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DIEU TRi BIEN CHIJfNG BENH DTD ■ ■ BIEN CHLfNG MAN TINH Cac benh tang huyet ap, tac mach mau cl chi du6i, nhoi mau cO tim, roi loan md mau khong phai la bien chiing triic tiep cua benh DTD song lai la nhiing benh hay gap d ngUdi DTD va lam cho tien liidng cua benh DTD trd nen xau hdn nhieu lan (khoang 80% so" ngUdi m&c DTD cl cac nUdc phat trien tu vong vi cac benh tim-mach) Bien chiing dac trUng cua benh DTD bao gom 1) benh ly vong mac DTD; 2) benh cau than DTD; 3) benh than kinh DTD la nhiing benh ly lien quan den ton thiidng mach mau nho Benh vong m ac DTD Benh vong mac DTD la nguyen nhan gay mu hang dau d ngiidi 16n tii 20-74 tuoi Tai thdi diem mdi diidc chan doan da cd tii 10-20% so" ngiidi mac DTD typ cd benh ly vong mac DTD Sau 20 nam mac benh, hau het benh nhan DTD typ va khoang 60% benh www.daithaoduong.vn ♦ 93 nhan DTD typ co benh ly vdng mac DTD [Donald S Fong, MD, MPH, (2003), “Diabetic Retinopathy”, Diabetes Care, Volume 26, Supplement 1, 99-101.] Dieu tri sdm va tich ctfc benh DTD co the giam duoc nguy cO benh ly vong mac DTD ttf 62-86% benh nhan DTD typ va giam dtfdc 25% bien chiing mach mau nho d benh nhan DTD typ [Donald S Fong, MD, MPH, (2003), “Diabetic Retinopathy", Diabetes Care, Volume 26, Supplement 1, 99-101.] Benh khong co trieu chtfng d giai doan dau, ca thi ltfc v ln binh thudng hoac khong co bieu hien gi dac biet soi gtfdng khong cd nghia la mat van “binh thtfdng”, vay cac kham nghiem mat can phai thtfc hien deu dan (6-12 thang/lan) Nhiing roi loan thi ltfc dau tien bieu hien bang nhin md hoac thay “ruoi bay” Phan loai theo cac giai doan: - Giai doan dau: vi phinh mach, phu gai, xuat tiet nhe O giai doan thi lUc hau nhii khong bi anh hudng - Benh vong mac tien tang sinh: vung thieu mau, chay mau lan toa, xuat tiet mach, o nhii “dam bong” - Benh vong mac tang sinh: tan tao mach mau, chay mau dich klnh, bong vong mac Thi ltfc giam nhanh chong, neu xuat huyet nhieu lan cd the dan den mu hoan toan Trong vdng nam sau phat hien cd benh vdng mac tang sinh: 43% benh nhan DTD typ va 60% benh nhan DTD typ se bi mu 94 ♦ Dieu tri benh ly vdng mac: Quan ly dudng mau va md mau tot (HbAlc < 6,5%) lam cham xuat hien to’n thudng vong mac DTD Vdi ngUdi dudng mau tang cao lau va cd bieu hien benh ly vong mac phai dua dUdng mau ve binh thUdng mot cach tii tii (sau 1-2 thang), neu lam giam dUdng mau qua nhanh se lam nang len benh vong mac DTD Dieu tri tang huyet ap tich cUc 500mg/ngay: giam triglycerid la 52% va tang HDL 23% - Tac dung phu gay b§nh ly cd va hinh soi mat, thuoc lam tang nguy cd suy than; vi vay nhom dtfdc khuyen cao khong dung cho ngtfdi dai thao dtfdng co benh ly than hoac giam chtfc nang than * Acid nicotinic (niacin) Niacin co tac dung len tat ca cac hinh thai cua liporotein: Giam LDL, VLDL va triglycerid lam tang nong HDL - Tac dung phu: gay da di tfng, roi loan chtfng nang gan, tang acid uric lam tang nguy cd cua benh gout, tang nong dtfdng mau * Estrogen: Vai trd cua estrogen ngan ngtfa benh ly mach vanh chtfa co dtfdc stf danh gia thong nhat Estrogen co the ddn tri lieu hoac ket hdp vdi progestin Nhtfng estrogen co the lam tang triglycerid, nen ngtfdi ta khong chi dinh cho ngtfdi benh co tang triglycerid * Lieu phap ket hcfp: - Che dinh dtfdng www.daithaoduong.vn ♦ 213 Che an luon co vi tri quan lam giam can nang - Ket hdp thuoc: Nhom statin va fibrat thtfdng dtfdc chon neu ddn tri lieu it ket qua Tuy nhien phai het stfc than tac dung khong mong muon len cd va nhiem doc gan Sa xit tri 214 ♦ B an g 21: M uc dich dieu tri cho ngitdi ddi thao ditdng co roi loan chuyen hoa lipid Muc dich toi thieu Ly tirting Toan phan < 200m g/dl (5,2mmol/l) * 170mg/dl (4,4mmol/l) LDL < 130mg/dl (3,4mmol/l) a lOOmg/dl (2,6mmol/l) TC khong < 160mg/dl (4,1) a 130mg/dl (3,4mmoI/l) Cholesterol HDL www.daithaoduong.vn *2 VAN OE BENH LY TAM THAN NGUdl OAI THAO O l/dN G Khi dtfdc phat hien m&c benh dai thao dtfdng, ngtfdi benh thtfdng co dau hieu tam than buon chan Nhieu ngtfdi cl vao trang thai soc hoac tram cam Nhieu nghien ctfu cl tre bi m ic benh dai thao dtfdng cho thay tinh trang roi loan tam than cl benh nhi va cha me cac chau chi trd lai binh thtfdng sau nam Nhtfng trtfdng hdp keo dai tren nam buoc phai co bien phap can thiep * Cac yeu to nguyen nhan gay roi loan tam than luc chan doan: - Lo lang ve tinh hinh benh tat hien tai - Cam thay nhtf bi toi loi va/ hoac ttfc gian biet bi dai thao dtfdng - Cam thay bat tai, bat ltfc trtfdc benh tat (lo khong co kha nang quan ly, dieu tri benh) - Lo sd ve cac bien chtfng ttfdng lai va chet sdm 216 ♦ - Mat muc dich song, khat vong song benh tat - Lo ling ve ttfdng lai khong dtfdc dam bao chac chan - Thtfa nhan stf thay doi phtfdng thtfc song la vinh vien hau qua cua benh dai thao dtfdng * De tien hanh dieu tri co hieu qua, can lam mot so viec: - Thao luan vdi ngtfdi benh va gia dinh ho (bo", me hoac vd, chong) ve ke hoach giao due va dieu tri cho ngtfdi benh dai thao dtfdng - Thanh lap cac doi cong tac de quan ly benh vait ro cua ngtfdi thay thuoc chuyen khoa la rat quan Ho phai la ngtfdi dieu hoa cac chuyen nganh khac nhtf dinh dtfdng, tam than, dieu dtfdng - Dat van de giao due la muc dich chinh cho ngtfdi benh dai thao dtfdng de ngtfdi benh phai ttf hoc hoi, ttf xac dinh, tim cho minh mot htfdng di thich hdp - Phai chu y toan dien den giao due che an, loai bo thdi quen co hai (nhtf uong rtfdu, hut thuoc la, cac roi loan ve an, uong ) theo chien ltfdc dtfdi day: Cf g sd - Tao dieu kien thuan tien cho cong viec dtfdc giao - Thdi gian lam viec cang uyen chuyen cang tot - Thtfdng co ngtfdi nhac nhd cong viec - Cd ke hoach lam viec cang chi tiet, ti mi cang tot www.daithaoduong.vn *217 D oi quan ly benh ddi thao diidng - Co moi lien he chat che gitfa ngtfdi benh va doi quan ly benh dai thao dtfdng - Tim hieu nhtfng dieu ngtfdi benh hy vong - Thao luan vdi ngtfdi benh ve nhtfng dieu ho nen hy vong - Trang bi cho ngtfdi benh nhtfng kien thtfc cd ban dac biet - Tranh dung nhieu thuat ngtf chuyen mon - Khich le ngtfdi benh noi nhtfng quan diem cua ho, de ho dat nhtfng cau hoi - Khich le ngtfdi benh tap trung phoi hdp hanh dong v6i thay thuoc Che do• sinh h oat • vd lam viec • - Loi cuon ngtfdi benh va gia dinh ho vao ke hoach hanh dong - De ngtfdi benh thao luan can nh&c cung thay thuoc lap ke hoach va xac dinh muc dich dieu tri va che dieu tri - Giam gia va han che den mtfc thap nhat cac phtfc tap co the lam dtfdc (gia thap, ddn gian nhat ve che an, luyen tap va thuoc) - Thich tfng che cho ngtfdi benh va gia dinh ho ve cac mat: loi song, van hoa, tai chinh 218 ♦ Chien liicfc gia o due - Phd bien cac kien thiic ve dai thao diidng va thiidng xuyen bo sung kien thiic mdi, ky thuat mdi - Nen viet cac tai lieu ro rang, de hieu Chien liicfc ve hanh vi doi xit - Khuyen khich ngtfdi benh hdp tac vdi thay thuoc va ttf theo ddi quan ly benh tat cua minh - Thiet lap muc tieu quan ly dtfdng mau cho doi ttfdng - Khuyen khich gia dinh va cong dong tham gia thay doi hanh vi cua ngtfdi benh, giup ngtfdi benh ttf phan dau dat den muc dich dieu tri - Htfdng dan ngtfdi benh biet sii dung cac phtfdng tien theo ddi dtfdng mau, biet cach ghi chep nhtfng thong sd" cd lien quan den van de dtfdng mau Cac bien chiing cua ddi thao dudng co roi loan tam than * Cac bien chiing xay tiic thdi: - Tinh trang nhiem toan ceton - Ha dtfdng mau nang * Cac bien chiing keo ddi: Giong nhtf ngtfdi bi dai thao dtfdng khac, cac bien chtfng cd the la benh ly ve mat, than hoac than kinh; cd dieu stf can thiep kho khan hdn tinh trang tam than khong on dinh cua ngtfdi benh, ddi hoi thav thuoc va gia dinh ngUdi benh ton nhieu cong stfc hdn www.daithaoduong.vn ♦ 219 Stress vd ddi thao ditdng Ngiidi ta chtfa ro moi lien he giiia cac stress va stf xuat hien benh Nhiing cac stress co tac dung trtfc tiep len ngtfdi benh thi da dtfdc thtfa nhan, vi du cac stress lam giam kha nang theo doi benh, stress lam ngtfdi benh chan ddi, an uong that thtfdng, tham chi tang uong rtfdu de giai sau Nhtfng hanh vi khong chi lam tinh trang quan ly dtfdng mau kem di, ma lam tram them cac bien chtfng khac neu co 220 ♦ M U C LUC Ltii tiCa Dinh nghia Phan lo a i Ddi thao dieting (DTD) typ .7 Ddi thao dieting typ vo can Ddi thao dieting typ 11 Cac loai ddi thao dieting khac .16 Ddi thao dieting co th a i 18 Mot so yeu to nguy cd anh hudng den kha nang mac benh DTD 21 Ngudi mdc benh DTD co nen sinh con? 25 Phdng ngiea vd p h a t hien sdm benh D T D 29 Trieu chung benh D T D 35 Chan doan benh D TD 36 Dieu tri benh DTD 41 Che an dieu tri benh D TD 41 Mot so mau thUc ddn cho ngietii DTD 58 www.daithaoduong.vn ♦ 221 Van dong the liic 73 Thuoc uong dieu tri benh DTD 83 Thuoc lam cham hdp thu diidng 83 Nhom Biguanide 83 Sulfamide diicfng huyet 86 Thuoc kich thich tiet insulin khong phai sulfamid 88 Nhom thiazolidinediones (glitazone) 89 Byetta - mot loai thuoc mdi dieu tri benh ddi thao diidng typ 90 Dieu tri bien chung benh D T D .93 Bien chiing man tinh 93 Benh vong mac DTD .93 Due thuy tinh th e 95 Tang nhan dp 97 Ton thiiefng day than kinh vd cd m at 97 Benh than DTD 98 Benh than kinh DTD 104 Benh ly ban chan DTD 107 Roi loan cUdng dudng d ngudi D T D 109 Tang huyet dp vd DTD 113 Bien chiing cap tinh 126 Ha diidng huyet d benh nhan D T D 126 Hdn me tang diidng huyet 131 Insulin dieu tri benh D T D 136 Khdi niem chung 136 222 ♦ Ai can dtfdc dieu tri bang insulin .137 Nguon goc cac loai insulin dtfdc sti dung dieu tri DTD 141 Cac cach tiem insulin 150 Ky thuat tiem insulin 154 Nguyen tac cd ban dediiu chinh lieu insulin 165 Bao quan insulin .166 Tii dieting mau vd ttf kiem soat benh 171 Quan ly DTD thai (PGS.TS Ta Van Binh) 178 Hoi chtfng chuyen hoa (PGS.TS Ta Van Binh) 196 Nhtfng van de cd ban ve rdi loan chuyen hoa lipid (PGS.TS Ta Van Binh) 208 Van de benh ly tam than d ngtfdi DTD (PGS.TS Ta Van Binh) 216 www.daithaoduong.vn ♦ 223 NHA XUAT BAN Y HOC Oja chi: D o i C a n , B a D in h , H a N oi 0T: 04 Fax: Email: x u a tb a n y h o c @ fp t.v n Chi nhanh HCM: 9 T n H u n g D a o , P , Q O T : (0 ) Phong va dieu tri benh dai thao fluting C H IU T R A C H N H IE M X U A T B A N : Giam doc: DS Hoang Trong Quang B IE N T A P : BS Nguyen Huy Cirong SLTA B A N IN: BS Nguyen Huy Cixong T R IN H B A Y B iA : Starbooks In 0 c u o n kho x tai C o n g ty in S a o V ie t so d a n g ky k e h o a c h x u a t b a n 3 - 0 /C X B /4 - /Y H in x o n g v a lop lull c h ie u Q u y n a m 0 TIM D O C B E N H O A I T H A O DUONG n PHONG Ww H| IjMI BAI THAO BUONG p'? 'f Nttt xuit ban Y hoc ... insulin ttfc thi (mmol/1) tiem tinh mach 30 0-4 00 (16, 7 -2 2 ,2) Toe truyen - ddn vi/gid 40 0-5 00 (2 2 -2 1,8) ddn vi ddn vi/gid > 500 (27 ,8) 12 ddn vi ddn vi/gid 134 ♦ - Neu dtfdng mau khong giam > 10% sau... nhtfng ngtfdi thtfa can va beo phi Thiia can BMI 2 3 -2 4,9kg/m2 B eo p h i > 25 kg/m2 Do > 2 5 -2 9,9kg/m2 Do > 30kg/m2 [BMI = can nang (kg)/chieu cao2 (m2)] B eo bung vong bung >90cm d nam gidi, >80cm... lOOOml/gid - ALTMTT 3-8 cm H20: 500ml/gid - ALTMTT 8-1 2cm H20: 25 0mygid o Can bang dien giai: - Na+ : khung canh bu ntfdc (xem tren) - Bu K+ K+ < 5mmol/l: K+ < 3mmol/l: 20 mmol/gid K+ 3-4 mmol/l: