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GLUCOCORTICOIDLM DNG V X TR CC BIN CHNG CAIBS. TRN HU HIN CAO HC NI 2014 2016HYK PHM NGC THCH

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NI DUNGLch s thuc corticocoidCu trc tuyn thng thnTrc h i tuyn yn tuyn thng thnC ch tc ng, cu trc, liu tng ng ca corticoidTc dng ca glucocorticoidCh nh ca glucocorticoidTc dng ph ca glucocorticoidKm pht trin tr em do GCLong xng do GCCai GC2

LCH S THUC CORTICOID1855 Bnh Addison1856 Vai tr ca tuyn thng thn cho s sinh tn1930 Cu trc tuyn thng thn1932 Hi chng Cushing1949 Hench v cng s (s dng corticoid trong vim khp dng thp)1952 Pht hin ra aldosterone

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Cu trc tuyn thng thn

Widmaier EP, Raff H, Strang KT: Vander's Human Physiology: The Mechanisms of Body Function, 11th ed. McGraw-Hill, 20084

Trc h i tuyn yn tuyn thng thn

J. Larry Jameson, editor.Harrisons Endocrinology.2nd Edition. 20105

C CH TC NG CA CORTICOID6

Qu trnh sinh tng hp glucocorticoid7

Dao ng nng ACTH v glucocorticoid(11-OHCS) trong huyt tng c ngy

J Clin Endocrinol Metab.1971;32:266

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Tc dng ca glucocorticoid: c ch min dch v khng vim

Goodman And Gilman's The Pharmacological Basis of Therapeutics 12th edition

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C ch khng vim ca corticoid10

Tc dng ca glucocorticoid: chuyn ha- ngoi bin: gim s dng glucose, lm tng thoi ha protein ( c) v lipid (m m) lc i. - gan: to glucose t acid amin v glycerol, chuyn glucose thnh glycogen.- Tng d tr m v ti phn phi m khng ng u: m tch t xng n, sau c v mt lm mt bnh nhn y n nh mt trng trn (moon face) nhng li mt m chi. - Tng gi Na+v nc, tng bi tit K+ (th th mineralcorticoid) v tng lc cu thn, c ch tng hp v bi tit vasopressin lm tng bi tit mui v nc qua thn (th th GC)

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

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Dc lc v liu tng ng cc thuc corticoid

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

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13CH NH DNG GLUCOCORTICOID

iu tr thay th khi thiu hormone

Suy v thng thn mn tnh (nguyn pht v th pht) Suy v thng thn cp tnhTng sn v thng thn bm sinh

14Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

iu tr vimVim khp dng thpLupus ban h thng Hi chng thn hHen ph qun COPD

15Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

iu tr nhim khun

Vim phi do Pneumocystis carinii trong bnh AIDS Vim mng no do Haemophilus influenza loi BVim gan virusTng bch cu n nhn do nhim khun Sc nhim trng

16Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

Bnh c tnh

Bnh HodgkinBnh bch cu cp dong lymph a u ty U no nguyn pht Nn do ha tr Ph no do di cn Bnh gim tiu cu Ph hy hng cu t min

17Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

Cc bnh khc

Sc phn vMy ayBnh huyt thanhVim lot i trngBnh CrohnBnh u htBnh v da v mtBnh vim a cTn thng ct sng v t quChng thi ghp c quan

18Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

TC DNG PH CA GCSuy gim min dch Tng ng huyt do tng gluconeogenesis, khng insulin v dung np glucose ("i tho ng steroid"); thn trng nhng ngi c bnh i tho ngMng da, d bm tmGim canxi do gim hp thu canxi rut*Long xng do steroid: gim mt xng (long xng, hoi t xng, nguy c gy xng cao hn, lnh xng chm hn)

19*Br J Rheumatol.1993 May;32 Suppl 2:11-4

Tng cn do tng lng ng cht bo tng v thn ngi (bo ph) v kch thch s thm nTng cortisol mu vi vic s dng ko di v / hoc qu nhiu (cn c gi l hi chng Cushing ngoi sinh)Suy gim tr nh v s ch *Suy thng thn (nu s dng trong thi gian di v dng li t ngt m khng gim liu)Thoi ha c (phn gii protein), yu c, gim khi lng c bp v sa chaU m (lipomatosis) trong khoang ngoi mng cng**

20TC DNG PH CA GC*Neurology47(6): 1396402**Endocrinol. Metab.11(3): 8690

Kch thch h thn kinh trung ng (hng phn, ri lon tm thn)Ri lon chu k kinh nguytChm tng trng, chm dy thTng axit amin huyt tng, tng hnh thnh ur, gim nitTng nhn p do tng p lc nhn cuc thy tinh th21TC DNG PH CA GC

KM PHT TRIN TR EM DO GC22

TM VC THP (SHORT STATURE) TR EMC ch: c ch tc dng pht trin xng v sn ca somatomedinKhc phc:Hn ch k n glucocorticoid cho tr emCh dung liu thp trong thi gian ngnNu phi dung ko di th dng liu cao, cch ngy thay th liu hng ngy gim r rt cc tc dng ph tr*

23*Endocrinol Metab Clin North Am.1996 Sep;25(3):699-717.

Dng glucocorticoid (GC) nhiu ln ca m lc mang thai lm tng nguy c sinh non, nh hng xu n tng trng thai nhi v gim chu vi vng u.

24nh hng n pht trin no bActa Paediatr.2011 Mar;100(3):364-9

nh hng n pht trin no b

Thai nhi tip xc nhiu vi GC trong giai on pht trin quan trng ca no c th lm thay i h vin (ch yu l vng hi m - hippocampus), dn n nh hng lu di i vi nhn thc, hnh vi, b nh, s phi hp ca h thng thn kinh thc vt.

25Korean J Pediatr. Mar 2014; 57(3): 101109.

iu tr GC sau sinh cho bnh phi mn tnh tr non, c bit l dexamethasone, c chng minh l gy ra s suy gim pht trin thn kinh v lm tng nguy c mc bnh bi no.* Ngc li vi nhng nghin cu lin quan n dexamethasone sau khi sinh, cc nghin cu theo di di hn cho iu tr hydrocortisone khng tit l nh hng xu n kt qu pht trin thn kinh.** Nh vy, da trn cc nghin cu lm sng v thc nghim, c bng chng khuyn thn trng vic s dng GC trong giai on chu sinh26*Neonatology.2010;98(4):289-96.**J Pediatr.2007 Apr;150(4):351-7.Korean J Pediatr. Mar 2014; 57(3): 101109.nh hng n pht trin no b

27LONG XNG DO GC

C CH LONG XNG DO GCGlucocorticoid tng ti hp thu xng, lm gim s hnh thnh xng, lm gim hp thu canxi rut, thn v lm tng bi tit canxi.iu tr glucocorticoid c lin quan nguy c ng k cho s mt xng, gy xng v gy xng xy ra cc gi tr mt cht khong trong xng cao hn xy ra sau mn kinh b long xng.

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Cc nguy c gy xng c bo co: prednisone vi liu 2,5-7,5 mg (dng hng ngy) hoc tng ng vi liu ny.*Lm sng: long xng do GC cng ging nh cc nguyn nhn khc ca bnh long xng. Thng thng, khng c biu hin lm sng cho n khi c mt vt nt.Bt c bnh nhn dng bt c liu glucocorticoid vi thi gian 3 thng cn nh ginh gi cc yu t nguy c lm sng cho gy xngMt khong xng (DXA) ca hng v ct sng o nng 25-hydroxyvitamin D29*J Bone Miner Res.2001 Jan;16(1):104-12.NH GI LONG XNG DO GC

Liu v thi gian iu tr GC cng thp v cng ngn cng tt, bi v ngay c liu thay th c th gy ra mt xng. Bnh nhn cn c khuyn khch cc bi tp chu trng ti chng li s mt xng v teo c. Bnh nhn nn trnh ht thuc, ung ru qu mc v c bin php ngn nga t ng. i vi bnh iu tr GC ko di vi thi gian 3 thng, nn b sung canxi v vitamin D: 1.200 mg canxi nguyn t hng ngy, tng cng ch n ung b sung, v 800 IU vitamin D mi ngy.* 30D PHNG LONG XNG DO GC*Arthritis Care Res(Hoboken).2010Nov;62(11):1515-26

LA CHN THUC IU TR LONG XNG DO GCi vi nam gii v ph n sau mn kinh, la ch hng u l bisphosphonates. Nn chn alendronate* hoc risedronate** ung mi tun. Cc d liu th nghim lm sng chng minh hiu qu ph n v nam gii ca hai thuc ny so vi cc bisphosphonates khc .Axit zoledronic tim tnh mch l la chn cho bnh nhn khng dung np c bisphosphonates ung

31*J Rheumatol.2009 Aug;36(8):1705-14**Arthritis Rheum.1999 Nov;42(11):2309-18.

Hormone cn gip khng l thuc la chn u tay iu tr hoc phng nga bnh long xng do glucocorticoid v chi ph cao v s sn c ca cc thuc khc. Estrogen khng cn c coi l mt loi thuc hng u phng chng long xng sau mn kinh. Bi v: Cc th nghim lm sng ph n sau mn kinh cho thy s dng lu di kt hp estrogen-progestin ung khng lm gim nguy c bnh mch vnh nh c mong i da trn cc nghin cu quan st.* Ngoi ra, liu php phi hp lm tng nguy c ung th v, t qu, v huyt khi tnh mch.

32LA CHN THUC IU TR LONG XNG DO GC*JAMA.2002 Jul 17;288(3):321-33.

CAI GLUCOCORTICOID33

NH GI TRC H I TUYN YN TUYN THNG THN (HPA) BNH NHN IU TR GC

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TIU CHUN NH GI BNH NHN C KH NNG SUY GIM TRC HPABt c ai nhn c mt liu glucocorticoid tng ng vi hn 20 mg prednisone mt ngy trong hn ba tunBt c ai nhn c mt liu bui ti / trc i ng prednisone trong mt vi tunBt k bnh nhn c xut hin dng Cushing35

CC YU T CN NH GI KHI CAI GC

Cc yu t tui tc, bnh ng pht, mc nguy him v kh nng bng pht ca bnh nnCc bnh phi n nh gim liu dn n liu thch hpCc yu t tm lNu thi gian dung thuc di 3 tun c th ngng t ngtDng liu thp nhng ko di nhiu thng vn phi gim liu trc khi ngng36

Ann Intern Med.1976Mar;84(3):304-15.

CH NH CAI GCTc dng ph, chng hn nh bnh long xng ct sng tht lng hoc tng huyt p, tr nn nghim trng hoc khng kim sot c bng thucHai bin chng cn ngng GC hoc gim vi liu sinh l, ch khng gim dn:Lon tm thn cp tnh do GC khng p ng vi thuc chng lon thnHerpesvirus gy ra vim lot gic mc, c th nhanh chng dn thng gic mc v m la vnh vin37

CH GIM LIU GC

5-10 mg / ngy mi 1-2 tun t mt liu ban u trn 40 mg prednisone hoc tng ng cho mi ngy.5 mg / ngy mi 1-2 tun liu prednisone gia 40 v 20 mg / ngy.2,5 mg / ngy mi 2-3 tun liu prednisone gia 20 v 10 mg / ngy.1 mg / ngy mi 2-4 tun liu prednisone gia 10 v 5 mg / ngy.0,5 mg / ngy mi 2-4 tun liu prednisone t 5 mg / ngy xung. 38

SO SNH GIM LIU PREDNISOLONE KO DI V GIN ON TR EM MC HC THN H Mt th nghim nh gi 46 tr em b hi chng thn h v c iu tr vi liu cao prednisolone (60 mg /m2 mi ngy) Gim liu dn c thc hin hn tm tun hoc nm thng. 29 tr trong nhm gim liu ngn nhn 60 mg / m2 mi ngy trong bn tun, tip theo l 40 mg / m2 mi ngy ba ngy mt tun trong bn tun. Prednisolone sau b dng. 17 tr trong nhm gim liu di nhn c 60 mg / m2 mi ngy trong bn tun, 60 mg / m2 mi ngy cch ngy trong bn tun, sau gim dn bng 10 mg / m2 mi ngy mi bn tun qua nm thng. Kt qu: s bnh nhn b ti pht vi cc hi chng thn h trong vng su thng sau khi gim liu cao hn ng k nhm gim liu nhanh chng.39J Pediatr.1988 Jan;112(1):122-6.

GII QUYT TI PHT BNH NN KHI GIM LIU GCBnh nhn b bnh thp khp c th phn nn v cc triu chng ti pht ca bn khi gim liu GCCn phn bit gia cc triu chng cai GC (tc l, au khp v au c hay gi thp khp - pseudorheumatism) hoc l ti pht ca bnh thp khp Nu cc triu chng khng nng, i 7-10 ngy, v s dng mt loi thuc khng vim khng steroid hoc thuc gim au khc. Gii quyt ca cc triu chng trong thi gian ny cho thy l pseudorheumatism.Nu cc triu chng khng gim dn trong khong thi gian ny, cn tng liu prednisone 10-15 phn trm v duy tr liu 2-4 tun. Sau khi cc triu chng ti pht c gii quyt, cn tip tc li ch gim liu40

Nu xut hin cc trng hp cp tnh (nh ti pht cp tnh ca vim thn lupus, tn huyt nng, vim a c cp tnh, hoc vim mch) cn dng li liu ban u, liu cao nht ca GC c th thc hin.

41GII QUYT TI PHT BNH NN KHI GIM LIU GC

THANK YOU SO MUCH

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