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OAl THAO OlfCfNG I DAI CU’CTNG D jn h nghTa D th a o d u a n g (D T D ) la tin h tra n g tang du’O’ng huye t m an tin h dac tru n g b o i n h u n g roi loan chuyen hoa ca rb o h yd t, co kem th e o roi loan chuye n hoa lipid va protein giam tu y e t doi hoac tu a n g doi tac dung sinh hpc cua in sulin v a /h o a c tie t insulin P h an loai - D a i th a o d u a n g typ 1: b en h tu m ien djch: cac te bao P tu ye n tu y bi pha huy b a i chat trun g gian m ien djch, s u p h a huy co th e nhanh hoa c cham T ien trie n n h a n h gap a n g u a i tre < 30 tuoi, trieu chipng la m s a n g ram rp k h a t nhieu, uong nhieu, sut can, m e t m oi X u a t hien cac tu khan g the kh6n g d a o tu y (IC A : isle t c e ll a u to a n tib o d ie s ), tu khan g th e khan g in su lin va t u kh a n g th e khan g G A D (g lu cta m ic acid d e c a rb o x y la s e ) tro n g 85 - 90% tru a n g h a p B ien c h u n g cap tin h hay g§p la hon m e nhiem to a n ce to n D ie u trj b i t b u p c phai d ieu trj bang in sulin, ti le g a p < 10% T he tien trie n cham hay g£p a n g u a i la n , g o i la d a i th a o d u a n g tu m ien djch tie m ta n g a n g u a i la n (LA D A : la te n t a u to im m u n e dia b e te s in a d u lts) - D th a o d u a n g typ 2: dai th a o d u a n g typ tru a c day d u a c goi la dai th a o d u a n g khong phu th u o c insulin, dai th a o d u a n g a n g u a i la n, benh co tin h gia dinh D a c tru n g cua dai th a o d u a n g typ la khang insulin di kem v a i th ie u hut in sulin tu a n g doi Tuoi > 30 tuoi, trieu c h u n g lam sang am tham , th u a n g phat hien m uon Bien c h u n g ca p tin h hay gap la hon m e tang ap lu c th a m thau C o the dieu trj b in g che an, th u o c uong v a /h o a c insulin T i le gap 90 - 95% - D th a o d u a n g thai ki: dai th a o d u a n g thai ki la tin h tra n g roi loan dung nap d u a n g huyet xay th a i ki m ang thai - C ac tin h tra n g ta n g d u a n g h u ye t dac biet khac: giam c h u c nang te bao beta khiem kh u ye t gen: M O D Y 1, M O D Y 2, M O D Y 3, dai th a o d u a n g ti lap the, giam hoa t tin h in sulin khiem khuye t gen Benh li tu ye n tuy: vie m tuy, xa , soi tuy, ung th u tuy, M ot so benh noi tiet: to cac vie n cu c, hoi c h u n g C u sh in g , th u o c, hoa chat, nhiem khuan II chAn o o An XA C DjNH • T h e o tieu c h u a n ch a n d oa n cua To c h u c Y te T he g ia i nam 1998 (xem bang 1) - D u a n g h u ye t (g lu c o s e m au - G M ) luc doi £ ,26g/l = ,0 m m o l/l (it n h a t lan) - G M lam bat ki th a i d ie m n£o £ 2g/l = 11 m m ol/l co kem th e o cac trieu c h u n g lam sang hoac G M sau g ia lam n g h ie m p p ta n g d u a n g huye t £ 11,1m m ol/l N eu 1,1 g/l < G M < 1,26g/l: can lam ngh iem phap dung nap g lu co se de chan doan xac dinh H i/O n g d A n c h A n o o A n vA o i£ u t r i bEnh 412 NOi khoa B a n g C h an d o a n d thao dw & ng h o a c ro i lo a n d u n g n a p g lu c o s e theo dip&ng h u y e t m ao m a c h h o a c tin h m a c h Mao mach (mmol/L) Tinh mach (mmolA) Goi 2:6,1 7,0 Sau gid 11,1 11,1 Odi < ,1 < ,0 Sau gid 7,8 7,8 Ket luan OTO Roi loan dung nap glucose III XET NGHIEM CAN LAM SANG CAN LA m D£ THEO DOI D l£ ll TRj - D u a n g huyet: luc doi, sau an gia - H bA1c: lan dau phat hien va clp m oi thang/1 lan - Sinh hoa m au: cre a tin m au, cholesterol, tryglice rid, H D L-C , LD L-C (luc m a i chan doan vd sau m6i thang) - T ong phan tic h n u a c tieu lam th u a n g quy M icro a lb u m in nieu (sau nam doi v a i dai thao (Jirtmg typ va tai th a i diem chan doan doi v a i dai th a o d u a n g typ 2) - D ien tam do: lan dau pha t hien va m oi thang - Sieu am D o p p le r m ach canh, m ach chan: luc m a i chan doan, nghi n g a co ton th u a n g - C hup tim phoi: luc m a i chan doan va nghi n g a co ton th u a n g phoi - K ham m it: luc m a i chan doan va sau m oi nam Khi co ton th u a n g m it : m oi - thang IV l£ u TRI M uc tieu dieu trj M uc tieu kiem soat d u a n g huyet theo A D A , 2010 - H b A 1c < 7% d u a c coi la m uc tieu chun g cho ca dai th a o d u a n g typ va typ - G lu co se m au (G M ) luc doi nen tri a m u c 3,9 - ,2 m m o l/l (70 - 13 m g /d l) - G M sau an g ia < 10m m ol/l (< 180m g/dl) - D ie u tri cac yeu to nguy c a di kem : tang huyet ap (TH A ), roi loan lipid m au (tham khao phan dieu tn bien c h u n g m an tin h cua benh nhan dai thao d u a n g ) P h ac dd dieu trj tan g d u a n g hu y§t a C h e an - T h u c hien che dp an h a p li, can doi cac phan: g lucid 50- 60% , protid 15 - 20% , lipid 20 - 30% tong so calo tron g ngay, nen chon loai th u c pham co ch i so tang d u a n g hu ye t (G I) thap, nhieu chat xa (rau 100 - 200g/bu'a), kieng ngot D th a o d u a n g typ an bCra c h in h (sang, tru a toi), Benh nhfin dang tiem insulin co the chia th a n h - b u a phong d u a n g huyet b H o a t d o n g th e lire - Toi th ie u la 30 phut/ngay, nga y/tuan , lu u y kiem tra d u a n g huye t, HA, tin h tran g tim m ach trucrc tap C ac loai h inh luyen tap di bo, b a i loi, cau long, leo cau th a n g deu d u p e N h u n g chpn loai nao pha phu h o p v a i tin h h inh slpc khoe va bien c h u n g va benh di kem cua tipng n g u a i benh (lu u y 14mmoM < d u a n g huye t doi < m m o l/l khon g luyen tap) C an tham kh a o th e m y kie n cu a cac thay thuoc cfiuy^*1 khoa ve hinh th u c luyen tap va cach theo doi d u a n g huyet tru a c va sau tap H u o n g d An c h An o o An v A d i £ u tri b £n h N oi kho a 413 c D ie u t r i b a n g in s u lin • P h a c d o d ieu trj b ln g insulin C h i dinh: - La b i t bu c v o i dai th a o d u o n g typ 1, dai th a o d u o n g thai ki - D a i th a o d u o n g typ co: + M at bu stress, nh ie m trung, vet th u o n g cap, tang d u o n g hu ye t v o i tang ceton m au cap nang M at can khon g kie m soat d u g c + C an th ie p n go khoa + C o thai + S uy gan, than + Di u n g v d i ca c th u o c vie n d u d n g huyet + T t bai v d i th u o c vie n d u d n g huyet + C h i d in h ta m th d i n g a y cd d u d n g h u y e t ta n g c a o > - 0 m g /d l (14 - ,5 m m o l/l), H b A c > 11% - D th a o d u d n g cd hdn m e toan ceton hoac tang ap lu c th a m th lu - D th a o d u d n g b en h li tuy: vie m m an, sau phau th u a t c i t - T rong m pt so tru d n g h g p nhu cau insulin cua benh nhan tang cao: d ieu tri m ot so th u o c gay tSng d u d n g huye t (co rtico id ) Lie u tiem in sulin: - Lieu Insulin can th ie t d n h u n g benh nhan dai th a o d u d n g typ t u 0,5 - ,0U I/kg can nang Lieu kh d i dau th u d n g tu 0,4 - ,5 U I/kg /n g a y Lieu thong th u d n g 0,6U I/kg, tiem d u d i da - lan tron g Sau dd can c u tren ket q u a d u d n g h u ye t tang hoac giam lieu insulin tu - 2U I/lan - Lieu insulin d benh nhan dai th a o d u d n g typ 2: b i t dau tu 0,2U I/kg/ngay T h u d n g 0,3 - 0,6U I/kg/ngay - Lieu insulin nen 0,1 - 0,2U I/kg - Vi tri tie m Insulin (xem phu luc s o vj tri tiem insulin) C ac p h a c d ie u tri: - Cd nhieu ph £ c d ieu tri in sulin khac D oi v d i dai th a o d u d n g typ th u d n g s ir dung phac den m ui D o i v d i dai th a o d u d n g typ ngoai pha c n h u dai th a o d u d n g typ cd the s u dung them ph a c m ui in su lin phoi h g p v d i th u o c vie n (In su la ta rd hoa c lantus) - D 6i th a o d u d n g th a i ki th u d n g s u d un g pha c - m u i/n g a y th e o nong d