc tht trc trng
cha mui phosphat c tc dng sau 2 - 15 pht). Bnh nhn cn ung nhiu
nc khi dng cc thuc nhm ny.
147
Khng nn dng ko di cc thuc nhun trng mui v c th gy ri
lon dch v in gii. Khng dng mui magnesi cho bnh nhn c bnh
tim, thn v thuc c th hp thu gy bun ng, l ln. Liu cao c th gy
tng huyt p.
Thuc nhun trng kch thch

Gm cc dn cht anthraquinon (casanthrol, danthron, senna...) v
diphenylmethan (bisacodyl...).
Thuc kch thch vo cc u dy thn kinh thnh rut lm tng nhu
ng rut, ng thi gi nc i trng. Thuc c tc dng sau 6 - 12 gi
nn thch hp dng trc khi i ng v to cm gic cn i ngoi vo
sng hm sau.
Khng nn dng cc thuc ny ko di v c th gy ri lon nc, in
gii v mt trng lc chc nng i trng.
Thuc lm mm phn v thuc lm trn

Cc thuc ny c tc dng lm gim cng ca khi phn, lm cho
phn d lu chuyn trong rut.
Thuc tc dng tt trong trng hp i ngoi au, v d nh vi bnh
nhn b tr hay nt hu mn. Thuc c khuyn dng cho nhng bnh
nhn cn trnh gng sc rn khi i ngoi (hi phc sau t qu, nhi mu c
tim, phu thut trc trng...); ph hp vi to bn ngi cao tui.
Thuc lm mm phn: Gm cc mui calci, kali, natri ca dioctyl
sulfosuccinat (Docusat). Chng c tc dng lm gim sc cng b mt,
nc d thm vo phn, lm mm phn, d i ngoi. Thuc c tc dng
sau 1 - 3 ngy khi dng ng ung, sau 2 - 15 pht nu dng ng
trc trng. Thuc ch yu c dng phng to bn.
Thuc lm trn lng rut: Hay c dng l du parafin lng. Thuc
lm gim hp thu cc vitamin tan trong du A, D, E, K nn hin t
c dng. Du parafin c th hp thu gy ra nhng u parafin mng
treo ca rut. Thuc c th ht vo phi gy vim phi nn cn trnh
dng cho tr em di 6 tui, ngi cao tui, m yu v khng c dng
thuc ngay trc khi i nm ng. Thuc c th r ra qua hu mn gy
vim, nga hu mn.
2. Tiu chy
2.1. Vi nt v bnh
Tiu chy l hin tng i ngoi nhiu ln ( 3 ln) trong ngy, s tng
phn nhanh v phn nhiu nc. C th km theo st, au bng v bun nn.
148
Trn th gii hng nm c ti 5 triu ngi t vong v mt nc do
tiu chy, c bit hay gp tr di 5 tui. Ngi cao tui v m yu cng
d b tiu chy.
Tiu chy c th l hu qu ca s tr dch trong lng rut hoc ri
lon nhu ng rut. Bnh nhn c th b tiu chy n thun, t khi (cp
tnh) hoc tiu chy mn tnh, th pht do mt bnh no (vim rut, i
tho ng...). Nhim khun ng tiu ho (do virus, vi khun, k sinh
trng ng rut) l nguyn nhn gy tiu chy hay gp nht. Mt s thuc
nh methotrexat, thuc chng vim khng steroid, cc khng sinh ph rng
(ampicilin, erythromycin, lincomycin...) cng c th gy tiu chy.
Tiu chy ko di c th gy hu qu nghim trng. Mt nc v gim
Na+ do mt dch kh ph bin, gim K+ c th dn ti lon nhp tim v tc
lit rut. Mt bicarbonat qua phn cng s gim bi tit acid qua thn c
th gy toan chuyn ho.
2.2. iu tr
2.2.1. Nguyn tc iu tr
Mc ch iu tr l lm tng qu trnh hp thu cc dch trong lng
rut, ng thi lm gim nhu ng rut.
Vic iu tr bao gi cng gm 2 phn: B nc v in gii; iu tr
triu chng. Vi cc trng hp tiu chy cp tnh, khng cn thit
phi dng thuc iu tr, ch cn b nc v in gii l . Ch nn
dng thuc trong trng hp tiu chy mn tnh, l triu chng ca
nhng bnh nghim trng nh vim lot i trng, bnh Crohn...
Trng hp tiu chy do nhim khun phi iu tr bng khng sinh,
thuc dit k sinh trng...
2.2.2. B nc v in gii cho bnh nhn tiu chy
c bit quan trng i vi tr nh v ngi cao tui. Dung dch ung
b nc v in gii c khuyn co bi T chc Y t Th gii (Oresol -
vit tt l ORS) c cha glucose, Na+, K+, Cl, HCO3 trong dung dch ng
trng (thnh phn c th c k trong bng 12.2).
Bng 12.2. Thnh phn dung dch ORS.
Thnh phn Nng (mmol/L) Thnh phn/1 lt nc

Glucose 111 20 g (glucose)
Natri 90 3,5 g (NaCl)
Kali 20 1,5 g (KCl)
Clorid 80 -
Bicarbonat 30 2,5 g (NaHCO3)
149
Liu dng tu thuc vo mc mt nc, tui v cn nng ca bnh
nhn. Mi ln i ngoi ngi ln cn c b 400 ml, tr em 100 ml v tr
nh 50 ml. Bnh nhn nn c 5 - 10 pht ung mt hp hn l ung mt
lng nhiu nhng khng thng xuyn.
Cc trng hp mt nc nng cn nhp vin v iu tr bng truyn
tnh mch cc dung dch nh Ringer lactat, NaCl 0,9%, glucose 5%...
2.2.3. Thuc iu tr tiu chy

Hai nhm thuc c bn cm tiu chy l nhm thuc lm gim nhu
ng rut v nhm thuc hp ph. Ngoi ra, mt s thuc lm tng khi
lng phn nh metylcellulose dng vi t nc cng dc dng iu tr
tiu chy mn tnh. Cc ch phm thay th h vi khun rut (Lactobacillus
acidophilus, Lactobacillus bulgaricus) cng c dng iu tr tiu chy
lon khun rut do dng khng sinh ph rng. Trong cc trng hp tiu
chy c km theo st, nhim c, phi s dng khng sinh tu theo nguyn
nhn gy bnh (xem Bi 8. Nguyn tc s dng thuc khng sinh v khng
khun).
Thuc hp ph
Thuc c tc dng hp ph nc lm gim t l nc trong phn, to
khun cho phn v lm gim s ln i ngoi. Cn ch l khi dng cc thuc
hp ph s kh nh gi lng nc v dch bnh nhn b mt do i ngoi.
Cc thuc ny u khng hp thu nn khng gy tc dng ph ton thn.
Thuc lm gim hp thu cc thuc dng ng thi.
Thuc lm gim nhu ng rut
Cn c gi l cc thuc opioid iu tr tiu chy
Thuc lm gim nhu ng rut, lm tng qu trnh hp thu nc v
in gii ng tiu ho, lm gim thnh phn nc trong phn.
Cc thuc ny lm chm qu trnh thi cc yu t gy nhim khun (vi
khun, virus...) ra khi c th, lm ko di triu chng. V vy ch nn dng
khi tht cn thit, v d khi s ln i ngoi qu nhiu ln gy phin phc
cho bnh nhn.
Loperamid hp thu chm v khng hon ton sau khi ung, chm v t
qua c hng ro mu no nn rt t tc dng n thn kinh trung ng.
Codein, diphenoxylat c th gy nghin nn t c dng hn. Cc thuc ny
u khng nn dng cho tr em di 6 tui.
150
Bng 12.3. Mt s thuc iu tr tiu chy
Nhm Hot cht Dng dng Liu dng

thuc
Hp ph Attapulgit Vin nn 300 mg, 600 mg 1,2-1,5 g sau mi ln i
Hn dch ung 300 mg/7,5 ml ngoi, ti a 9 g/ngy
Polycarbophil Vin nn 500 mg 1 g x 4 ln/ngy, ti a 6
g/ngy
Gim nhu Loperamid Vin nang 2 mg 2 mg sau mi ln i ngoi,
ng rut ti a 16 mg/ngy
Diphenoxylat Vin nn 2,5 mg 5 mg x 4 ln/ngy, ti a
Codein 20 mg/ngy
Vin nn (phi hp cht 30-60 mg x 3-4 ln/ngy,
khc) ti a 240 mg/ngy
Kt lun
To bn v tiu chy l nhng ri lon tiu ho hay gp v thng t
khi. Vic thay i ch n v li sng trong nhiu trng hp c th gii
quyt c bnh to bn. Nu cn thit phi s dng cc thuc nhun trng,
cc thuc phi c la chn ph hp vi tnh trng ring ca tng bnh
nhn. Vi tiu chy cp, vic b nc v in gii l cn thit trnh mt
nc, ri lon in gii. C th s dng cc thuc hp ph hoc gim nhu
ng rut cho bnh nhn tiu chy. Cc dc s lm sng, bng kin thc v
kinh nghim ca mnh s ng vai tr quan trng trong vic t vn cho bnh
nhn t iu tr cc ri lon tiu ho ny mt cch hp l v hiu qu nht.
T lng gi
1. Ba nhm thuc c th gy to bn l:
A. .
B. .
C. .
2. Cc bin php iu tr to bn khng dng thuc bao gm:
A. n nhiu cht x
B. .
C. .
D. .
151
3. Ba thuc/nhm thuc c th gy tiu chy l:
A. .
B. .
C. ..
4. iu tr tiu chy gm 2 phn:
A. ..
B. .
5. Cc thuc lm gim nhu ng rut nh loperamid khng nn dng cho tr
em (A) tui.
6. Thuc lm trn lng rut iu tr to bn lm gim hp thu (A) nn
hin t c dng.
7. Cc thuc nhun trng lm mm phn
A. Ch dng bng ng ung
B. Ph hp iu tr cho ngi cao tui.
C. Ch dng iu tr, khng dng phng to bn.
D. C 3 trn u ng
8. Cc i tng d b to bn l :
A. Ngi cao tui
B. Ph n c thai
C. Bnh nhn phi nm lu
D Tt c cc i tng trn
9. S dng dch b nc v in gii cho bnh nhn tiu chy :
A. c bit quan trng i vi tr nh v ngi cao tui.
B. Liu dng ch ph thuc vo tui v cn nng ca bnh nhn
C. Trong mi trng hp ch dng ng ung.
D. C 3 trn u ng.
S
10. Trong iu tr tiu chy, nn hn ch dng cc thuc gim nhu
ng rut, ch dng khi tht cn thit.
11. Cc thuc hp ph hay gy tc dng ph ton thn.
12. Cc thuc nhun trng kch thch nu dng ko di c th gy
ri lon nc, in gii.
13. Chng ch nh dng thuc lm tng khi lng phn cho ph
n c thai.
14. Ch cn s dng khng sinh trong trng hp tiu chy do
nhim khun.
152
Phn 2
Thc hnh
153
154
Phn 2.1
Thc hnh hng dn s dng thuc

ti lp hc
Mc tiu
1. C c cc k nng giao tip v k nng khai thc thng tin t bnh nhn.
2. C c k nng khai thc cc ngun thng tin phc v cho hng dn s
dng thuc
3. C c cc k nng truyn t thng tin thuc khi hng dn s
dng thuc.
Thi lng: 12 tit (3 bui)
Ni dung thc hnh:

Bi 1. K nng giao tip v khai thc thng tin t bnh nhn phc v cho
hng dn s dng thuc
Bi 2. K nng khai thc cc ngun thng tin lin quan n s dng thuc
Bi 3. K nng hng dn s dng thuc
155
Bi 1
k nng giao tip v khai thc thng tin

t bnh nhn
Mc tiu
1. C c k nng giao tip vi bnh nhn
2. C c k nng khai thc thng tin t bnh nhn phc v cho s
dng thuc
I. l thuyt
1. k nng giao tip
1.1. Thi trong giao tip vi bnh nhn
Lun t ra t nh, thng cm v tn trng bnh nhn.
Lun t ra quan tm n bnh nhn v cn nhc nhng g mnh ni.
Lun lng nghe bnh nhn v p li cho h hiu rng h s c chm
sc tn tnh. iu ny s lm cho bnh nhn an tm rng thuc s c
bn ng nh k trong n thuc v chc chn vic iu tr c hiu
qu.
Tip nhn nhng li phn nn bng thi n ho lch s. Khng bao
gi ln ting vi khch hng. Sau khi lng nghe nhng li phn nn,
hy trnh by li cho dc s qun l nh thuc gii quyt. Dc s
qun l nh thuc l ngi c kin thc nm vn nhm gii
quyt hay gii thch cho khch hng hiu r vn .
1.2. S dng ging ni v thut ng trong giao tip

Ging ni v thut ng trong giao tip ph hp i tng. Ging ni
thn mt khi ni chuyn vi bnh nhn s gip h tr nn ci m hn,
nh vy s lng thng tin thu nhn c s nhiu hn.
Khng s dng thut ng chuyn mn qu su v s lm bnh nhn
kh hiu, lm gim hiu qu tun th iu tr hoc lm cho bnh nhn
lo lng. Vi mt s i tng nh ngi c trnh vn ho thp, tr
156
em nh tui, nn s dng c ngn ng v k hiu, ni v lm mu
m t iu mun truyn t.
2. K nng khai thc thng tin t bnh nhn

Khai thc cc thng tin lin quan n c im ca bnh nhn (tui,
gii, thi quen, ngh nghip, a ch ...).
Khi khai thc thng tin phi m bo c tnh ring t, trnh cho
bnh nhn cm thy e ngi khi phi ni trc m ng nhng vn
t nh lin quan n sc kho v bnh tt.
Thng tin thu thp phi t m v chnh xc.
Trong qu trnh khai thc thng tin phi m bo cc nguyn tc ca
k nng giao tip vi khch hng, nh mt thn thin, lun hng
n bnh nhn, tt nht l khng ngt qung bng cc cng vic
khc.
Mt s i tng rt cn lu khi giao tip, l:
+ Ngi cao tui, c bit l i tng sng c n. y l nhng ngi
d mc cm, e ngi hoc lnh lng. Nu ph v c ro cn tm l
s tng kh nng thu nhn thng tin v hp tc trong iu tr.
+ Ngi c khuyt tt v th gic hoc thnh gic, suy gim nhn thc
(hay qun). Vi i tng ny, kh nng giao tip rt kh khn, v
vy cn la chn hnh thc giao tip ph hp nh li ni, hnh v,
bn vit...
II. Thc hnh

Phng php: ng vai
Mi t c chia lm cc nhm, mi nhm gm 3 sinh vin.
Ni dung:
+ Sinh vin th 1: ng vai bnh nhn
Vi mi t s la chn cch ng vai bnh nhn theo tnh hung cc la
tui: ngi cao tui, ngi trung nin, tr em hoc cc i tng c
bit khc nh: Ngi c khuyt tt v th gic hoc thnh gic, suy
gim nhn thc (hay qun), c giao 1 n thuc ph hp vi tnh
hung bnh ca mnh, bnh nhn khi n mua thuc c th c php
hi, phn nn, thc mc hoc c th khng ni g. Khi ngi bn
thuc hi bnh nhn, bnh nhn phi tr li ph hp vi tnh hung
bnh ca mnh.
+ Sinh vin th 2: ng vai ngi bn thuc.
157
Ngi bn thuc cn nm r cc ni dung v k nng giao tip v cch
khai thc thng tin bnh nhn, cng nh cch s dng cc ngun thng
tin thuc c sn ti hiu thuc nhm hng dn bnh nhn s dng
thuc hp l. Ngi bn thuc phi t cc cu hi ph hp khi khai
thc thng tin bnh nhn hoc khi hng dn s dng thuc (xem ni
dung trn).
+ Sinh vin th 3: L ngi quan st v a ra nhn xt v k nng
giao tip ca ngi bn thuc da vo bng kim c cho sn.
Thi lng: Mi nhm c thc hnh trong 20-30 pht
Bng kim: Thc hin bng phng php cho im:
0: Khng c; 1: Kh (cha y ); 2: Tt (y )
TT Ni dung im Ghi ch
I. Thi trong giao tip bnh nhn
1 V mt (thn thin)
2 nh mt (hng v BN)
3 Lng nghe (ch lng nghe BN)
II. S dng ging ni v thut ng trong giao tip
4 Cho hi (thn thin, lch s)
5 Xng h (ph hp, t nh)
6 Ging ni (ci m, tn trng, khng ln ting)
7 Thut ng (khng chuyn su, d hiu, d nh)
III. Khai thc thng tin bnh nhn lin quan n s dng thuc
8 a ch
9 i tng c bit (tr em, ngi cao tui, ph n c thai v
cho con b)
10 Suy gan
11 Suy thn
12 C bnh mc km khc
13 Thi quen c hi (ht thuc l, ung ru bia)
14 Thuc hin ang s dng
15 Tin s d ng
158
Bi 2
k nng khai thc thng tin

s dng Thuc
Mc tiu
1. Nm vng c cc thng tin c bn cn cho s dng thuc.
2. C c k nng khai thc cc ngun thng tin thuc c sn ti hiu
thuc.
I. l thuyt
1. Cc ngun thng tin thuc
Thut ng Thng tin thuc c xut hin vo nhng nm u ca
thp k 60. Dc s c trch nhim gii p cc cu hi lin quan n thuc
v gii p nhng vn ny, h thng xuyn cn n s tr gip ca
Dc th hay Dc in...
Cho n ngy nay s bng n s lng cc thuc mi ngy cng a
dng v c ch tc dng, dng k thut bo ch tinh vi, c tnh ca thuc...
i hi ngi dc s trung hc bn thuc mun hng dn s dng thuc an
ton, hp l v hiu qu phi xc nh r cch s dng thuc da vo cc
ngun thng tin c sn ti cc hiu thuc nh: T hng dn s dng thuc
trong cc hp thuc; cc sch nh Dc th, Thuc v bit dc, Mims,
Vidal hoc c th hi kin ca dc s ph trch hiu thuc.
Tm li khi hng dn s dng thuc cho bnh nhn, ngi Dc s
bn thuc cn phi cn cu trn cc ngun thng tin c sn, tuy nhin cng
phi xem xt cc ngun thng tin khc khi tr li cc cu hi cn tnh xc
thc cao.
2. Cc thng tin c bn cn cho s dng thuc

Nhm iu tr
Ch nh
Chng ch nh
ng dng (dng bo ch)
Liu dng
159
S ln dng trong ngy
Thi im dng thuc
Nc ung cng vi thuc
Lu mt s i tng c bit
Hng dn s dng mt s thuc c bit (nu c) (xem Ph lc).
II. Thc hnh

Cc ngun thng tin c th s dng bng ting Vit:
+ Dc th Quc gia Vit Nam
+ MIM'S pharmacy guide
+ Thuc v bit dc (Nhiu tc gi)
+ Vidal Vit Nam
+ Sch hng dn iu tr ca B Y t
Ni dung:
1. Tra cu cc thng tin thuc sau

Tn bit dc, tc dng dc l, ch nh, tc dng khng mong mun,
chng ch nh, liu dng ca cc thuc ph bin ti cc hiu thuc, v
d nh:
Nhm thuc gim au, h st (chng vim):
Aspirin
Diclofenac
Ibuprofen
Piroxicam
Paracetamol
Thuc khng Histamin H1:
Fexofenadin
Alimemazin
Clorpheniramin
Thuc long m:
Acetylcystein
Bromhexin
Thuc iu tr tiu chy:
ORS, Hydrit
160
Loperamid
Thuc khng sinh:
Amoxicilin
Cefalexin
Cefuroxim
Erythromycin
2. Tra cu thng tin thuc theo n hng dn

Mi sinh vin c pht cho mt t n hng dn s dng thuc; da
vo cc ti liu tra cu c sn ti phng thc tp v c yu cu tra cu
theo cc yu cu thng tin c bn ca 1 thuc c trong n (xem ni dung l
thuyt). Kt qu c bo co bng bng tng kt nh sau:
Bng tng kt tra cu thng tin thuc
H v tn:
Lp:.
T: n s:..
S Thi Nc
Tn Tn Nhm ng ung Lu
TT C CC Liu ln im HDSD
BD gc T dng TB
/ngy ung thuc
161
Bi 3
k nng Hng dn s dng thuc
Mc tiu:
1. Lit k c cc thng tin thuc cn truyn t cho bnh nhn
2. C c k nng hng dn s dng nhng thuc bn khng cn n
(OTC).
I. L thuyt
1. Cc thng tin thuc cn truyn t cho bnh nhn

Ch nh
Chng ch nh
ng dng (mt s dng bo ch)
Liu dng
S ln dng trong ngy
Thi im dng thuc
Nc ung cng vi thuc
Lu mt s i tng c bit
Theo di hiu qu iu tr v ADR
Hng dn s dng mt s thuc c bit (nu c).
V d:
Cc thng tin lin quan n gi ung thuc, cch ung thuc l nhng
thng tin thng gp nht. Vi bnh nhn mc bnh mn tnh nh bnh lao,
bnh tng huyt p,... thng tin v di liu trnh iu tr m bnh nhn
phi thc hin l rt quan trng. Nhng thng tin lin quan n cch thc
theo di tin trin ca bnh ti nh (v d cch kim tra huyt p), chu k
ti khm... l nhng thng tin phi truyn t v phi xc nh chc chn
bnh nhn hiu v tin tng thc hin.
162
Vi nhng thuc c dng bo ch c bit nh: Thuc nh mt, thuc
m bi mt, thuc nh tai, thuc xt mi, ming dn ngoi da, bnh xt kh
dung, ngi bn thuc phi hng dn cch dng thuc ht sc t m
nhm m bo hiu qu tc dng ca thuc (xem phn ph lc).
2. K nng hng dn s dng thuc

Bn cnh nhng k nng giao tip, cch khai thc thng tin bnh
nhn, khai thc thng tin s dng thuc c trong n thuc, thc hin
mc ch hng dn iu tr theo n, ngi dc s bn thuc phi hng
dn chnh xc v t m cch thc thc hin y lnh bao gm vic dng thuc
v cc du hiu cn nhn bit v tin trin theo chiu hng xu ca bnh.
Mun lm tt vic ny, ngi dc s bn thuc phi to lp c lng
tin t pha bnh nhn v phng php kim tra kh nng nhn thc ca h
vi cc thng tin c truyn t; thng th nn ngh bnh nhn hoc
ngi nh bnh nhn (vi bnh nhn nh tui hoc ngi b bnh tm
thn...) nhc li.
Cch t cu hi khi tip xc vi bnh nhn, ngoi cc th tc cho hi
ban u, mt s cu hi c quy nh nh sau tu tnh hung:
Cc cu hi c bn hng dn dng thuc
Tnh hung Cu hi
Khi bnh nhn mua 1. Bc s dn thuc ny cha bnh g?
thuc ln u 2. Bc s dn ung thuc ny nh th no?
3. Bc s dn ung thuc ny s c nhng tc dng g?
Kim tra li:
4. Xin lm n nhc li thuc ny s c ung nh th no?
1. Anh/ch... dng thuc ny cha bnh g?
Khi bnh nhn mua 2. Anh/ch... ung th no?
thuc ln th 2 tr i 3. Khi dng thuc ny c vn g xy ra khng?
Bng ch nu ni dung c bn ca cu hi, tu tnh hung, cch din

t c th rt khc nhau.
V d:
Ch cch gi bnh nhn bng anh/ch, ng/b... hay tn cng to ra s
thn mt, lm thu hp khong cch giao tip.
Vi cu hi 1, c th hi nhiu cch:
+ Thuc ny gip cha bnh g?
+ Thuc ny dng lm g?
163
+ V sao phi dng thuc ny?
Vi cu hi 2 "Bc s dn ung thuc ny nh th no?" c th lm r
hn khi hi:
+ Mi ln ung bao nhiu?
+ Sau bao lu ung 1 ln?
+ Ung ko di bao lu?
+ Phi lm g nu qun ung thuc?
+ Ung 3 ln 1ngy ngha l th no?
+ Ung xa ba n ngha l th no?
+ Ti sao khng c ung thuc vi sa?
+ Hai thuc no khng c ung cng mt lc?
.....
Ni chung cch t cu hi lm tng s hiu bit ca bnh nhn,
tng tun th iu tr. Ni dung cu hi phi d hiu, r rng, dt khot.
Cn lu vi cc dng thuc c cch dng c bit.
Vi cu hi 3 "Bc s dn ung thuc ny s c nhng tc dng g?" y
l cu hi v tc dng iu tr v tc dng ph. C th lm r nh sau:
+ Thuc ny s c hiu qu g?
+ Lm th no bit thuc c hiu qu?
+ C th thy triu chng kh chu no?
+ Lm th no gim bt bun nn khi dng thuc ny?
Thc ra tt c thng tin trn u phi c bc s dn d t trc,
nhim v ca dc s bn thuc l hi nhc li v sa nhng ni dung m
bnh nhn hiu khng ng, v vy ngi dc s bn thuc cn lng
nghe v ngh bnh nhn lp li, cng c th lm mu bnh nhn d
hiu hn.
Khi hi, ngi dc s bn thuc phi hi cc loi cu hi no?

Cu hi m: Cu hi m thng c m u bng cc t: Ti sao? Ci
g? nh th no? Bao lu?, lm g?... Loi cu hi ny khuyn khch
bnh nhn cung cp thng tin v ngi nghe d dng nh gi c
nhn thc ca ngi tr li; tuy nhin hn ch l s hp tc v trnh
ca bnh nhn, s kin nhn ca ngi dc s bn thuc....
Cu hi ng: Loi cu hi ny ch cn tr li c hoc khng nhng
kh nh gi thc s bnh nhn c hiu ng vn khng v khng
164
khuyn khch c bnh nhn tm hiu k vn .
Cu hi dn dt: Loi ny a thng tin m ngi dc s bn thuc
mun kim tra li nhn thc ca bnh nhn xc nh bnh nhn
nm bt ng ni dung thng tin truyn t v cch dng thuc
cha, tuy nhin cu tr li cng ch l c hoc khng, v vy cng
khng nh gi c hiu bit ca bnh nhn thc s.
V d sau y hi v cch ung thuc vi 3 loi cu hi trn so snh:
+ Cu hi m: " Bc s dn mi ngy anh/ch phi ung my vin?"
+ Cu hi ng: "Bc s c dn anh/ch cch ung thuc khng?"
+ Cu hi dn dt: "Bc s bo anh/ch ung mi ngy 2 vin phi
khng?"
R rng cu hi m c u vit hn 2 loi cu hi kia. Tuy nhin, cu
hi ng li thun tin vi nhng thng tin n gin cn cu hi dn dt
hng s ch ca bnh nhn vo vn cn lm r v thun li vi bnh
nhn hn ch v kh nng din t.
II. Thc hnh

Thi lng: Mi nhm c thc hnh trong 20 - 30 pht.
Phng php: ng vai
Mi t c chia lm cc nhm, mi nhm gm 3 sinh vin, trong :
Ni dung: Trong mi nhm sinh vin s thay i cch ng vai qua cc
bi thc tp, nhm to c hi cho mi sinh vin c th rn luyn c
cc k nng.
+ Sinh vin th 1: ng vai bnh nhn
Ngi ng vai bnh nhn mi nhm s ng vai cc la tui: Ngi
cao tui, ngi trung nin, tr em hoc cc i tng c bit khc
nh: ngi c khuyt tt v th gic hoc thnh gic, suy gim nhn
thc (hay qun), c giao 1 n thuc ph hp vi tnh hung bnh
ca mnh (n thuc ny c tra cu bi 2), bnh nhn khi n mua
thuc c th c php hi, phn nn, thc mc Khi ngi bn thuc
hi bnh nhn, bnh nhn phi tr li ph hp vi tnh hung bnh
ca mnh.
+ Sinh vin th 2: ng vai ngi bn thuc.
Ngi bn thuc ngoi vn dng nhng k nng bi hc trc (k
nng giao tip v cch khai thc thng tin), cn phi nm r c cc
yu cu lin quan n cc thuc c trong n. Khi hng dn s dng
thuc trong n, ngi bn thuc phi a ra nhng li gii thch ph
hp vi ngi bnh, nhm m bo cho ngi bnh an tm, tin tng
165
vo qu trnh iu tr.
+ Sinh vin th 3: Ngi quan st v nhn xt.
Ngi quan st phi a ra nhn xt v k nng giao tip, cch khai
thc thng tin bnh nhn, cch khai thc thng tin bnh nhn ca
ngi bn thuc da vo bng kim.
Bng kim: Thc hin bng phng php cho im:
0: khng c; 1: Kh (cha y ); 2: Tt (y )
TT Ni dung im Gii thch

I. K nng hng dn s dng thuc
1. Thi trong giao tip bnh nhn
1 V mt (thn thin)
2 nh mt (hng v BN)
3 Thi (ho nh, nh nhng)
2. S dng ging ni v thut ng trong giao tip
4 Cho hi (thn thin, lch s)
5 Xng h (ph hp, t nh)
6 Ging ni (ci m, tn trng, khng ln ting)
7 Thut ng (khng chuyn su, d hiu, d nh)
II. Cc thng tin thuc truyn t cho bnh nhn
1 Ch nh thuc
2 Chng ch nh
3 ng dng
4 Liu dng
5 S ln dng trong ngy
6 Thi im dng thuc
7 Nc ung cng vi thuc
8 Yu cu bnh nhn nhc li
9 Hng dn cch dng thuc c bit
10 Dn bnh nhn theo di tc dng ph ca thuc
11 Lu mt s i tng c bit
166
Phn 2.2
Thc hnh cc hot ng hng dn

s dng thuc ti hiu thuc
Mc tiu:
1. Nm vng thng tin lin quan n cc thuc OTC c ti hiu thuc.
2. Rn luyn cc k nng giao tip, khai thc thng tin bnh nhn ti
hiu thuc.
3. Rn luyn k nng hng dn s dng thuc ti hiu thuc.
ni dung thc tp ti hiu thuc

1. Thc hnh cc hot ng giao tip v khai thc thng tin bnh nhn ti
nh thuc.
2. Thc hnh phn loi cc thuc ti hiu thuc theo nhm iu tr
3. Hng dn s dng thuc hp l ti cc hiu thuc.
Bo co kt qu t thc tp
Kt thc thc tp ngh hc vin np tiu lun gm cc ni dung:
1. Phn loi cc thuc nh thuc theo nhm iu tr.
2. Trnh by 1 trng hp c th gp ti nh thuc v cc ni dung
chnh sau:
Thng tin c im bnh nhn: Tn, tui, gii tnh, ngh nghip, a
ch.
Trnh by 1 n thuc thc t gp phi ti hiu thuc.
Phn tch v hng dn cch s dng cc thuc c trong n trn.
167
Ph lc
Hng dn cch dng cc dng thuc c bit
1. Thuc nh mt
Ra sch tay
Trong qu trnh thao tc, khng c chm tay vo u nh thuc
Nhn ln, ko mi mt di to ra khe h mt
Nh thuc ng liu lng khuyn dng vo khe h
Nhm mt trong vi pht, ch khng nhm nghin mt vo
Lau nhng git thuc trn ra ngoi bng khn sch
Nu cn nh nhiu loi thuc, phi nh cch nhau t nht 5 pht
Thuc nh mt c th gy cm gic xt nhng ch c ko di trong
vi pht, nu b xt ko di phi hi kin bc s hoc dc s.
Nu nh thuc mt cho tr em:
Cho tr nm nga, gi u thng, nhm mt
Nh thuc vo gc mt, gi u thng, lau phn thuc chy trn
ra ngoi
2. Thuc m bi mt
Ra sch tay, m tup thuc nhng khng c chm vo u bi thuc
Hi nga c ra pha sau, mt tay cm tup thuc, mt tay ko mi di ca
mt, to thnh mt khe h mt.
a thuc li gn khe h nhng khng c tup thuc chm vo
mt, bp mt lng thuc nh c khuyn dng vo khe h
Nhm mt khong 2 pht, lau phn thuc trn ra ngoi bng khn sch.
Lau u nh thuc bng khn sch.
3. Thuc nh tai
Lm m thuc nh tai bng cch nm trong lng bn tay hoc kp vo
nch vi pht, khng dng nc nng v c th to nhit qu cao
Nghing u v mt bn hoc c th nm nghing mt bn, quay pha
tai cn nh thuc ln trn
Ko nh vnh tai lm l r l tai, nh lng thuc c khuyn dng
vo l tai
Gi vi pht ri mi quay sang nh tai cn li
168
Ch dng bng bt l tai sau khi nh thuc nu nh sn xut ch dn
lm nh vy
Thuc nh tai c th gy nga, kch ng nhng ch c php ko di
trong vi pht
4. Thuc nh mi
X sch mi
Nga mnh u ra pha sau hoc nm nga v k mt ci gi di vai,
gi u thng.
a u nh thuc vo su trong l mi khong 1 cm v nh lng
thuc c khuyn dng
Ngay sau gp u ht mc v pha trc (kp u vo gia hai u gi)
Ngi thng dy sau vi pht, thuc s chy xung hu
Lp li tng t cho bn l mi cn li
Ra u nh thuc bng nc un si
5. Thuc xt mi
X sch mi
Ngi thng, u hi ci v pha trc
Lc l thuc
a u xt thuc vo 1 l mi
Bt bn l mi cn li v ngm ming
Xt bng cch xoay v n l thuc t t
a l thuc ra khi mi v gp u v pha trc tht mnh (a u
vo gia hai u gi)
Ngi thng dy sau vi pht, thuc s chy xung hu
Th ra bng ming
Lp li tng t cho bn l mi cn li
Ra u nh thuc bng nc un si
6. Ming dn ngoi da
V tr dn thuc c ghi r trong t gii thiu sn phm
Khng dn ln nhng ch da b tn thng hoc bm tm
Khng dn ln cc np gp da, khng mc qun o b cht bn ngoi
ch dn thuc.
Dng tay kh v sch dn thuc
Lau sch v lm tht kh v tr da s dn ming thuc
Ly ming dn ra khi bao b, ch khng chm vo mt cha thuc
t ming dn ln da v n cht xung, mit cc mp.
Bc ming dn v thay ming mi theo ch dn.
169
7. Bnh xt kh dung
C gng khc ht m ra
Lc k thuc trc khi dng
Gi bnh xt theo hng nh sn xut khuyn co (thng l thng
ng)
a bnh xt vo ming v ngm kn mi xung quanh ming bnh.
Hi nga u ra pha sau
Th ra chm, cng nhiu cng tt.
Ht su ng thi n bnh xt, nh n li xung pha di
Nhn th 10 - 15 giy
Th ra bng mi
Nu cn lp li liu th hai, i khong 1 pht. Sau lp li cc ng
tc trn.
Sc ming k vi nc m: Ngm mt ngm nc, nga c cho ti khi
thy trn nh, kh k c hng, nh ra, lp li 3 ln.
V sinh v bnh xt hng tun. Tho ng kim loi ra khi v bnh (ng
nha). M np ng nha, ra bng nc m, lau kh ri gn bnh xt
bng kim loi vo ng nha, y np l
8. Thuc ht dng vin nang
C gng khc ht m ra
t vin thuc vo dng c theo hng dn ca nh sn xut
Th ra chm, cng nhiu cng tt.
a bnh xt vo ming v ngm mi kn xung quanh ming bnh.
Hi nga u ra pha sau
Ht mt hi su qua bnh xt.
Nhn th 10 - 15 giy
Th ra bng mi
Sc ming k vi nc m: Ngm mt ngm nc, nga c cho ti khi
thy trn nh, kh k c hng, nh ra, lp li 3 ln.
9. Thuc t trc trng
Ra sch tay
Tho v bc vin thuc (tr khi vin thuc qu mm)
Nu vin thuc qu mm nn lm lnh trc tng rn ( vin
thuc cn nguyn v vo t lnh hoc di vi nc lnh).
Lm mt nhng b sc cnh bng cch lm m ln trong tay
Lm m vin thuc bng nc lnh
Nm nghing mt bn, co u gi
Nh nhng nht vin thuc vo trc trng, bng u trn.
170
Nm nguyn vi pht
Ra tay
Trnh i ngoi trong vng 1 gi sau
10. Thuc t m o c dng c
Ra tay sch
Tho v bc vin thuc
t vin thuc vo u m ca dng c
Nm nga, chng u gi ln v hi m ra
Nh nhng a dng c c vin thuc pha trc vo m o cng su
cng tt, nhng khng c n mnh
n ci cn ca dng c vin thuc c y ra
Rt dng c ra
Vt b dng c (nu l dng mt ln) hoc ra c hai phn ca dng
c tht k vi x phng v nc un si ngui
Ra tay
11. Thuc t m o khng c dng c
Ra tay sch
Tho v bc vin thuc
Nhng vin thuc vo nc un si ngui lm m
Nh nhng n vin thuc vo m o cng su cng tt, khng c n mnh
Ra sch tay
12. Thuc m, kem v gel bi m o
Ra tay
M np tup thuc
Xoy dng c vo tup
Bp tup thuc cho ti khi c lng thuc cn dng c
Ly dng c ra khi tup thuc (cm vo xilanh)
Bi mt t thuc ra pha ngoi dng c
Nh nhng a dng c c vin thuc pha trc vo m o cng su
cng tt, nhng khng c n mnh
Gi v xilanh v dng tay kia n xilanh y thuc vo m o
Rt dng c ra khi m o
Vt b dng c (nu l dng mt ln) hoc ra c hai phn ca dng
c tht k vi x phng v nc un si ngui
Ra tay
171
p n
Bi 1: Bi m u
1. A : Dc
B : S dng thuc
C : Dc, y v sinh hc.
2. B : An ton cao
C : Tin dng
D : Kinh t.
3. A : K nng giao tip vi bnh nhn
B : K nng thu thp thng tin
C : K nng nh gi thng tin
4. A : Chnh xc v t m
B : Vic dng thuc
C : Cn nhn bit v tin trin theo chiu hng xu ca bnh.
5. D; 6. C; 7. E; 8. A
Bi 2: Cc thng s dc ng hc ng dng trn lm sng
1. A : Cho lng thuc
B : dng cn hot tnh.
2. A : Gia sinh kh dng
B : ng ung
C : ng tnh mch.
3. A : Gia hai gi tr sinh kh dng
B : Cng hot cht
C : Dng bo ch.
4. B : Tng tc thuc
C : La tui.
5. A : Vng tun hon u
B : Tng
C : Qua gan.
172
6. A : Thi gian cn thit
B : Trong mu
C : Mt na.
7. B : Tng tc thuc
C : Chc nng thn
D : Chc nng gan.
8. A : Chm
B : Ko di
C : dng cn hot tnh.
9. D; 10. A; 11. B; 12. C; 13. ; 14. ; 15. S; 16. ; 17. ; 18. ; 19. S;
20. S; 21. ; 22. S; 23. ; 24. ; 25. S
Bi 3: Tng tc thuc
1. B : Nc ung c ga, nc hoa qu, nc khong kim
C : Sa
D : C ph, ch.
2. A : D dy
B : Thc qun
C : Gy kch ng v gy lot.
3. A : Di
B : Khng b nh hng.
4. B : Dc l thi khc
C : Tng tc thuc thuc.
D : Tng tc thuc thc n.
5. B : Thuc hp thu qu nhanh khi i.
C : Thuc c thc n lm tng hp thu
6. B : Thuc km bn trong acid dch v
C : Thuc bao tan trong rut.
7. A, C, E, F, I, J.
8. A, D, H, J.
9. A, B, D.
10. A, C.
173
11. A, B, D.
12. A, C, D.
13. A; 14. D; 15. D; 16. C
Bi 4 : Phn ng bt li ca thuc v cnh gic thuc
1. A : c hi
B : nh trc
C : Thng dng.
2. A : p ng c th
3. A : iu tr.
B : Gii c.
4. A : Thay i
B : iu tr c hiu
5. A : e da tnh mng
B : Bnh tt lu di.
6. A : Trc tip
B : Gin tip
7. A : 1/100
B : 1/1000
C : 1/100
D : 1/1000.
8. A : Tin lng c
B : Liu dng
C, D : Tc dng dc l
9. A : Tin lng c
B : c tnh dc l.
10. A: Pht hin
B : nh gi
C : X l.
11. A : Ng c thuc
B : Lm dng.
174
12. A : Phn ng bt li
B : Thay i tn sut
C : Yu t nguy c.
13. A; 14. A; 15. E; 16. E; 17. E; 18. ; 19. ; 20. ; 21. S; 22. ; 23. S;
24. S; 25. ; 26. S; 27. ; 28. S; 29. ; 30. ; 31. S; 32. S
Bi 5: Thng tin thuc
1. A : i tng c thng tin
B : Ngun thng tin.
2. A : Chnh xc
B : Mang tnh khoa hc
C : R rng, dt khot.
3. A : Cn b y t
B : Bnh nhn
4. A : Tc dng
B : Dng dng, liu dng, cch dng.
C : Triu chng ca cc tc dng khng mong mun v cch x tr.
D : Tng tc thuc
E : Cch bo qun lng thuc mua.
5. A : n gin, r rng, dn d, d hiu
B : Khoa hc, kh hiu.
6. A; 7. D; 8. D; 9. B; 10. D; 11. A; 12. C; 13. ; 14. S; 15. S; 16. ; 17. ;
18. S; 19. S; 20. ; 21. ; 22. S
Bi 6: Xt nghim lm sng v nhn nh kt qu
1. A : Lc cu thn
B : Chc nng lc cu thn
2. A : Insulin
B : Adrenalin
C : Glucocorticoid
3. A : Gt
4. A : T bo gan
175
5. A : Ti thn
B : Sau thn
C : Trc thn
6. A : Sau gan
B : Ti gan
C : Trc gan.
7. A : Trung tnh
B : Lympho.
8. A : Tng
B : Gim
9. A : Suy ty, ri lon tng hp porphyrin
B : Thiu mu tan mu.
10. A : Vim nhim.
11. D; 12. D; 13. D; 14. D; 15. B; 16. D; 17. C; 18. C; 19. D; 20. D; 21. ; 22.
; 23. ; 24. ; 25. S; 26. ; 27. S; 28. S; 29. S; 30. ; 31. S; 32. S
Bi 7. S dng thuc cho cc i tng c bit
1. A : iu tr
B : Gy hi.
2. A : Tt c hoc khng c g
B : Phi bo cht
C : Pht trin hon ton bnh thng
3. A : Thi k phi
B : Ngy th 18
C : Ngy th 56.
4. A : Khng c nguy c
5. A : Chng ch nh.
6. A : Kh nng lin kt protein huyt tng
B : Tnh tan trong lipid
D : Phn t lng.
7. A : Tui, cn nng v din tch b mt c th
B : Hon thin ca chc nng gan, thn.
8. A : Nn nhiu
176
B : Hn m
C : Tc rut.
9. A : thanh thi creatinin
10. A : Tng tc thuc - thuc.
B : Tc dng khng mong mun.
11. A : Thuc khng th th H2
B : Thuc chn th th Beta 2
12. A : Kh nng gi thng bng
13. A : Chng trm cm 3 vng
B : Ch phm thuc phin
14. A : 1/3 - 1/2.
15. B; 16. D; 17. D; 18. D; 19. ; 20. ; 21. ; 22. S; 23. ; 24. ; 25. ;
26. ; 27. S; 28. ; 29. ; 30. S
Bi 8 : Nguyn tc s dng thuc khng sinh v thuc khng khun
1. A : nhy cm
B : Khng sinh
C : In vitro.
2. A : Khuyn co thng thng
B : Khng mang li
3.
Metronidazo 7 Cefotaxim 1
l
Doxycyclin 4 Cefuroxim 1
Ampicilin 1 Tinidazol 7
Cephalexin 1 Gentamicin 2
Ciprofloxaci 3 Ofloxacin 3
n
Cloramphen 6 Erythromycin 5
icol
Clindamycin 8 Pefloxacin 3
Pen. G 1 Spiramycin 5
177
Lincomycin 8 Kanamycin 2
4. B : Xt nghim lm sng thng quy
C : Tm vi khun gy bnh.
5. B : Rifampicin
C : Metronidazol
D : Cephalosporin th h 3.
6. B : Lincomycin
D : Rifampicin
7. A : Mc nng thp nht
B : Khng thay i.
8. A : Nng thp nht
B : Gim dn
9. 2. Aminosid
3. Tetracyclin 8. Quinolon
5. Nitro-imidazol 9. Lincosamid.
10. A; 11. E; 12. B; 13. D; 14. C; 15. ; 16. S; 17. S; 18. ; 19. S; 20. S;
21. ; 22. S; 23. ; 24. ; 25. S; 26. S; 27. ; 28. S; 29.
Bi 9: Nguyn tc s dng vitamin v cht khong
1. A : Ch n ung.
2. A : Khng to
B : Glucid, lipid.
3. A : Rt nh
B : S sng.
4. A : Enzym
B : C hot tnh mnh
5. Vitamin C: 60 mg
Vitamin A: 5.000 vqt
Vitamin B1: 1,5 mg
Vitamin B12: 6 mcg
Ca: 1.000 mg
Fe: 18 mg
I: 150 mcg.
178
6. A; 7. C; 8. D; 9. C; 10. C; 11. B; 12. B; 13. S; 14. ; 15. S; 16. ; 17. S;
18. ; 19. ; 20. S; 21. ; 22. ; 23. ; 24. S; 25. S; 26. ; 27. S
Bi 10: Thuc chng vim cu trc steroid v khng steroid
I- Thuc chng vim cu trc steroid
1. A : Vi khun
B : Gim
C : Tc nhn gy bnh.
2. A : Gim
B : Protein.
3. A : Liu cao
B : Ko di.
4. C, D, E
5. A, B, C, D
6. A, D
7. A; 8. B; 9. B; 10. E; 11. D; 12. B; 13. A; 14. B; 15. C; 16. C; 17. E;
18. B; 19. A
II- Thuc chng vim khng steroid (NSAID).
1. C, D, E.
2. A, B, C, D.
3. A, B, D.
4. B; 5. D; 6. D; 7. D; 8. A; 9. C; 10. D; 11. C
Bi 11 : Thuc iu tr hen ph qun
1. B; 2. B; 3. B; 4. C; 5. C; 6. B; 7. ; 8. S; 9. ; 10. S; 11. ; 12. ;
13. ; 14. S
Bi 12 : S dng thuc trong iu tr to bn v tiu chy
1. A : Chn knh calci
B : Chng trm cm 3 vng
C : Li tiu
2. B : Tng vn ng
C : Ung nhiu nc
D : Luyn tp.
3. A : Methotrexat
B : Khng sinh ph rng
C : Chng vim khng steroid.
4. A : B nc v in gii.
179
B : iu tr triu chng.
5. A : Di 6 tui.
6. A : Vitamin tan trong du A, D, E, K.
7. B; 8. D; 9. A; 10. ; 11. S; 12. ; 13. S; 14.
180

Hoa Dư C-Dư C Lý III

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b Y t

Tham gia t chc bn tho:

Bn quyn thuc B Y t (V Khoa hc v o to)

Thc hin mt s iu ca Lut Gio dc, B Y t ban hnh chng

Phn 2: Thc hnh 153

DS. Nguyn Thnh Hi, DS. V nh Ho

1.3. Vi nt v mn hc dc lm sng trn Th gii v Vit Nam

1.5. Mc tiu cho hc phn Dc lm sng h trung hc Dc

Sau khi hc xong hc phn ny, hc vin c kh nng:

2. nhng ni dung phi thc hin t c mc tiu S

2.1. Cc tiu chun la chn thuc an ton - hp l

TT Tiu chun la chn K hiu

2.2. Cc k nng cn c ca DSLS khi hng dn iu tr

1. K nng giao tip vi bnh nhn

thc hin c k nng ny, DSLS phi to lp mi quan h gn gi

2. K nng thu thp thng tin

3. K nng nh gi thng tin

nh gi cc thng tin lin quan n vic dng thuc trong qu trnh

4. K nng truyn t thng tin

Cc thng tin phi truyn t c lin quan n hng dn dng thuc

1. Sinh kh dng (Bioavailability, k hiu: F)

1.2. Cch tnh sinh kh dng

1.2.1. Khi nim v din tch di ng cong

Hnh 2.1. S bin i nng thuc theo thi gian

Ghi ch: Thuc a theo ng tnh mch

Din tch di ng cong (ca th biu din s bin thin ca nng

1.2.2. Sinh kh dng tuyt i

Nu thuc c a qua ng tnh mch (I.V) th F = 1.

1.2.3. Sinh kh dng tng i

Thc cht khi so snh, ngi ta s dng hai ch phm cng mt mc

1.3.1. Tng tc thuc

1.3.3. nh hng ca chc nng gan

2. Thi gian bn thi (t1/2)

2.1. Khi nim

A: Theo t l thng B : Theo t l bn logarit

Hnh 2.2. ng cong bin i nng thuc theo thi gian

2.2. Nhng yu t nh hng n thi gian bn thi

2.2.1. nh hng ca tng tc thuc

2.2.2. nh hng ca la tui

2.2.3. nh hng ca chc nng thn

2.3. ngha ca tr s t1/2

S ln t1/2 Lng thuc c thi tr (%)

Quy tc 5 t1/2: Sau thi gian ny, thuc s bo ho cc m trong c

Chn cu tr li ng nht (t cu 9 n cu 12)

Nhng cu sau y u ng, tr:

Phn bit ng/sai (t cu 13 n cu 26)

3. Tng tc thuc vi ung

+ Ru v thuc chng i tho ng:

4. nh hng ca thc n n thuc

5. Hng dn thi gian ung thuc hp l

5.1. Nhng yu t quyt nh thi im ung thuc

5.2. La chn thi im ung thuc

Thi gian ung Nn ung

Pivmecilinam o sa, alcol

Cefalexin o sa, alcol

Tt c tetracylin z sa Khong cch

Doxycylin z sa Khng ung

Clindamycin o nc soda Khng ung

Lincomycin z nc soda Khng ung

Acid nalidixic o Khng ung

Griseofulvin z alcol Thc n m

Ketoconazol o alcol nhiu nc nt

Chng ng mu vo mt gi c nh alcol Trnh thc n