B Y T ------S: 3280/Q-BYT

CNG HA X HI CH NGHA VIT NAM c lp - T do - Hnh phc --------------H Ni, ngy 09 thng 09 nm 2011

QUYT NH
V VIC BAN HNH TI LIU CHUYN MN HNG DN CHN ON V IU TR BNH I THO NG TP 2

B TRNG B Y T
Cn c Ngh nh s 188/2007/N-CP ngy 27/12/2007 ca Chnh ph quy nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t; Theo ngh ca Cc trng Cc Qun l khm, cha bnh,

QUYT NH:
iu 1. Ban hnh km theo Quyt nh ny Ti liu chuyn mn hng dn chn on v iu tr bnh i tho ng tp 2. iu 2. Ti liu chuyn mn hng dn chn on v iu tr bnh i tho ng tp 2 c tham kho v p dng ti cc c s khm bnh, cha bnh trong c nc. iu 3. Quyt nh ny c hiu lc k t ngy k, ban hnh. iu 4. Cc ng, b: Chnh Vn phng B, Chnh thanh tra B, Tng cc trng, Cc trng v V trng cc Tng cc, Cc, V thuc B Y t, Gim c S Y t cc tnh, thnh ph trc thuc trung ng, Gim c cc Bnh vin, Vin trc thuc B Y t, Th trng Y t cc ngnh chu trch nhim thi hnh Quyt nh ny./. KT. B TRNG TH TRNG

Ni nhn:
- Nh iu 4; - B trng ( bo co); - Cc Th trng; - Cng thng tin in t B Y t; Website Cc KCB; - Lu: VT, KCB, PC.

Nguyn Th Xuyn

HNG DN
CHN ON V IU TR BNH I THO NG TP 2 (Ban hnh km theo Quyt nh s 3280/Q-BYT ngy 09 thng 9 nm 2011 ca B trng B Y t) I. KHI NIM i tho ng l mt ri lon mn tnh, c nhng thuc tnh sau: 1. Tng glucose mu; 2. Kt hp vi nhng bt thng v chuyn ha carbonhydrat, lipid v protein; 3. Bnh lun gn lin vi xu hng pht trin cc bnh l v thn, y mt, thn kinh v cc bnh tim mch khc. II. NGUYN NHN - C CH SINH BNH V BIN CHNG

1. Nguyn nhn c im ln nht trong sinh l bnh ca i tho ng tp 2 l c s tng tc gia yu t gen v yu t mi trng. a) Yu t di truyn. b) Yu t mi trng: y l nhm cc yu t c th can thip lm gim t l mc bnh. Cc yu t l: - S thay i li sng: nh gim cc hot ng th lc; thay i ch n ung theo hng tng tinh, gim cht x gy d tha nng lng. - Cht lng thc phm. - Cc stress. c) Tui th ngy cng tng, nguy c mc bnh cng cao: y l yu t khng th can thip c. 2. C ch bnh sinh Suy gim chc nng t bo beta v khng insulin a) Tnh trng tha cn, bo ph, t hot ng th lc, l nhng c im thng thy ngi i tho ng tp 2 c khng insulin. Tng insulin mu, khng insulin cn gp ngi tin i tho ng, tng huyt p v cn, ngi mc hi chng chuyn ha. b) Ngi i tho ng tp 2 bn cnh khng insulin cn c thiu insulin - c bit khi lng glucose huyt tng khi i trn 10,0 mmol/L. 3. Bin chng ca bnh c im cc bin chng ca bnh i tho ng tp 2 l gn lin vi qu trnh pht sinh v pht trin ca bnh. Nn ngay ti thi im pht hin bnh trn lm sng ngi thy thuc phi tm cc bin chng ca bnh. V phn loi bin chng, c th phn ra cc bin chng cp tnh, mn tnh. Trong cc bin chng mn tnh li chia ra cc bin chng mch mu ln, mch mu nh. III. CHN ON V PHN LOI BNH I THO NG. 1. Chn on a) Chn on sm bnh i tho ng tp 2: i tng c yu t nguy c sng lc bnh i tho ng tp 2: Tui 45 v c mt trong cc yu t nguy c sau y: - BMI 23 (xem ph lc 1: Tiu chun chn on tha cn, bo ph da vo BMI v s o vng eo p dng cho ngi trng thnh khu vc Chu (theo IDF, 2005) - Huyt p trn 130/85 mmHg - Trong gia nh c ngi mc bnh i tho ng th h cn k (b, m, anh, ch em rut, con rut b mc bnh i tho ng tp 2). - Tin s c chn on mc hi chng chuyn ha, tin i tho ng (suy gim dung np ng huyt lc i, ri lon dung np glucose). - Ph n c tin s thai sn c bit (i tho ng thai k, sinh con to - nng trn 3600 gam, sy thai t nhin nhiu ln, thai cht lu). - Ngi c ri lon Lipid mu; c bit khi HDL-c di 0,9 mmol/L v Triglycrid trn 2,2 mmol/l. b) Chn on tin i tho ng (Prediabetes). - Ri lon dung np glucose (IGT), nu mc glucose huyt tng thi im 2 gi sau nghim php tng glucose mu bng ng ung t 7,8 mmol/l (140 mg/dl) n 11,0 mmol/l (200 mg/dl).

- Suy gim glucose mu lc i (IFG), nu lng glucose huyt tng lc i (sau n 8 gi) t 6,1 mmol/l (110 mg/dl) n 6,9 mmol/l (125 mg/dl) v lng glucose huyt tng thi im 2 gi ca nghim php tng glucose mu di 7,8 mmol/l (< 140 mg/dl). c) Chn on xc nh i tho ng: Tiu chun chn on bnh i tho ng (WHO1999), da vo mt trong 3 tiu ch: - Mc glucose huyt tng lc i 7,0 mmol/l ( 126 mg/dl). - Mc glucose huyt tng 11,1 mmol/l (200 mg/dl) thi im 2 gi sau nghim php dung np glucose bng ng ung. - C cc triu chng ca i tho ng (lm sng); mc glucose huyt tng thi im bt k 11,1 mmol/l (200 mg/dl). Nhng im cn lu : - Nu chn on da vo glucose huyt tng lc i v/hoc nghim php dung np tng glucose mu bng ng ung, th phi lm 2 ln vo hai ngy khc nhau. - C nhng trng hp c chn on l i tho ng nhng li c glucose huyt tng lc i bnh thng. Trong nhng trng hp c bit ny phi ghi r chn on bng phng php no. V d i tho ng tp 2 - Phng php tng glucose mu bng ng ung. 2. Phn loi i tho ng (Phn loi n gin). a) i tho ng tp 1: L hu qu ca qu trnh hy hoi cc t bo beta ca o ty. Hu qu l cn phi s dng insulin ngoi lai duy tr chuyn ha, ngn nga tnh trng nhim toan ceton c th gy hn m v t vong. b) i tho ng tp 2. c) Cc th c bit khc. - Khim khuyt chc nng t bo beta, gim hot tnh ca insulin do gen. - Bnh l ca ty ngoi tit. - Do cc bnh Ni tit khc. - Nguyn nhn do thuc hoc ha cht khc. - Nguyn nhn do nhim trng. - Cc th t gp, cc hi chng v gen. d) i tho ng thai k. Trnh t tin hnh xt nghim chn on i tho ng tp 2 (WHO-2011)

Ghi ch: HL- ng huyt lc i, HBK- ng huyt bt k, H2H- ng huyt 2 gi sau ung 75g glucose, OGTT- Nghim php dung np glucose ng ung, SGHL- Suy gim ng huyt lc i, RLDNG- Ri lon dung np glucose, T- i tho ng. * Xc nh li chn on nu ng mu lc i ban u 5,5-6,9 mmol/l hoc ng mu bt k 5,5-11,0 mmol/l. ** Nu glucose huyt tng lc i di 7,0 mmol/l th lm Nghim php tng ng huyt. Nu ng huyt t 7,0 mmol/l chn on l i tho ng. # Ngi c ng huyt ban u ph hp vi chn on T hoc RLHL/ RLDNG m khng c xc nh li s phi xt nghim li sau 1 nm v cn c vo kt qu xt nghim sau 1 nm xc nh ln xt nghim tip theo. IV. IU TR BNH I THO NG TP 2 Hng dn iu tr ny ch p dng cho nhng ngi mc bnh i tho ng tp 2 giai on khng c nhng bnh cp tnh, nh nhi mu c tim, nhim trng cp, hoc phu thut, hoc ung th. Hng dn iu tr ny khng p dng cho ngi di 18 tui mc bnh i tho ng tp 2. 1. Nguyn tc chung: a) Mc ch:

- Duy tr c lng glucose mu khi i, glucose mu sau n gn nh mc sinh l, t c mc HbA1c l tng, nhm gim cc bin chng c lin quan, gim t l t vong do i tho ng. - Gim cn nng (vi ngi tha cn, bo ph) hoc duy tr cn nng hp l. b) Nguyn tc: - Thuc phi kt hp vi ch n v luyn tp. y l b ba phng php iu tr bnh i tho ng. - Phi phi hp iu tr h glucose mu, iu chnh cc ri lon lipid, duy tr s o huyt p hp l, phng, chng cc ri lon ng mu. - Khi cn phi dng insulin (nh trong cc t cp ca bnh mn tnh, bnh nhim trng, nhi mu c tim, ung th, phu thut). 2. Mc tiu iu tr Ch s Glucose mu - Lc i - Sau n HbA1c Huyt p BMI Cholesterol TP HDL-c Triglycerid LDL-c Non-HDL % mmHg kg/(m)2 mmol/l mmol/l mmol/l mmol/l mmol/l n v mmol/l 4,4 6,1 4,4 7,8 6,5 130/80* 18,5 - 23 < 4,5 > 1,1 1,5 < 2,5** 3,4 6,2 7,0 7,8 10,0 > 6,5 n 7,5 130/80 - 140/90 18,5 - 23 4,5 - 5,2 0,9 1,5 - 2,2 2,5 - 3,4 3,4 - 4,1 > 7,0 > 10,0 > 7,5 > 140/90 23 5,3 < 0,9 > 2,2 3,4 > 4,1 Tt Chp nhn Km

* Ngi c bin chng thn- t mc c microalbumin niu HA 125/75. ** Ngi c tn thng tim mch LDL-c nn di 1,7 mmol/l (di 70 mg/dl). 3. La chn thuc v phng php iu tr Mc tiu iu tr phi nhanh chng a lng glucose mu v mc qun l tt nht, t mc tiu a HbA1C v khong t 6,5 n 7,0% trong vng 3 thng. Khng p dng phng php iu tr bc thang m dng thuc phi hp sm. C th - Nu HbA1c trn 9,0% m mc glucose huyt tng lc i trn 13,0 mmol/l c th ch nh hai loi thuc vin h glucose mu phi hp. - Nu HbA1C trn 9,0% m mc glucose mu lc i trn 15,0 mmol/l c th xt ch nh dng ngay insulin. - Bn cnh vic iu chnh lng glucose mu phi ng thi lu cn bng cc thnh phn lipid mu, cc thng s v ng mu, duy tr s o huyt p - Theo di, nh gi tnh trng kim sot mc glucose trong mu bao gm mc glucose mu lc i, glucose mu sau n, c bit l mc HbA1c c o t 3 n 6 thng/ln. - Thy thuc phi nm vng cch s dng cc thuc h glucose mu bng ng ung, s dng insulin, cch phi hp thuc trong iu tr v nhng lu c bit v tnh trng ngi bnh khi iu tr bnh i tho ng.

- i vi cc c s y t khng thc hin xt nghim HbA1c, nh gi theo mc glucose huyt tng trung bnh (Xem ph lc 3: Mi lin quan gia glucose huyt tng trung bnh v HbA1c). a) La chn thuc v phi hp thuc - Tham kho hng dn la chn thuc, phi hp thuc ca Hi i tho ng Hoa K. - Xem thm phn Ph lc 2: Cc thuc iu tr i tho ng tp 2.

Nhng iu ch khi la chn thuc - Phi tun th cc nguyn tc v iu tr bnh i tho ng tp 2, mc 2 (La chn thuc v phng php iu tr); - Trn c s thc t khi thm khm lm sng ca tng ngi bnh m quyt nh phng php iu tr. Trng hp bnh mi c chn on, mc glucose mu thp, cha c bin chng nn iu chnh bng ch n, luyn tp, theo di st trong 3-6 thng; nu khng t mc tiu iu tr phi xem xt s dng thuc. - Thuc la chn ban u ca ch n tr liu nn da vo ch s khi c th (BMI), nu BMI di 23 nn chn thuc nhm sulfonyl urea, nu BMI t 23 tr ln, nn chn nhm metformin. - cc bc 1, 2, 3 u c th phi hp vi cc thuc thuc nhm c ch alphaglucosidase. b) Nhng nguyn tc s dng insulin khi phi hp insulin v thuc h glucose mu bng ng ung. Khong mt phn ba s ngi bnh i tho ng tp 2 buc phi s dng insulin duy tr lng glucose mu n nh. T l ny s ngy cng tng do thi gian mc bnh ngy cng c ko di. Duy tr mc glucose mu gn nh mc sinh l, c chng minh l cch tt nht phng chng cc bnh v mch mu, lm gim t l t vong, ko di tui th v nng cao cht lng cuc sng ca ngi i tho ng. - Cn gii thch cho ngi bnh hiu v yn tm vi phng php iu tr phi hp vi insulin, hng dn ngi bnh cch t theo di khi dng insulin. - Chn bt tim hoc bm tim phi ph hp vi loi insulin (1ml = 100 n v hay 1ml = 40 n v; 1ml = 50 n v insulin). Ch nh s dng insulin:

- C th ch nh insulin ngay t ln khm u tin nu mc HbA1C trn 9,0% m mc glucose mu lc i trn 15,0 mmol/l. - Ngi bnh i tho ng nhng ang mc mt bnh cp tnh khc; v d nhim trng nng, nhi mu c tim, t qu - Ngi bnh i tho ng suy thn c chng ch nh dng thuc vin h glucose mu; ngi bnh c tn thng gan - Ngi i tho ng mang thai hoc i tho ng thai k. - Ngi iu tr cc thuc h glucose mu bng thuc vin khng hiu qu; ngi b d ng vi cc thuc vin h glucose mu Bt u dng insuline: Thng liu sulfonylurea c gim i 50% v ch ung vo bui sng. - Liu insulin thng bt u vi liu 0,1 UI/kg loi NPH, tim trc lc i ng hoc - Ngy hai mi tim vi insulin hn hp (insulin mixt), ty thuc vo mc glucose huyt tng v/hoc HbA1c. iu chnh liu insulin: - Khi tng liu sulfonylure n mc ti a hoc liu php insulin t ti mc 0,3 UI/kg m vn khng lm h c lng ng trong mu. - iu chnh mc liu insulin c 3-4 ngy/ln hoc 2 ln/tun. 4. iu tr i tho ng ti cc tuyn Nguyn tc chung: Hng dn phn tuyn iu tr c p dng chung trong ton quc. Ty iu kin ca c s iu tr (v nhn lc v phng tin), ngi ng u c s y t c th quyt nh mc can thip v chuyn tuyn. a) Tuyn x - phng Nu c bc s ni khoa c th iu tr cho ngi bnh i tho ng, nht l cc th nh v trung bnh. C th mc glucose huyt tng mu lc i di 10,0 mmol/l v/hoc HbA1C di 8,0%. Khi mc glucose huyt tng mu lc i trn 10,0 mmol/l phi chuyn ngay ln tuyn huyn. Khng c bc s phi chuyn ngay ln tuyn trn. b) Ti tuyn huyn: Nu mc glucose huyt tng mu lc i t 10,0 mmol/l tr ln n di 13,0 mmol/l; HbA1c di 9,0% m ngi bnh khng c bin chng g nng (v d bin chng bn chn, tim mch) c th iu tr cho bnh nhn ti tuyn huyn. Chuyn tuyn trn nu c mt trong cc tnh trng sau: - Glucose huyt tng mu lc i trn 13,0 mmol/l v/hoc HbA1C trn 9,0%. - Ngi bnh km theo cc bin chng nng v tim mch (thiu mu cc b c tim, nhi mu c tim), bn chn i tho ng, bin chng thn. - C nhng du hiu ca bin chng cp tnh, phi tin hnh s cu v chuyn ln tuyn trn nhanh nht. - iu tr tch cc nhng sau 3 thng vn khng t c nhng ch tiu v qun l glucose mu. c) Tuyn tnh: L tuyn cui ca cc a phng nn phi phn u iu tr bnh mt cch ton din. Chuyn tuyn khi c mt trong cc tnh trng sau: - Bnh c nhng bin chng nng vt qu kh nng can thip.

- Sau 6 thng iu tr vn khng t c cc mc tiu iu tr. V. TIN TRIN V BIN CHNG 1. Tin trin: i tho ng tp 2 l mt bnh tin trin tnh tin. Nhng bin chng ca bnh lun pht trin theo thi gian mc bnh. 2. Bin chng: a) Bin chng cp tnh: - Hn m nhim toan ceton - H glucose mu - Hn m tng glucose mu khng nhim toan ceton - Hn m nhim toan Lactic - Cc bnh nhim trng cp. * Hn m nhim toan-ceton: L mt bin chng nguy him tc thi n tnh mng ngi bnh, nguyn nhn l do thiu insulin gy ra nhng ri lon nng n trong chuyn ha protein; lipid v carbonhydrate. y l mt cp cu ni khoa cn phi c theo di ti cc khoa iu tr tch cc. Yu t thun li: Nhim toan ceton nhiu khi xy ra khng r nguyn nhn, nhng s d dng xy ra nu ngi mc bnh i tho ng tp 1 c thm: - Cc bnh nhim trng nh vim phi, vim mng no, cc nhim trng ng tiu ha, nhim trng tit niu, cm cm.v.v. - Chn thng: K c cc stress v tinh thn. - Nhi mu c tim, t qu. - S dng cc thuc c cocain. - S dng thuc h glucose mu khng ng ch nh v liu lng. - S dng corticoid. Cc triu chng v du hiu lm sng Cc triu chng: - Bun nn v nn - Kht nhiu, ung nhiu v i nhiu - Mt mi v/hoc chn n. - au bng - Nhn m - Cc triu chng v thc nh ng g, m mng Du hiu: - Nhp tim nhanh - H huyt p - Mt nc - Da kh nng

- Th kiu Kusmaul - Suy gim thc v/hoc hn m - Hi th c mi ceton - St cn Cn lm sng: - pH mu ng mch < 7,2 - Bicacbonat (huyt tng) < 15mEq/l hoc 15 mmol/l) - Glucose mu > 13,9 mmol/l. - Ceton mu tng, ceton niu dng tnh Theo di v iu tr Mc ch: - Loi b nhng yu t nguy him n mng sng ngi bnh. - Chng mt nc, b lng insulin, thng bng in gii, toan kim. Nhng ch s cn theo di Theo di lm sng: - Tnh trng tinh thn 1 gi/ln - Cc ch s sinh tn (nhit , mch huyt p, nhp th) 1 gi/1 ln - Cn nng (nu c th). Theo di cn lm sng: - in tm - Glucose mu (ti ging) 1 gi/1 ln - Kali mu, pH 1 2 gi/1 ln - Na+, Cl-, Bicarbonat 2 4 gi/1 ln - Phosphat, magnesium 4 - 6 gi/1 ln - Ure hoc creatinin 4 - 6 gi/1 ln - Th ceton niu 2 - 4 gi - Calci mu: theo ch nh - Hematocrid: theo ch nh Cc xt nghim khc (nu cn): cy mu; cy nc tiu, soi tm t bo, cng thc mu, c bit quan tm n s lng bch cu; amylaza mu; cc ri lon v chuyn ha lipid mu, ht dch d dy xt nghim; ceton mu. Theo di iu tr - Lng dch vo - ra 1 n 4 gi/1 ln - Lng insulin tim truyn (n v/h) 1 n 4 gi/1 ln - Kali (mmol/l/h) 1 n 4 gi/1 ln - Glucose huyt tng (mmol/l) 1 n 4 gi/1 ln - Bicarbonate v phosphate 1 n 4 gi/1 ln. iu tr - s cu: Thng dng insulin ng tnh mch

- Liu ban u t 0,1 - 0,15 IU/kg/h (tim tnh mch) hoc - Truyn tnh mch vi liu v tc 0,1 IU/kg/h - Chuyn ln tuyn trn. Phn tuyn: iu tr nhim toan ceton cn c tin hnh cc trung tm cp cu. - Cp phng x s cu chuyn ngay ln tuyn huyn. - Cp huyn ch nh truyn dch, tim truyn insulin v chuyn ln tuyn trn. Phng nga: Nhim toan ceton ngi i tho ng c th ngn nga bng cch gio dc cho ngi bnh nhng kin thc cn thit v s chm sc ca thy thuc. Vi ngi bnh: - Bit cch t theo di lng glucose mu v ceton nc tiu. - Lin h ngay vi thy thuc khi c mc thm mt bnh khc, khi xut hin cc triu chng bt thng nh bun nn, st, au bng, a chy hoc nng glucose mu cao, ceton trong nc tiu dai dng..v.v. y l nhng du hiu bo trc kh nng nhim toan ceton. - Khng bao gi c t gim liu tim insulin, hoc t b thuc ngay c khi mc mt bnh khc. Vi thy thuc. - Thng bo cho ngi bnh bit tnh hnh bnh tt, cch pht hin nhng triu chng hoc du hiu nguy him cn i khm bnh. - Khi thm khm phi t m pht hin nhng din bin bt thng ca bnh. Phn loi ngi bnh theo giai on bnh c k hoch chm sc cho ph hp. * H glucose mu Cc nguyn nhn thng gp: - Tng bi tit insulin (cht c tc dng c ch sn xut glucose ti gan, kch thch tiu th glucose c vn v m m) - Gim tip nhn thc n (do ch n ung kht khe hoc c vn v ri lon hp thu). - Tng mc luyn tp (lm tng s dng glucose c vn) Triu chng lm sng - cn lm sng: H glucose mu lm sng thng xy ra khi: - Sinh ha: Nng glucose huyt tng lc i < 2,8 mmol/l (50 mg/dl) l h glucose mu nng, cn khi lng glucose mu < 3,9 mmol/l (< 70 mg/dl) bt u c xem l c h glucose mu. Cng cn lu rng ngi bnh tr tui c xu hng biu hin lm sng mc glucose huyt tng cao hn (3,8 mmol/l = 68 mg/dl) so vi ngi trng thnh (3,1 mmol/l = 56 mg/dl). - Lm sng: Chia ra 3 mc : + Mc nh: Thng l cc triu chng v m hi, run chn tay v i. y l triu chng ca h thn kinh t ng. Cc triu chng ny s mt i sau khi ung 10 15 gram carbonhydrate, t 10 15 pht. Mc ny ngi bnh c kh nng t iu tr c. + Mc trung bnh: mc ny cc phn ng biu hin lm sng c c 2 mc ca h thng thn kinh t ng v du hiu thn kinh ca gim lng glucose m nh: au u, thay i hnh vi, d b kch thch, gim kh nng ch , ng g. Nu khng can thip kp thi, ngi bnh cng mau chng chuyn sang mc nng. + Mc nng: Lc ny lng glucose mu h rt thp. Biu hin lm sng bng hn m, mt cm gic hoc nhng cn co git. Cp cu lc ny cn truyn glucose tnh mch v/hoc glucagon. iu tr cn h glucose mu

- Vi th nh: Ch cn 10-15g Carbonhydrate ung l glucose mu nhanh chng tr li bnh thng. Khng dng Scla v kem iu tr h glucose mu cp, v lng m c trong thc n ny s hn ch hp thu ng, ng thi s l yu t lm tng cn. - Trng hp ngi bnh ang i trn ng, hoc ang iu khin phng tin giao thng, c du hiu h glucose mu, phi dng li 10-15 pht i khi glucose mu tr li bnh thng hy tip tc cng vic. - Th trung bnh: C th dng ng ung can thip, nhng cn thi gian di hn v liu dng cao hn glucose mu tr li bnh thng. C th dng glucagon tim bp hoc di da kt hp vi ng ung. - H glucose mu nng: Do ngi bnh mt thc nn khng c kh nng nut, cho ung c th s b sc vo ng th. Nhng ngi bnh ny buc phi dng glucagon tnh mch v truyn glucose u trng: Glucagon - Liu Glucagon cn cho iu tr h glucose mu th trung bnh hoc nng: Liu thng dng l 1 mg. - ng dng: C th tim di da, tim bp hoc tnh mch. - Cch s dng glucagon phi c hng dn cho ngi thn ca ngi bnh, thm ch cho c nhng ch nh tr hoc nhn vin khch sn h c th s dng c trong nhng trng hp cn thit phi cp cu. Glucose tnh mch: L phng php iu tr c bn nht nu c sn nhn vin y t phc v. Trng hp h glucose mu nng, glucose tnh mch phi hp vi glucagon c xem l phng php cp cu hon ho nht. Thng khi bt u cp cu ngi ta thng dng: + 10 - 25g (trong dung dch Dextrose 50%) tim tnh mch + 50 - 100ml dung dch glucose 30% + Thi gian tin hnh cp cu ban u t 1 - 3 pht. + Liu cp cu tip theo ph thuc vo tnh trng p ng ca ngi bnh. Thng thng glucose ng tnh mch vi liu 5 10 g/gi. Glucose s c tip tc truyn cho n khi ngi bnh hi phc hon ton v c kh nng t n, ung c. Phng cn h glucose mu. L phng cc nguyn nhn: - Nhng nguyn nhn c lin quan n s dng insulin + Do qu liu + Thi gian s dng khng ph hp vi ba n hoc loi dng khng thch hp, tim insulin nhng b ba n. + Liu php iu tr tng cng bng insulin + Tht thng hp thu ca insulin ti ni tim: Hp thu nhanh hn nu tim vng hay vn ng, v tr tim c vn : teo lp m di da hoc lon dng vng tim. + S dng nhiu insulin tinh khit hoc i t dng tng hp sang cc dng insulin trn hoc insulin ngi lm thay i tc hp thu. + Ch dinh dng khc kh: n t, thi gian gia cc ba n cha ph hp + Luyn tp sai: Khng c k hoch, mc v thi gian luyn tp khng ph hp. + Ung ru v s dng phi hp vi mt s thuc Phn tuyn: Cp cu hn m h glucose mu phi c tuyn truyn, gio dc, ph bin rng ri khng ch cho nhn vin y t m c nhng ngi c nhiu iu kin giao tip vi ngi bnh.

- Tuyn phng, x v tng ng: + Cp cu c ngi hn m h glucose mu mc nh v trung bnh. + S cu ngi hn m h glucose mu mc nng. - Tuyn huyn, qun: Phi cp cu c ngi hn m h glucose mu mc nng. * Hn m tng glucose mu khng nhim toan ceton (Hn m tng p lc thm thu HMTALTT) c im: Thng gp ngi mc i tho ng tp 2 trn 60 tui, n thng gp hn nam. - Bnh c tin lng xu, t l t vong cao ngay c khi c cp cu nhng trung tm c y phng tin v c nhng chuyn gia gii, nu c qua khi cng thng li di chng. - Tng glucose mu khng nhim toan ceton c th gp ngi cha bao gi c chn on i tho ng tp 2. - C nhiu im ging vi hn m nhim toan ceton. Khc bit chnh l tng glucose mu, mt nc v ri lon in gii. - c im quan trng phn bit vi hn m nhim toan ceton l khng c th ceton hoc c rt nh trong nc tiu. Nguyn nhn v yu t thun li: Cc yu t thun li lm xut hin hn m tng glucose mu khng nhim toan ceton. Cc thuc s dng Cc Glucocorticoid Li niu Diphenylhydantoin Thuc chn AlphaAndrenergic Diazoxide L-asparaginase Cc thuc c ch min dch. Lm sng v cn lm sng: C 4 c im chnh - Lng glucose mu tng cao ( 33,3 mmol/l) thng t 55,5 - 111,1 mmol/l - Khng c th ceton trong nc tiu hoc c rt nh - p lc thm thu huyt tng hoc huyt thanh trn 340 mosM - Du hiu mt nc nng. Phn bit lm sng gia hai loi hn m. Cc yu t Tui Din bin T l t vong (%) Glucose mu Nhim toan ceton Bt k la tui no Vi gi hoc vi ngy >5 Cao Tng p lc thm thu Thng trn 60 tui Vi ngy hoc vi tun 50 Rt cao Qu trnh iu tr Lc mng bng Thm phn mu Cc stress ngoi khoa. Truyn nhiu glucose. Sau phu thut Bnh mn tnh Bnh thn Bnh tim Tng huyt p t qu Ung ru Bnh tm thn Mt cm gic kht Bnh cp tnh Nhim trng Nhim khun tit niu Lot g Nhim trng mu Chy mu ng tiu ha Tai bin mch no Nhi mu c tim Vim ty cp.

p lc thm thu Natri mu Bicarbonat Ceton mu ang iu tr - Glucose mu

Cao Bnh thng hoc thp < 15 ++++ Insulin

Rt cao Bnh thng hoc cao Bnh thng hoc hi thp m tnh hoc + nh Ch n thuc vin h DM.

Cc xt nghim cn lm sng: Buc phi c chn on v theo di: - in gii mu, nht l Natri mu - Kali mu. - Ur v Creatinin mu - Bicarbonate, c th tng nh do lng acid lactic b tch li (do h huyt p v tc tun hon ngoi bin b suy gim). C th da vo cng thc sau tnh p lc thm thu mu: p lc thm thu mu = 2 (Na + K) + Urea + Glucose (V tnh cc ch s l mmol/l). Chn on xc nh khi ALTT > 340 mosM. Nguyn tc theo di, iu tr. - Theo di: Nh vi ngi hn m nhim toan - ceton. - iu tr: Ngi bnh phi c iu tr cc Trung tm hi sc tch cc. S dng insulin, dch truyn v kali cho ph hp l iu kin a ngi bnh ra khi tnh trng hn m. + B ph nc, in gii: L yu t quan trng nht, dch c chn l cc dung dch ng trng. iu cn nh l khi nng glucose mu gim xung, s mt cn bng th pht gia p lc trong v ngoi t bo li xy ra. + Insulin: S dng insulin vi liu lng nh cn c ch nh sm. Ngi bnh hn m tng p lc thm thu thng nhy cm vi insulin, do vy d b h glucose mu, nht l khi truyn tnh mch. Liu khi u c th ging vi hn m nhim toan ceton; sau phi tip tc theo di tng liu cho ti khi mc glucose t c khong t 14-17 mmol/l phi gim liu insulin 1-2 n v/gi v chuyn dn sang ch tim di da. + Chng ng mu: Khc vi ngi bnh hn m nhim toan ceton, ngi bnh hn m do tng p lc thm thu c nguy c tc mch cao hn nhiu, v th nn xem xt vic dng thuc chng ng cho ngi bnh. b) Bin chng mn tnh. Thng li c chia ra bnh mch mu ln v mch mu nh hoc theo c quan b tn thng; v d - Bnh l mch mu: X va mch vnh, X va mch no, Bnh mch mu ngoi vi, Bnh vng mc, Bnh l cu thn. - Bnh l thn kinh: Bnh l thn kinh gic quan-vn ng, thn kinh t ng. - Bnh phi hp gia thn kinh v mch mu: Lot g, lot chn. V. PHNG BNH Ni dung phng bnh i tho ng bao gm: phng khng b bnh; khi c nguy c mc bnh, phng khng tin trin thnh bnh v loi tr cc yu t nguy c c th thay i c;

khi mc bnh, phng bnh khng tin trin nhanh v gim thiu ti a cc bin chng ca bnh nhm ci thin cht lng cuc sng cho ngi bnh. ngha ca vic phng bnh trong i tho ng khng km phn quan trng so vi vic iu tr bnh v n cng l mt phn ca iu tr. 1. Phng bnh cp 1: Sng lc tm ra nhm ngi c nguy c mc bnh; can thip tch cc nhm lm gim t l mc bnh i tho ng trong cng ng. 2. Phng bnh cp 2: vi ngi b mc bnh i tho ng, nhm lm chm xy ra cc bin chng, lm gim mc nng ca bin chng, nng cao cht lng sng cho ngi mc bnh.

PH LC 1
TIU CHUN CHN ON THA CN, BO PH DA VO BMI V S O VNG EO P DNG CHO NGI TRNG THNH KHU VC CHU (THEO IDF, 2005) (Ban hnh km theo Quyt nh s 3280/Q-BYT ngy 09 thng 9 nm 2011 ca B trng B Y t) Yu t nguy c phi hp Phn loi BMI (kg/m2) S o vng eo <90cm (vi nam) 90cm <80cm (vi n) 80cm Gy Bnh thng Bo + C nguy c + Bo 1 + Bo 2 < 18,5 18,5 - 22,9 23 23- 24,9 25- 29,9 30 Tng Tng trung bnh Nng Tng trung bnh Nng Rt nng Thp (nhng l yu t nguy c vi cc bnh khc) Bnh thng Bnh thng Tng

PH LC 2
THUC IU TR BNH I THO NG TP 2 (Ban hnh km theo Quyt nh s 3280/Q-BYT ngy 09 thng 9 nm 2011 ca B trng B Y t) 1. Cc thuc h glucose mu bng ng ung a) Metformin (Dimethylbiguanide): l thuc c s dng rng ri tt c cc quc gia. Trc y 30 nm l thuc iu tr chnh ca i tho ng tp 2. Cc loi vin Glucophage 500 mg, 850 mg, 1000 mg - Liu khi u vin 500 hoc 850mg: 500 hoc 850 mg (vin/ngy) - Liu ti a: 2500 mg mt ngy Metformin tc ng ch yu l c ch sn xut glucose t gan nhng cng lm tng tnh nhy ca insulin ngoi vi. Tc dng h glucose trong khong 2-4 mmol/l v gim HbA1c n 2%. V n khng kch thch ty ch tit insulin nn khng gy h ng mu khi s dng n c. Metformin cn l thuc c khuyn co la chn dng iu tr ngi i tho ng c tha cn, bo ph, duy tr hoc lm gim cn nng, thuc cn c tc dng c li n gim lipid mu.

Metformin c th gy ra tc dng khng mong mun ng tiu ha, nn dng cng ba n v bt u bng liu thp (500 mg/ngy). Ngng liu hiu qu lm sng trong khong 1500 mg n 2000 mg/ngy, v liu ti a l 2500 mg/ngy. Chng ch nh ca metformin: suy tim nng, bnh gan (k c nghin ru), bnh thn (creatinin mu > 160 mol/l), ngi c tin s nhim toan lactic, do lm tng nguy c nhim acid lactic. Metformin cng chng ch nh nhng trng hp c thiu oxy m cp nh ngi ang c nhi mu c tim, shock nhim trng... b) Sulphonylurea Sulphonylure kch thch ty tit insulin. Tc ng lm gim glucose trung bnh l 50 60 mg/dl, gim HbA1c ti 2%. Sulphonylure c dng thn trng vi ngi gi, ngi b bnh thn (creatinine mu > 200 mol/L) hoc ri lon chc nng gan khi liu thuc cn c gim i. Sulfonylure khng c s dng iu tr tng glucose mu ngi bnh i tho ng tp 1, nhim toan ceton, ngi bnh c thai, v mt s tnh trng c bit khc nh nhim trng, phu thut Cc loi sulphonylure: - Th h 1: Nhng thuc thuc nhm ny gm tolbutamide, chlorpropamide, diabetol, thng ng vin 500 mg. Cc thuc thuc nhm ny hin nay t c s dng do c tnh cao i vi thn (v thuc c trng lng phn t ln). - Th h 2: Nhng thuc thuc nhm ny bao gm glibenclamide, gliclazide, glipizide, glyburide Nhng thuc thuc th h ny c tc dng h glucose mu tt, t c hn nhng thuc thuc th h 1. Nhm gliclazide cc tc dng c hiu ln knh KATP lm phc hi nh tit sm ca insulin gn ging s bi tit insulin sinh l nn t gy h glucose mu hn cc thuc sulfonylure khc. Nhm glimepiride: Tc dng h glucose mu tt, ngoi tc dng kch thch t bo bta ca ty bi tit insulin gn ging vi bi tit insulin sinh l (tc dng c hiu ln knh KATP lm phc hi nh tit sm ca insulin) cn c tc dng lm tng nhy cm ca m ngoi vi vi insulin. Thuc c t tc dng ph v khng gy tng cn ngi bnh i tho ng tha cn. Ch ung 1 ln trong ngy nn thun tin cho ngi s dng (ring diamicron 30mg MR thuc th h 2 cng dng mt ln trong ngy). Liu thng thng vi cc nhm thuc l: - Glipizide t 2,5 mg n 20,0 mg/ngy. - Gliclazide t 40 320 mg/ngy - Gliclazide MR t 30 120 mg/ngy. - Glimepiride t 1,0 6,0 mg/ngy - c bit ti 8,0 mg/ngy. - Glibenclamide t 1,25 15,0 mg/ngy. Cc thuc sulfonylurea c s dng rng ri di dng n tr liu hoc phi hp vi cc thuc nhm biguanide, glitazone, thuc c ch alfaglucosidase, c ch DPP-4, insulin. c) c ch Alpha - glucosidase Thuc c tc dng c ch enzym alpha-glucosidase-enzym c tc dng ph v carbohydrate thnh ng n (monosaccharide). Tc dng ny lm chm hp thu monosaccharide, do vy h thp lng glucose mu sau ba n. Nhng thuc nhm ny gm: - Th h 1 (nhm acarbose): Loi ny thng gy cc tc dng khng mong mun km theo nh y bng, a chy, Liu thuc c th tng t 25mg n 50mg hoc 100mg/mi ba n.

- Th h 2 (nhm voglibose): thuc nhm ny ch yu c ch qu trnh phn hy ng i nn t cc tc dng khng mong mun hn. Liu thuc c th tng t 01 n 02 vin/mi ba n. - Ch khi s dng thuc: + Thuc cn s dng phi hp vi mt loi h glucose mu khc. + Thuc ung ngay trong khi n. c) Meglitinide/Repaglinide - thuc kch thch bi tit insulin sau n. V l thuyt nhm ny khng thuc nhm sulfonylurea; nhng n c kh nng kch thch t bo bta tuyn ty tit insulin - nh c cha nhm benzamido. V cch s dng c th dng nh mt n tr liu hoc kt hp vi Metformin, vi insulin. Ngi ta cng c nhng s liu chng minh vic kt hp Repaglinid vi NPH trc khi i ng t kt qu tt trong iu tr h glucose mu ngi i tho ng tp 2. Liu dng: Hin c hai thuc trong nhm ny - Repaglinide liu t 0,5 n 4 mg/ba n. Liu ti a 16 mg/ngy. - Netaglinide liu t 60 n 180 mg/ba n. Liu ti a 540,0 mg/ngy. d) Thiazolidinedione (glitazone) Thuc lm tng nhy cm ca c v t chc m vi insulin bng cch hot ha PPAR (peroxisome proliferator-activated receptor ) v vy lm tng thu np glucose t mu. Thuc lm tng nhy cm ca insulin c vn, ng thi ngn cn qu trnh sn xut glucose t gan Thuc chnh sn c l Pioglitazone. Thuc ny c th dng n c hoc kt hp vi cc thuc ung khc hoc insulin. Tc dng ph bao gm tng cn, gi nc v ri lon chc nng gan. Khi dng thuc xt nghim chc nng gan phi c lm thng quy 2 thng mt ln. Liu dng: Pioglitazone liu t 15 n 45 mg/ngy. Chng ch nh ca nhm thuc ny l nhng ngi c triu chng hoc du hiu suy tim, tn thng gan, thn. Nhiu chuyn gia, nhiu quc gia cng khuyn co khng nn phi hp nhm thuc glitazone vi insulin. ) Gliptin Gliptin l nhng thuc c ch DPP-4 (Dipeptidylpeptidase-4) lm tng nng incretin ni sinh, c tc dng kch thch bi tit insulin do tng glucose sau n. Cc thuc c ch DPP-4 cho n nay c 2 th h: - Cc thuc c ch hot ng ca DPP-4 c kim chng ln u vo cui nhng nm 1990 ca th k 20, nhng khng c s dng vo lm sng. - Th h 1 pht trin hon thin v c p dng vo iu tr l cc thuc Sitagliptin (2007); - Th h 2 l Saxagliptin (2009). Ngoi ra l cc thuc nh Vidagliptin (2008) ph bin chu u. Liu dng: - Sitagliptin liu 100 mg/ngy - Vildagliptin liu 2x50 mg/ngy. - Saxagliptin liu 2,5 - 5 mg/ngy. 2. Phi hp cc thuc vin h glucose mu. Thnh phn Nng (mg)

Metformin + Glibenclamide Metformin + Glipizide Metformin + Pioglitazone Metformin + Vildagliptine Metformin + Sitagliptin Metformin + Repaglinide Pioglitazone + glimepirid

250:1,25; 500:2,5; 500:5,0 250:2,5; 500:2,5; 500:5,0 500:1,5; 850:1,5 850:50; 1000:50 500:50; 1000:50 500:1,0; 500:2,0 45:4

* Ch : Ngi ta thng da vo tc dng ca thuc phn chia liu lng v loi thuc, sao cho t c tc dng ti a. Khng dng phi hp hai loi bit dc ca cng mt nhm thuc. 3. Insulin a) C s s dng insulin Ngi bnh i tho ng tp 1 ph thuc vo insulin ngoi sinh tn ti. Ngc li, ngi bnh i tho ng tp 2 khng phi ph thuc vo insulin ngoi sinh tn ti. Nhng sau mt thi gian mc bnh nhiu ngi bnh i tho ng tp 2 gim st, thm ch mt kh nng sn xut insulin, i hi phi b sung insulin ngoi sinh kim sot glucose mu mt cch y . S dng insulin t c hiu qu kim sot chuyn ha glucose tt nht i hi s hiu bit v khong thi gian tc dng ca cc loi insulin khc nhau. b) Cc loi Insulin ngi theo thi gian tc dng Ch phm insulin Insulin tc dng nhanh: - Insulin lispro - Insulin aspart - Insulin gluisin Insulin tc dng ngn: - Regular - Actrapid Insulin tc dng trung bnh: - NPH - Lente - Insulatard HM - Insulatard FlsxPen Insulin tc dng chm: - Ultralente - Glargine - Determir Insulin hn hp - 70/30 human mix 30 - 60 pht Theo 2 pha 10 - 16 gi 6 - 10 gi 2 - 4 gi 2 - 4 gi 10 - 16 gi Khng c nh 6 - 14 gi 18 - 24 gi 20 - 24 gi 16 - 20 gi 2 - 4 gi 3 - 4 gi 1 - 1,5 gi 1 - 1,5 gi 4 - 10 gi 4 - 12 gi 4 - 12 gi 4 - 12 gi 10 - 16 gi 12 - 18 gi 24 gi 24 gi 30 - 60 pht 30 pht 2 - 3 gi 1 - 3 gi 5 - 8 gi 8 gi 5 - 15 pht 5 - 15 pht 5 - 15 pht 30 - 90 pht 30 - 90 pht 30 - 90 pht 3 - 5 gi 3 - 5 gi 3 - 5 gi Bt u tc dng nh tc dng Thi gian thuc c hiu qu

- 70/30 aspart analog mix. - Mixtard HM (70/30) - Mixtard 30 FlexPen - NovoMix30 FlexPen c) Quy trnh tim

5 - 15 pht 30 pht 30 pht 10 - 20 pht

Theo 2 pha 2 - 8 gi 2 - 8 gi 1 - 4 gi

10 - 16 gi 24 gi 24 gi 24 gi

Insulin nn c tim vo t chc di da. Ngi bnh c th t tim bng cch ko nh da gp ln v tim gc 90o. Nhng ngi gy hoc tr em c th dng kim ngn hoc c th vo da ln v tim gc 45o trnh tim vo c, c bit vng i. c bit khi dng bt tim insulin, kim nn lu li trong da 5 giy sau khi n ton b pt tng m bo cung cp ton b liu insulin. Tim insulin vo t chc di da bng thng c dng, nhng cng c th tim mng, i hoc cnh tay. Quay vng v tr tim l cn thit nga ph i hoc teo t chc m di da ti ni tim. d) Bo qun insulin L insulin khng c s dng nn t lnh, nhng trnh trong ngn , trnh insulin tip xc vi nh nng. Nhit qu cao hoc qu thp v lc nhiu c th lm hng insulin. Insulin ang s dng c th gi nhit phng hn ch gy kch thch ti ch v tr tim.

PH LC 3
MI LIN QUAN GIA GLUCOSE HUYT TNG TRUNG BNH V HBA1C (Ban hnh km theo Quyt nh s 3280/Q-BYT ngy 09 thng 9 nm 2011 ca B trng B Y t) HbA1c % 6 7 8 9 10 11 12 Glucose HT (mg/dl) 126 154 183 212 240 269 298 Glucose HT (mmol/l) 7.0 8.6 10.2 11.8 13.4 14.9 16.5