CAC THUOC CHONG LOAN NHP THNG DUNG

TS TON THAT MINH

PHAN LOAI
I. Nhom I: I.a : Quinidine, Disopyramide I.b : Lidocaine, Mixelitine I.c : Flecaine, Propafenone II. Nhom II: c che Beta Propranolol, Atenolol, Metoprolol III. Nhom III: Amiodarone, Sotalol, Ibutilide IV. Nhom IV: c che Calci

AMIODARONE
1. Ch nh: -Loan nhp that tai phat, e doa tnh mang (RT, NNT co RL huyet ong), NNTT ma khong ap ng vi cac thuoc chong loan nhp khac. 2. Tac dung dc ly: -Dc hoc: Keo dai thi gian ien the hoat ong va thi gian tr cua te bao c tim. -Dc ong hoc: t max 3-7 gi, thc an lam tang hap thu. 96% ket hp vi proteine. Thuoc qua nhau thai va sa. Bai tiet chu yeu qua mat, 50% sau 2.510 ngay, 50% con lai sau 26 107 ngay (53).Loc than o tac dung.

AMIODARONE
3. Chong ch nh: -Suy nut xoang -Bloc nh that o II, III -Nhp tim cham gay ngat (tr khi co PM) -Choang tim -Man cam vi thuoc. 4. Tac dung phu: a.Tim mach: Lam xau hn tnh trang: RL nhp, suy tim, nhp cham, suy nut xoang, bloc tim, tut HA, choang tim, nhanh that.

AMIODARONE
b. Than kinh: Met, run, mat ngu, nhc au, c ong ngoai thap, ham muon tnh duc. c. Da: nhay cam anh sang, viem da, Ste. John. d. Mat-TMH: th lc, ong mau GM e. Tieu hoa: chan an, non, tao bon, tiet nc bot bat thng, tieu chay.

f. Huyet hoc: RL ong mau, tieu cau i. Khac: Cng giap, suy giap, Sot (tiem)

 5.Tng tac thuoc:

AMIODARONE

a. Chong ong: td, 30-50% khi dung ong thi. b. c che : nguy c tut HA & nhp cham. c. Ca (-): bloc NT cua Verapamil &Dilti. & HA d.Fluoroquinolon, Disopyramide: QT dai e.Cimetidine: nong o Amiodarone f.Digoxine: nong o Digoxine g.Fentanyl: tut HA, nhp cham & lu lng tim h.Flecaine, Theophylline, Quinidine: nong o

AMIODARONE
6. Lieu lng: a.Loan nhp that e doa tnh mang: *Uong: lieu tan cong 800-1600mg X 1-3 tuan

600-800 trong 1 thang *Tiem: 1000mg / 24 gi au, chia nh sau: 150mg TM >10 phut (1.5mg/ph) 360mg / 6 gi tiep theo (1mg/ph) 540mg / 18 gi tiep theo (0.5mg/ph) Sau 24 gi, duy tr lieu 0.5mg/ ph (750mg)

AMIODARONE
b. Rung nh kch phat, Cuong nh co trieu chng, NNKPTT: * Uong: 600-800mg / ngay trong 7-10 ngay sau o 200-400mg / ngay c. Loan nhp benh nhan suy tim xung huyet: * Uong 200mg / ngay LU Y: Lieu lng tren can c ieu chnh phu hp theo tuoi tac, chc nang gan than

SOTALOL
1. Ch nh: - ieu tr va phong nga loan nhp that -Duy tr nhp xoang BN rung-cuong nh 2. Dc hoc: -Bloc receptor. Td chu yeu tren tim (nhp tim), tren c trn mach mau (HA) va tren phoi (chc nang)

 3. Dc ong hoc: Uong hap thu 90-100%, 20% khi co thc an. Tac dung on nh sau 1-2ngay. Khong ket hp vi proteine, T1/2 la 12 gi. Bai tiet qua than di dang khong oi. Suy than can lieu. Suy gan khong can lieu 4. Chong ch nh: Man cam, bloc NT > o I, suy tim ro, nhp xoang cham, choang tim, hen phe quan, COPD, QT dai, chc nang loc than < 4ml/ph, Kali / mau < 4mEq / l

SOTALOL

SOTALOL
5. Tac dung phu: a. Tim mach: loan nhp tim, NNT, RT, xoan nh b. Than kinh: tram cam, nhc au, ac mong c. tieu hoa: chan an, buon non, non, tao bon, tieu chay, kho mieng. d. Nieu sinh duc: ham muon tnh duc, bat lc, tieu em. e. Ho hap: co that phe quan, kho th f. Khac: men gan, hay ng huyet

SOTALOL
6. Tng tac thuoc:

a. Amiodarone, Disopyramide, Procainamide: thi gian tr. b. c che calci: tut HA, td bloc NT c. Clonidine: tut HA d. Gatifloxacine, Moxifloxacine lam nguy c loan nhp nguy hiem. e. Insuline, Sulfonylurease: ng huyet

SOTALOL
7. Lieu lng: - Loan nhp that va tren that: Uong 80 mg X 2 lan / ngay

Co the 320 mg / ngay chia lam 2-3 lan Nen bat au t lieu thap va tang dan. * Neu o loc cau than con 40-60 ml th dung lieu 80 mg / ngay.

VERAPAMIL
* c che kenh Calci. Nondihydropyridine 1. ieu tr: * Tnh mach: - Chuyen nhp xoang trong NNKPTT ma khong ap ng vi PP kch thch phe v hay Adenosine. - Kiem soat tan so that trong RN hay CN ( khong co WPW hay LGL) - Ch tiem TM khi chc nang that T con bao ton

VERAPAMIL
* ng uong: - e phong nga NNKPTT tai phat - Ket hp vi Digitalis e kiem soat tan so that luc ngh & gang sc BN RN man &/ hay cuong nh. - Nhp nhanh nh a o hay o ngoai v BN co chc nang that T bao to - Nhp nhanh bo noi co trieu chng.

VERAPAMIL
@ Nhp nhanh kch phat tren that: * Tiem TM
- Phai + & NNKPTT co QRS rong khi Verapamil TM.

- Khi ng TM phai TD (monitor) HA & ECG lien tuc. Thi gian tiem TM > 2 phut, ngi cao tuoi > 3 phut. - Khi au 5-10mg (0.075-0.15mg/kg) TM > 2 ph. Mot so TG khuyen khi au 2.5-5mg (0.0375-0.975mg/kg) TM > 2ph.

VERAPAMIL
-Neu BN khong ap ng sau lieu au tien, co the cho lieu th hai 10mg (0.15mg/kg) khoang 30 phut sau lieu au tien. -Mot so tac ga khuyen tiem TM bo sung vi lieu 5-10 mg (0.075-0.15/kg) lap lai moi 15-30 phut khi can thiet cho en khi tong lieu toi a la 20mg. * Lieu uong: e phong nga NNKPTT 240-480 mg, chia lam 3-4 lan

VERAPAMIL
2. Chong ch nh: - RL chc nang that T nang - HA thap (HAtt < 90mmHg) hoac choang tim. - H/C suy nut xoang (tr khi co PM) - Bloc nh that o II-III (tr khi co PM) - RN hay CN trong H/C WPW hay LGL - BN ang thuoc c che - Verapamil TM khi BN co NNT QRS rong > 0.12 giay.

VERAPAMIL
3. Tng tac thuoc: - c che men chuyen: td ha HA - Aspirine: thi gian chay mau - c che : td Inotrope(-), Nhp tim, bloc Nh that - Digoxine: nong o & kha nang ngo oc - Erythromycine: nong o verapamil - Theophylline: nong o & thanh thai

DILTIAZEM
- Cung nhom va tnh chat vi Verapamil - Tac dung tren NNKPTT giong nh cua Verapamil @ Nhp nhanh kch phat tren that Tiem TM: Khi au 20 mg ( hay 0.25 mg/kg) tiem TM > 2 ph. mot so ngi ch can lieu0.15 mg/kg. Neu khong hieu qua, co the cho them lieu th hai 25 mg ( hay 0.35 /kg) thng 15 phut sau lieu khi au

DILTIAZEM
@Rung nh , Cuong nh * Tiem TM: Khi au lieu tan cong 25mg (hay 0.25mg / kg) tiem TM > 2ph, mot so BN co the cho 0.15 mg/kg. Neu khong ap ng cho 25mg (hay 0.25 mg / kg) 15 phut sau lieu au tien. e duy tr giam nhp that co the truyen TM 10mg / gi, truyen TM co the duy tr trong 24 gi. Toc o tuyen TM co the 5mg moi gi, nhng khong qua 15mg/gi. Thong thng lieu duy tr t 10-15mg/gi. Co the ch 5mg/gi.

MEXILETINE
1. Ch nh: - Loan nhp that nang - ieu tr ngoai tam thu that 2. Chong ch nh: - Man cam vi thuoc - Choang tim - Bloc nh that o II III ( tr khi co PM)

MEXILETINE
3. C che tac dung: - Thuoc nhom I b. - c che s di chuyen cua Natri vao ben trong te bao, giam o doc cua pha 0, lam tang ty le cua thi gian tr tuyet oi vi thi gian cua ien the hoat ong.

MEXILETINE
4. Dc ong hoc: - Ngi gia hap thu cham hn - Ket gan vi proteine 50 70% - Chuyen hoa gan - Thi gian ban huy 10 14 gi (ngi gia 14.4 gi), keo dai hn khi co suy gan hay suy tim - Bai tiet trong nc tieu (10-15% dang nguyen ven)

MEXILETINE
5. Tac dung phu: - TKTW: Nang au (10-25%), chong mat (20-25%), - Tieu hoa: H/C da day (41%), non buon non (40%) - Than kinh c: Run (13%), loang choang (10-20%) ...

MEXILETINE
Nghien cu CAST cho thay oi vi loan nhp that khong e doa tnh mang va khong co trieu chng th khong mang lai li ch khi co ieu tr loan nhp bang Flecaine hay Encainide, ma con co the co hai lam ty le t vong cao hn so vi nhom ieu tr bang placebo. Thuoc s dung can than /v BN b bloc nh that o I, Suy nut xoang, dan truyen nh that b keo dai, suy tim nang, suy gan.

MEXILETINE
6. Tng tac thuoc: - Cac thuoc co the lam tang tac dung cua Mexiletine: Nhom Quinolone, Rofecoxib, Theophylline, Miconazole, Ritonavir - Cac thuoc co the lam giam tac dung cua Mexiletine: Carbamazepine, Phenobarbital, Rifampicine

MEXILETINE
7. Cach dung: - Uong: Bat au vi 200mg moi 8 gi ( co the cho lieu toi a 400mg neu can thiet) chnh lieu trong 2-3ngay. Lieu thng dung 200mg-300mgmoi 8 gi. Khi dung e thay the cho mot thuoc chong loan nhp khac th bat au bang 200mg sau khi ngng thuoc dung trc o 6-12 gi. BN suy gan hay suy than can giam lieu 20-30% lieu thng dung.

1. Ch nh: *Loan nhp that nguy hiem *Loan nhp tren that BN khong co benh tim cau truc a dung cac thuoc khac khong hieu qua 2. Dc hoc: Lam cham dan truyen trong c tim bang cach thay oi s van chuyen ion qua mang te bao lam tang nhe thi gian tr, khong lam thay oi ien the hoat ong, tang ngng kch thch c tam that va he His-Purkinje. Co tac dung inotropic am tnh mc o trung bnh.

FLECAINIDE

FLECAINIDE
3. Dc ong hoc Hap thu nhanh qua ng uong, at nong o dnh sau 1.5 3 gi - ket hp vi alpha 1 glycoproteine 40 50%, chuyen hoa gan, hoat tnh sinh hoc 85 90%, thi gian ban huy t 7 22 gi, keo dai hn BnN suy tim hoac suy than. Bai tiet qua nc tieu 80 90%.

FLECAINIDE
4. Chong ch nh: - Man cam vi cac thanh phan cua Flecaine - Bloc nh that o II, III hay bloc hai phan nhanh (RBBB + LHB) [tr khi co PM] - Choang tim - Benh ly mach vanh (da vao NC CAST) - ang dung thuoc ritonavir hay amprenavir

FLECAINIDE
NC CAST (Cardiac Arrhythmia Suppression Trial) cho thay BN b NMCT co loan nhp that khong e doa tnh mang va khong trieu chng th viec dung Flecainide khong co li va con co hai, co the lam tang ty le t vong (7.7% so vi 3% nhom placebo). Khong nen dung cho BN b rung nh man tnh v nguy c gay roi loan nhp khac cung nh BN b suy tim. Thuoc co the lam tang ngng kch thch cua may tao nhp. Than trong vi BN suy gan.

FLECAINIDE
5. Tng tac thuoc: - Amiodarone co the lam tang nong o cua Flecaine trong huyet thanh. - Nong o Digoxine co the tang khi dung chung vi Flecaine - Ritonavir hay amprenavir lam tang oc tnh cua Flecaine oi vi tim. - Cimetidine lam giam chuyen hoa cua flecaine.

FLECAINIDE
6. Tac dung phu - TKTW: chong mat (19 30%) - Th giac:RL 16% - Ho hap: kho th 10% - Tim mach: hoi hop 6%, au ngc 5%, roi loan nhp 4 12%, suy nut xoang 1.2% - Tieu hoa: Non 9%, au bung 3%, chan an 1-3%, tieu chay 0.7 3% - TK c: run 5%

FLECAINIDE
7. Lieu lng ngi ln: * Uong: oi vi loan nhp that e doa tnh mang: Bat au vi 100mg moi 12 gi, neu can tang lieu 50 100mg moi 4 ngay. Lieu toi a 400mg oi vi nhp nhanh kch phat tren that BN khong co benh tim cau truc. Bat au vi 50mg moi 12 gi, neu can tang 50mg moi 4 ngay. Lieu toi a 300mg.