Kiến thức, thái độ về tuân thủ điều trị thuốc kháng virus của người bệnh viêm gan b mạn tính phòng khám ngoại trú bệnh viện đa khoa tỉnh nam định

BQ YTE TRIOAG DAI HOC DIEU DtfONG NAM DINH 19 BAO CAO TONG KET DE TAI NGHIEN CUU KHOA HOC CAP CO SO KIEN THUG, THAI DQ VE TUAN THU DIEU TRI THUOC KHANG VIRUS CUA NGlTdl BENH VIEM GAN B MAN TINH PHONG KHAM s• NGOAI TRU BENH VIEN DA KHOA TtNH NAM DINH Chu nhiem de tai: MAI THI• YEN • Nam Dinh, thang 11 nam 2019 BOYTE TRUONG DAI HOC DIEU DUONG NAM DINH 19 BAO CAO TONG KET DE TAI NGHIEN CUE KHOA HOC CAP CO SO KIEN THUG, THAI DO VE TUAN THU DIEU TRI THUOC KHANG VIRUS CUA NGtTCH BENH VIEM GAN B MAN TINH PHONG KHAM NGOAI TRU BENH VIEN DA KHOA TINH NAM DINH Chu nhiem de tai: MAI THI YEN Nhung nguoi tham gia: TS Nguyen Thi Minh Chinh Ths Bui Chi Anh Minh Ths Vu Thi Minh Phuong n?(/ONG DAI HOC DIFU DUONG Ths Vu Thi Thuy Mai nam dinh THWvi^n So: ' Nam Dinh, thang 11 nam 2019 X - X z • 2.10 Van de dao due nghien cun 19 Chiro ng KET QUA NGHIEN CUXJ 20 • A • ?% z z 3.1 Dac diem cua doi tuong nghien cuu 20 3.2 Kien thuc tuan thu dieu tri thuoc khang virus viem gan B 21 3.3 Thai NB doi voi tuan thu dieu tri thuoc khang virus 26 Chuang BAN LUAN 29 •A *> • Z\ ' • z 29 4.1 Dac diem cua doi tuong nghien cuu I z z ' • A 4.2 Kien thuc chung cua nguoi benh doi voi tuan thu dieu tri dimg thuoc khang virus viem gan B r \ 30 * 4.2.1 Hieu qua cua thuoc dieu tri 31 4.2.2 Nhung nguyen tac dieu tri viem gan B man tinh 32 4.2.3 Tac hai cua viec khong tuan thu dieu tri thuoc khang virus 32 4.2.4 Xet nghiem can thuc hien dinh ky 33 4.2.5 Tac dung phuc cua thuoc khang virus 34 4.2.6 Thuoc khang virus co chua khoi benh VGB man tinh 34 4.2.7 Kien thuc tuan thu ve each su dung thuoc, theo doi dinh ky dieu tri viem gan B truoc va sau can thiep 34 4.2.8 T6ng diem kien thuc noi chung 36 4.3 Thai ve tuan thu dieu tri thuoc khang virus viem gan B truoc va sau can thiep giao due 36 Ket luan 40 Kien nghi 41 TAI LIEU THAM KHAO PHU LUC .5 PHU• LUC • PHU LUC2 11 DANH MUC CAC CHLJ VIET TAT HBV NUC NB DTNC VGB HCC n % Viem gan virus B man tfnh Thuoc khang virus Ngirai benh Doi tuong nghien cmi Viem gan B Ung thu bieu mo te bao gan So lurang ngudi benh Ty le phan tram r *> z DANH MUC CAC BANG Bang 3.1 Mot so dac diem nhan khau hoc cua doi tuong nghien cuu 20 Bang 3.2 Kien thuc tuan thu thuoc dieu tri Viem gan B truoc va sau can thiep 21 Bang 3.3 Kien thuc tuan thu ve each su dung thuoc, theo doi dinh ky dieu tri viem gan B trade va sau can thiep 24 Bang 3.4 T6ng diim kitin thuc chung ve tuan thu dieu tri viem gan B 25 Bang 3.5 Thai tuan thu su dung thuoc dieu tri viem gan B trudc va sau can thiep 26 Bang 3.6 Thai cam nhan ve qua trinh dung thuoc truve va sau can thiep 28 DANH MUC CAC BIEU DO VA HINH • / a X • 11 Hinh 2.2 So quy trinh kham benh Bieu 3.1 Dac diem lien quan den gidi tinh ngubi benh viem gan B 16 20 Bieu 3.2 Ly quen uong thuoc trade can thiep 27 Hinh 2.1 Cac bien so nghien ctru A ■» • A / A X / A A A • A Bieu 3.3 Ly quen uong thuoc sau can thiep 27 DAT VAN DE Viem gan sieu vi B (VGSV B) man tinh la tinh trang nhiem sieu vi viem gan B keo dai, dien o ben te bao gan Berth lay nhiem qua: dubng xuyen qua da (tiem chich, truyen mau, phau thuat, vet tray xuac ), quan he tinh due khong an toan voi nguai nhiem benh, me nhiem benh truyen sang Viem gan B man tinh la nguyen nhan dan den xo gan, ung thir gan.Theo uoc tinh, tai Viet Nam co khoang 7,8 trieu trubng hop nhiem viem gan B man tinh Ben canh do, co hon 13.000 bi xo gan mat bit (tiic la berth xo gan da buoc vao giai doan cuoi), gan 6.000 ca bi ung thu te bao gan va hon 6.400 ca tir vong lien quan den gan Dac biet, uoc tinh chi cd 74.000 nguoi dupe dieu tn truoc Viet Nam la mot nhung nude co san cac loai thuoc khang vi nit dubng uong de dieu tri viem gan B man tinh tai cac benh vien va da dupe bao hiem y te chi tra Tuy cac loai thuoc khang virus khong chua dupe nhiem viem gan virus B (HBV), nhung dieu tri co the lam cham su tien trien cua xo gan, giam ty le mac benh ung thu gan va cai thien su song lau dai [13] Hien nay, tren toan the gioi uoc tinh cd it nhat ty nguoi (mot phan ba dan so the gioi) da bi nhiem HBV; khoang 240 trieu nguoi (tuong duong voi 6% dan so the gioi) nhiem HBV man tinh [30], [31] Su phat trien tu nhien cua nhiem HBV man tinh la tir trang thai khong hoat dong den viem gan B man tinh tien trien (CHB), cd the tien trien xo gan va ung thu bieu mo te bao gan (HCC) [21] Benh gan giai doan cuoi co lien quan den HBV gay hon 0,5-1 trieu ca tu vong moi nam va hien chiem 5-10% so ca ghep gan Cac nghien cuu theo chieu doc cua nhung benh nhan khong dupe dieu tri CHB cho thay rang: sau chan doan, ty le mac benh xo gan tang tu 5% len khoang - 20% Ty le HCC tren toan the gioi da tang, chu yeu la nhiem HBV va/hoac HCV Ty le HCC cd lien quan den HBV rat cao, dao dong tir 2% den 5% xo gan xay [21]; 82% trubng hop cd lien quan den viem gan virus, 55% o viem gan loai B (HBV), 89% o nhung vung cd HBV Phan Ion cac trubng hop HCC (ung thu bieu mo te bao gan) cd xo gan (70 - 90%), nhien, vi HBV la mot virus gay ung thu, nd cd the gay HCC ca khong cd xo gan £23} Nhu vay, viem gan B man tinh tro ganh nang benh tat doi voi he thdng y td cung nhu sue khoe nguoi dan la rat Ion /V *** Z Z z ' Z Z Z z e e z Z • Z \ Z Z 7 Z 7 e Z z z Z e z ' ' e * e Tuy nhien, tai Viet Nam mac du rat nhieu co so y te dieu tri cho nguoi benh benh viem gan B man tinh nhung nghien ciru str tuan thu dieu tri thuoc khang virus han che Cac ket qua cua cac nghien curu deu cho thay ty le tuan thu han che, dieu doi voi mot so thuoc dieu tri khang virus tro nen kh6 khan, dac biet ty le khang thuoc o benh nhan dieu tri thuoc khang virus o ngtroi benh viem gan B man tinh ty le tucmg doi cao nhu nghien curu cua Bui Phan Quynh Phuong va cong su nam 2017 cho thay co 16 tniong hop khang thu6c chiSm 22,2% [8], nghien cuu cua Nguyen Minh Ngoc va Bui Huu Hoang Z / nam 2012 cho thay ty le tuan thu su dung thuoc b viem gan B man tinh tai TP H6 Chi Minh la 63,8%[7], Theo nghien cuu cua Nguyen Thi Phuong cho thay co den 75,8% benh nhan viem gan B man tinh tuan thu dieu tri thuoc khang virus muc kern, chi co 24,2% tuan thu tot Tir nhung ket qua cua nhung nghien cuu tren cho thay rang ty le khang thuoc cao va tuan thu dieu tri thuoc han che [9] Trong hien tai tren dia ban tinh Nam Dinh co co so nhat cung cap diSu tri thu6c khang virus voi hon 367 nguoi benh viem gan B man tinh dang duoc dieu tri tai khoa truyen nhiem benh vien da khoa tinh Nam Dinh Tuy nhien, chua co de tai nghien cuu nao ve kien thuc, thai tuan thu dieu tri thuoc khang virus cua nguoi benh viem gan B man tinh Vi vay chiing toi tien hanh nghien cuu d6 tai “Kien thuc, thai ve tuan thu di6u tri thuoc khang virus cua nguoi benh viem gan B man tinh phong kham ngoai tni Benh vien Da khoa tinh Nam Dinh” voi muc tieu sau: Mo ta thuc trang kien thuc, thai ve tuan thu dieu tri thuoc khang virus cua nguoi benh viem gan B man tinh tai phong kham ngoai tni Benh vien Da khoa tinh Nam Dinh Danh gia su thay d6i kien thuc, thai ve tuan thu dieu tri thuoc khang virus cua nguoi benh viem gan B man tinh trudc va sau can thiep giao due sue khde tai phong kham ngoai tni Benh vien Da khoa tinh Nam Dinh Chirang TONG QUAN TAI LIEU 1.1 SO LUOC VE VIEM GAN B Viem gan vi nit B la mot berth bien toan cau, vi rut viem gan B (HBV) gay Benh co th£ lay truyen qua duong mau, duong tinh due, tu me truyen sang Neu me nhiem HBV va co HBeAg (+) thi kha nang lay cho la hon 80% va khoang 90% tre sinh se mang HBV man tinh Viem gan vi rut B co the dien bien cap tinh, hon 90% so truong hop khoi hoan toan, gan 10% chuyen sang viem gan man tinh va hau qua cuoi ciing la xo gan hoac ung thu gan [1] Nhiem HBV man tinh khong the dupe xu ly hoan toan bo gen cua HBV tich hop vao bo gen cua vat chu, DNA vong kin (cccDNA) cua virus lien ket cong hoa tri hat nhan cua te bao gan bi nhiem, dieu co the giai thich A sir tai hoat tinh HBV [21], Muc tieu chinh cua dieu tri viem gan virus B la lam giam su tien trien cua ton thuomg gan, lam cham su phat trien xof gan va HCC [13], £19] Muc tieu co the dat dupe neu chep HBV dupe ngan chan mot each ben vung Mot so benh nhan khong dat dupe dap ung virus keo dai, dieu tri keo dai nhieu nam, lam tang kha nang phat trien cac dong virus khang thuoc Hau qua la cac lua chon dieu tri se giam xuong Cac yen to nhu dpt bien virus, giam rao can di truyen cua mot so loai thuoc, va su thieu tuan thu dieu tri khang virus la nhung nguyen nhan gay khang thuoc [9] Hien nay, khang genotyp khong dupe xac nhan a bat ki benh nhan nao co dpt bien virus tiep nhan cac NUC co rao can di truyen cao nhu tenofovir va entecavir nen nguyen nhan chinh cua dpt bien virus chinh la tinh trang tuan thu kem, dieu co the kien thuc ve tuan thu kem dan den [13] 1.1.1 Chan doan xac dinh: - HBsAg (+) > thang hoac HBsAg (+) va Anti HBc IgG (+) - AST, ALT tang tung dpt hoac lien tuc tren thang •> a * r - Co bang chung ton thuemg mo benh hoc tien trien, xo gan (dupe xac dinh bang sinh thiet gan hoac dp dan hoi gan hoac Fibrotest hoac chi so APRI) ma khong can nguyen khac 1.1.2 Dieu tri: A a) Chi dinh dieu tri khi: - ALT tang tren lan gia tri binh thuong hoac co bang chung xac nhan co xo hoa gan tien trien/xo gan bat ke ALT o mire nao va - HBV-DNA >105 copies/ml (20.000 lU/ml) neu HBeAg (+) hoac HBVDNA >104 copies/ml (2.000 lU/ml) neu HBeAg (-) b) Dieu tri cu the: - Thuoc dieu tri: + Tenofovir (300mg/ngay) hoac entecavir (0,5 mg/ngay) + Lamivudine (lOOmg/ngay) su dung cho ngirbi benh xo gan mat bu, phu nu mang thai + Adefovir dung phoi hop voi lamivudine co khang thuoc + Peg-IFNa, IFNa (Peg-IFNa-2a lieu 180mcg/tuan; Peg-IFNa-2b lieu l,5mcg/kg/tuan; IFNa lieu trieu lU/ngay hoac 10 trieu lU/lan -3 lan/tuan, tiem duoi da tir 6-12 thang - Can theo doi tac dung khong mong muon cua thuoc de xu tri kip thoi) tru tien str dung truong hop phu nu muon sinh con, dong nhiem viem gan vi nit D, khong dung nap hoac that bai dieu tri voi thuoc uc che chep HB V' duong u6ng - Xem xet ngimg thuoc uc che chep HBV uong khi: + Truong hop HBeAg (+): sau 6-12 thang co chuyen doi huyet HBeAg va HBV­ DNA duoi nguong phat hien + Truong hop HBeAg (-): HBV-DNA duoi nguong phat hien lan xet nghiem lien tiep each moi thang va can Z ’ X e e theo doi tai phat sau ngimg thuoc de dieu tri lai 1.1.3 Theo doi dieu tri: - Tuan thu dieu tri: can tu van cho benh nhan ve loi ich cua viec tuan thu dieu tri va cac bien phap h§ trp tuan thu dieu tri (phuong tien nhac uong thuoc) Thang ddu tien sau bit dau dieu tri: theo doi AST, ALT, creatinine mau Sau mSi 3-6 thang qua trinh dieu tri: theo doi AST, ALT, creatinine mau, HBeAg, Anti-HBe, HBV-DNA, c6 the dinh lupng HBsAg - Neu dieu tri IFN hoac Peg IFN: theo doi cong thuc mau, glucose mau, ure mau, creatinin mau, chuc nang tuyen giap de phat hien tac dung khong mong muon cua thuoc - Sau ngimg dieu tri: + Theo doi cac trieu chung lam sang + Xet nghiem sau moi 3-6 thang: AST, ALT, HBsAg, HBeAg, anti-HBe, HBV DNA de danh gia tai phat - Can danh gia tuan thu dieu tri va tin cay cua xet nghiem HBV DNA trade ket luan that bai dieu tri (Trong truong hop chua lam dupe xet 32 \ z • lai sai Nghien cun cua chung toi thap han nghien cuu Ha Thi Dung [2] danh gia hieu qua tuan thu dieu tri NUC: lam giam ty le tu vong, 95,4% biSt co the giam mac benh xa gan, 81,4% biet co the du phong lay nhiem cho nguoi xung quanh, 66.9% biet co the cai thien tinh trang sue khoe C6 le doi tuang nghien cuu khac nhau, trinh van hoa khac nhau, kien thuc hieu biet i cua nguai benh khac nhau, nen su nhan thuc se khac Chinh vi vay, sau cung cap kien thuc,ty le da tang len dang ke sau can thiep lan luot la 80%, 84% va 90% co y nghia thong ke vai p Z ~ z z z het tac dung co the gap phai dung thuoc dan den sau so uong thuoc, muon bo thuoc Vi vay, chung toi da tu van day du each dung thuoc, tac dung phu cua thuoc co the gap phai va sau can thiep ty le tra lai dung la 100% c6 y nghia thong ke (p