Cp nhp 2013 v iu tr i tho ng ca ADA

TS. H Hunh Quang Tr

Vin Tim TP HCM
[Bacsinoitru.vn] Thng 1/2013 Hip hi i tho ng Hoa K (American Diabetes Association, vit tt ADA) a ra hng dn cp nhp
2013 v iu tr i tho ng (T).1 Trong nm 2012 c mt s hng dn lin quan vi iu tr T c cc chuyn gia Hoa K, Chu
u v Canada a ra gm: Hng dn x tr tng ng huyt trong T tp 2 do ADA v Hip hi Nghin cu T Chu u (European
Association for the Study of Diabetes, vit tt EASD) phi hp bin son, hng dn ca Chu u v phng nga bnh tim mch trong thc
hnh lm sng do Hi Tim mch Chu u (European Society of Cardiology, vit tt ESC) ch tr bin son v hng dn ca Chng trnh
Gio dc Tng huyt p Canada (Canadian Hypertension Education Program, vit tt CHEP). [2-4] Bi vit di y nu ln v phn tch
nhng im mi trong iu tr bnh nhn T tp 2 t cc hng dn ny, tp trung vo ba vn chnh l kim sot ng huyt, kim sot
huyt p v kim sot ri lon lipid mu.

KIM SOT NG HUYT TRONG T TP 2
Hng dn x tr tng ng huyt 2012 ca ADA v EASD ln u tin cp n tip cn ly bnh nhn lm trung tm (patient-centered approach).
[2] Tip cn ly bnh nhn lm trung tm c nh ngha l tip cn nhm cung cp mt s chm sc tn trng v p ng nhng s thch, nhu cu v
gi tr ca tng bnh nhn v m bo l chnh nhng gi tr ca bnh nhn hng dn tt c cc quyt nh lm sng. Trong cch tip cn ny, mc tiu
kim sot ng huyt phi ph hp vi tng c th bnh nhn da trn nhiu yu t: thi v s c gng ca bnh nhn, thi gian mc bnh, trin
vng sng, nguy c h ng huyt, bin chng mch mu, bnh km theo v mc di do ca cc ngun lc. Ty theo cc yu t ny m vic kim
sot ng huyt ca tng bnh nhn s thay i t mc tch cc thp nht (mc tiu HbA1c 7,5-8,0%) n mc tch cc cao nht (mc tiu HbA1c 6,0-
6,5%). Bng 1 tm tt cch la chn mc tch cc ca kim sot ng huyt da vo cc yu t ny tng bnh nhn.

Hng dn x tr tng ng huyt 2012 ca ADA v EASD cng a ra mt qui trnh chung cho vic kim sot ng huyt ca bnh nhn T tp 2.
Trong a s cc trng hp, bn cnh ch n king, c gng gim cn v tng cng vn ng th lc, metformin l thuc c la chn hng u.
Metformin c hiu qu gim HbA1c cao v nguy c h ng huyt nng thp. Thuc khng nh hng n cn nng v r tin. Cc tc dng ngoi ca
metformin gm ri lon tiu ha v toan huyt lactic. Nu dng liu metformin ti u nhng sau 3 thng vn khng t c mc tiu HbA1c th sang
bc k tip l phi hp metformin vi mt thuc th hai: sulfonylurea, thiazolidinedione (TZD), thuc c ch DPP-4, thuc ng vn th th GLP-1
hoc insulin nn. Cc c im chnh ca tng thuc phi hp bc 2 c nu trn bng 2. Nu dng phi hp hai thuc vi liu ti u trong 3
thng m vn cha t mc tiu HbA1c th sang bc 3 l phi hp ba thuc: metformin + sulfonylurea + (TZD hoc c ch DPP-4 hoc ng vn GLP-1
hoc insulin nn), metformin + TZD + (sulfonylurea hoc c ch DPP-4 hoc ng vn GLP-1 hoc insulin nn), metformin + c ch DPP-4 +
(sulfonylurea hoc TZD hoc insulin nn), metformin + ng vn GLP-1 + (sulfonylurea hoc TZD hoc insulin nn) hoc metformin + insulin nn +
(TZD hoc c ch DPP-4 hoc ng vn GLP-1). Nu bc 3 tht bi trong vic kim sot ng huyt th phi chuyn sang ch dng insulin phc
tp vi nhiu ln tim trong ngy. Liu php insulin dnh cho bnh nhn T tp 2 theo hng dn 2012 ca ADA v EASD i t n gin n phc
tp. Insulin nn thng l bc u tin ca liu php insulin. Liu insulin khi u l 0,1-0,2 n v/kg cn nng ty mc tng ng huyt. Insulin
nn thng c dng chung vi mt hoc hai thuc kim sot ng huyt ung. bnh nhn mun tim nhiu hn mt ln mi ngy v c HbA1c cao
( 9,0%), c th xem xt dng insulin trn sn (premixed) tim hai ln/ngy. Khi liu insulin nn c chnh t mt mc ng huyt lc i
chp nhn c nhng HbA1c vn cao hn mc tiu, xem xt phi hp t mt n ba mi tim ng dng insulin tc dng nhanh trc cc ba n vi
insulin nn. Mt gii php khc l chuyn t insulin nn sang insulin trn sn tim hai ln/ngy, v nu tht bi th mi chuyn sang dng insulin tc
dng nhanh trc cc ba n phi hp vi insulin nn. Khi chuyn sang ch dng insulin phc tp th nn ngng cc thuc kch thch tit insulin
ung (sulfonylurea, glinide).

Trong hng dn 2013, cc chuyn gia ca ADA nhc li s cn thit ca vic c th ha mc tiu iu tr. i vi a s bnh nhn T trng thnh
khng c thai, mc tiu HbA1c < 7% l ph hp. Tuy nhin mc tiu HbA1c c th thay i t < 6,5% n < 8% ty theo cc yu t: thi gian b
T, trin vng sng, bnh km theo, bin chng mch mu, nguy c h ng huyt nng.1 Bn cnh mc tiu HbA1c < 7%, ADA cn khuyn co t
mc tiu ng huyt trc n trong khong 70-130 mg/dl (3,9-7,2 mmol/l) v ng huyt sau n (o 1-2 gi sau khi bt u ba n) < 180 mg/dl (10,0
mmol/l) i vi a s bnh nhn T trng thnh khng c thai. ADA khuyn nn kim tra HbA1c t nht 2 ln mi nm cho nhng bnh nhn t
mc tiu iu tr (v c ng huyt c kim sot n nh) v mi qu mt ln cho nhng bnh nhn c thay i iu tr hoc cha t mc tiu iu
tr. Trong hng dn 2013 ca ADA, thuc c la chn hng u (nu khng c chng ch nh v c dung np) cng l metformin. Nu n tr
khng kim sot c ng huyt th phi hp nhiu thuc. Hng dn 2013 ca ADA nu r Nn dng mt tip cn ly bnh nhn lm trung tm
hng dn vic la chn thuc. Nhng vn cn xem xt gm hiu qu, chi ph, tc dng ngoi c th gp, nh hng trn cn nng, bnh km theo,
nguy c h ng huyt nng v thch ca bnh nhn.1
KIM SOT HUYT P TRONG T TP 2
Trong hng dn ca Chu u v phng nga bnh tim mch trong thc hnh lm sng 2012 c mt phn ring ni v mc tiu iu tr i vi bnh
nhn T tp 2. Mc tiu huyt p c a ra l < 140/80 mm Hg.3 Mc tiu huyt p tm trng < 80 mm Hg da trn kt qu ca phn tch di
nhm t nghin cu HOT (Hypertension Optimal Treatment) cho thy trong s nhng bnh nhn tham gia HOT c T, nhnh huyt p tm trng <
80 mm Hg c tn sut bin c tim mch nng thp hn c ngha so vi 2 nhnh huyt p tm trng < 85 mm Hg v < 90 mm Hg.5 V mc tiu huyt
p tm thu, hng dn 2012 ca Chu u cho rng mc < 130 mm Hg c nu ln trong cc hng dn trc y ch da trn chng c dch t hc ch
khng da trn kt qu ca cc th nghim lm sng phn nhm ngu nhin.3 Trong th nghim lm sng ADVANCE (Action in Diabetes and Vascular
disease: preterAx and diamicroN-MR Controlled Evaluation), h huyt p tm thu xung mc trung bnh 135 mm Hg gim c ngha cc bin chng
mch mu ca bnh nhn T tp 2 (so vi nhnh chng c huyt p tm thu trung bnh 141 mm Hg).6 Cn trong th nghim lm sng ACCORD
(Action to Control Cardiovascular Risk in Diabetes), h huyt p tm thu xung < 120 mm Hg khng gim t vong/bin c tim mch nng so vi iu tr
qui c (huyt p tm thu < 140 mm Hg).7 Da trn kt qu ca 2 th nghim lm sng ADVANCE v ACCORD, nhm bin son hng dn 2012 ca
Chu u cho rng mc tiu huyt p tm thu < 140 mm Hg l ph hp.3 Hng dn 2013 ca ADA cng ly mc < 140/80 mm Hg lm mc tiu iu tr
bnh nhn T c tng huyt p. Tuy nhin trong hng dn ny c b sung mt cu: Mc tiu huyt p tm thu thp hn, chng hn < 130 mm Hg,
c th thch hp vi mt s i tng, v d nhng bnh nhn tr, nu c th t mc tiu ny m khng phi tr gi bng mt gnh nng iu tr qu
mc.1 V la chn thuc kim sot huyt p, cc chuyn gia ca ADA khuyn co ch iu tr tng huyt p phi bao gm mt thuc c ch men
chuyn hoc mt thuc chn th th angiotensin (nu bnh nhn khng dung np mt nhm thuc th dng nhm thuc cn li).1 Tuy nhin cc chuyn
gia Canada li phn bit r 2 tnh hung: T c km bnh thn (t s albumin /creatinin nc tiu 2 mg/mmol nam hoc 2,8 mg/mmol n) v
T khng km bnh thn. Trong T c km bnh thn mt thuc c ch men chuyn hoc chn th th angiotensin c khuyn co dng hng u.
Cn trong T khng km bnh thn la chn thuc hng u rng hn, c th dng mt thuc c ch men chuyn, mt thuc chn th th angiotensin,
mt thuc chn canxi dihydropyridine hoc mt thuc li tiu thiazide.4
KIM SOT RI LON LIPID MU TRONG T TP 2
Theo hng dn 2012 ca Chu u, bnh nhn T (tp 1 ln tp 2) c xp vo nhm nguy c cao nu khng c yu t nguy c tim mch khc v
khng c tn thng c quan ch v c xp vo nhm nguy c rt cao nu c t nht mt yu t nguy c tim mch khc v/hoc tn thng c quan
ch (v d albumin niu vi lng). Mc tiu LDL-cholesterol (LDL-C) cn t l < 100 mg/dl i vi bnh nhn nguy c cao v < 70 mg/dl i vi bnh
nhn nguy c rt cao (i vi bnh nhn nguy c rt cao, nu khng t c mc tiu LDL-C < 70 mg/dl th phi h LDL-C t nht 50% so vi tr s
ban u).3 Hng dn 2013 ca ADA cp vn kim sot ri lon lipid mu ca bnh nhn T mt cch chi tit hn. Th nht, v mt tm sot,
hng dn ny khuyn nn kim tra dung mo lipid mu lc i t nht mt ln mi nm cho a s bnh nhn T trng thnh. Ring nhng bnh
nhn T trng thnh c dung mo lipid mu phn nh nguy c thp (LDL-C < 100 mg/dl, HDL-C > 50 mg/dl v TG < 150 mg/dl), c th kim tra lp
li mi 2 nm. Cc khuyn co v bin php iu tr v mc tiu iu tr c nu trn bng 3.
Bng 3: Khuyn co iu tr ri lon lipid mu bnh nhn T theo ADA 2013
- Thay i li sng tp trung vo vic gim m bo ha, m dng trans v cholesterol v tng lng axt bo n-3, cht si nhy v stanol/sterol thc vt
trong khu phn n; gim cn (nu c ch nh); v tng vn ng th lc c khuyn co nhm ci thin dung mo lipid mu ca bnh nhn T,
(mc chng c A)
- ng thi vi thay i li sng, nn dng statin bt k mc lipid ban u cho nhng bnh nhn T: C bnh tim mch (A) Khng c bnh tim mch
nhng tui trn 40 v c t nht mt yu t nguy c tim mch khc (tin s gia nh mc bnh tim sm, tng huyt p, ht thuc, ri lon lipid mu hoc
albumin niu) (A)
- i vi nhng bnh nhn nguy c thp hn (khng c bnh tim mch v tui di 40), xem xt dng statin ng thi vi thay i li sng nu LDL-C
vn cao hn 100 mg/dl. (C)
- ngi khng c bnh tim mch, mc tiu LDL-C l < 100 mg/dl (2,6 mmol/l) (B)
- ngi c bnh tim mch, mc tiu LDL-C l < 70 mg/dl (1,8 mmol/l), vi statin liu cao l mt la chn. (B)
- Nu bnh nhn c iu tr bng thuc khng t cc mc tiu ni trn d dng liu statin ti a c th dung np c, c th chn mt mc tiu
iu tr khc l h LDL-C khong 30-40% so vi ban u. (B)
- TG < 150 mg/dl (1,7 mmol/l) v HDL-C > 40 mg/dl (1,0 mmol/l) nam v > 50 mg/dl (1,3 mmol/l) n l nhng tr s c mong mun (C). Tuy
nhin liu php statin nhm t mc tiu LDL-C l chin lc c a chung hn. (A)
- Khng c chng c l phi hp thuc c li v mt tim mch hn so vi n tr bng statin v do phi hp thuc ni chung khng c khuyn co.
(A)- Statin chng ch nh trong thai k. (B)
Ni tm li, trong cc hng dn mi v iu tr bnh nhn T tp 2 c mt s im ng lu nh sau. V mt kim sot ng huyt, tip cn ly
bnh nhn lm trung tm c nhn mnh. Mc tiu HbA1c khng cng nhc m c th uyn chuyn ph thuc vo nhiu yu t v thay i t 6,0-6,5%
n 7,5-8,0%. Metformin vn c xem l thuc dng hng u kim sot ng huyt, tuy nhin c rt nhiu thuc c th dng bc 2. Cc thuc
mi nh c ch DPP-4 v ng vn th th GLP-1 cng c xp ngang hng vi cc thuc c t lu nh sulfonylurea v TZD. Vic la chn thuc
ty thuc nhiu yu t, trong c thch ca ngi bnh. V mt kim sot huyt p, mc tiu huyt p tm thu l < 140 mm Hg thay v < 130 mm Hg
nh trong cc hng dn trc y. Mc tiu huyt p tm thu < 140 mm Hg ph hp hn vi chng c c rt ra t cc nghin cu ADVANCE v
ACCORD. V mt kim sot ri lon lipid mu, vic t mc tiu LDL-C c xem l u tin hng u v statin l nhm thuc ch lc. V khng c
chng c l phi hp thuc gim hn na cc bin c tim mch nng so vi statin n tr, vic phi hp thm mt thuc h lipid mu khc (nh fibrate,
niacin) trn nn statin ni chung khng c khuyn co.
TI LIU THAM KHO
1. American Diabetes Association. Standards of medical care in diabetes 2013. Diabetes Care 2013;36 (suppl1):S11-S66.
2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes : A patient-centered approach. Position statement
of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364-1379.
3. Perk J, De Backer G, Gohlke H, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth
Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by
representatives of nine societies and by invited experts). Eur Heart J 2012;doi:10.1093/eurheartj/ehs092.
4. 2012 Canadian Hypertension Education Program Recommendations. Part 2: Recommendations for hypertension
treatment.http://www.hypertension.ca
5. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension:
principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998;351:1755-1762.
6. ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes
in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007;370:829-840.
7. ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-1585.