MT S CA LM SNG VI IU TR BNG NSAID

1. CA LM SNG 1 TC DNG KHNG MONG MUN

n thuc khng y
B B, 73 tui, chm tp th thao, c thi quen i b mi tun mt ln. Thnh
thong b phn nn v cn au u gi bn phi, gy kh khn cho vic di
chuyn hng ngy. Do s dng Paracetamol khng gim cn au, b phi
hon chuyn leo ni gn y vi bn b v ti gp bc s iu tr. Sng th by
tun ny, b a cho anh P, l sinh vin trng dc n thuc k Naproxen
550mg (1 vin x 2 ln/ngy) trong 7 ngy. Khi dc s kim tra vic bn thuc ca
P, dc s cm thy khng hi lng.
Liu anh P mc sai st?
Khng. Tuy nhin n thuc ny c v cha y . Da vo tui, b B c
nguy c cao gp tc dng khng mong mun trn ng tiu ha ca NSAID.
PHN TCH CA
* Cc NSAID c th gy ra mt s vn trn ng tiu ha nh au thng v,
bun nn, nn, ri lon nhu ng rut hoc vim thc qun, c bit c th gy
lot d dy, thng d dy rut, thm ch ngi bnh c nguy c t vong do xut
huyt.
* Cc tc dng khng mong mun ny ca NSAID c gii thch bi c ch tc
dng ca chng. S c ch cyclo-oxygenase -1 (COX-1) ca NSAID v gim tng
hp cc protaglandin E1 lm gim lp cht nhy v ion HCO3- ti d dy, cng
nh lm tng tnh thm ca lp cht nhy ng tiu ha, do lm gim yu t
bo v d dy (xem trang 7). S kch ng ny gy bi tit cc cytokin v huy ng
cc bch cu a nhn trung tnh, gy vim, thm ch gy lot lp mng nhy trn
ng tiu ha.
* Nguy c xy ra tc dng khng mong mun nghim trng trn ng tiu ha
cao hn bnh nhn s dng liu cao, c tin s lot d dy, v bnh nhn cao
tui. Cn thn trng khi s dng NSAID cc bnh nhn ny.

* bnh nhn cao tui, ngoi cc trng hp vim khp dng thp cp hay mn
tnh, ch xem xt s dng NSAID khi iu tr tht bi vi paracetamol. Phi bt
u iu tr mc liu thp nht c th v cn bo v d dy bng cc thuc c
ch bm proton 50% liu thng dng vi esomeprazol 20mg/ngy, lansoprazol
15mg/ngy, pantoprazol 20 mg/ngy hay omeprazol liu y 20mg/ngy hoc
bng dn cht ca prostaglandin E1- misoprostol (1/2-1 vin 200ug, 4 ln/ngy)
bnh nhn trn 65 tui.
X TR
* Dc s nn gi in cho bc s ngh thm mt thuc bo v d dy. Thm
vo , dc s cn nhn mnh vi b B v tm quan trng ca vic ung naproxen
trong ba n sng v ba ti, vi mt lng nc trnh dnh thuc vo thnh
thc qun.
* Khi b au thng v hoc cc triu chng khc trn ng tiu ha, cn dng
ngay vic iu tr vi naproxen.
* Ghi nh: Do nguy c cao gy tc dng khng mong mun trn ng tiu ha,
phi bo v d dy bng PPI hoc misoprostol bnh nhn trn 65 tui.
2. CA LM SNG 2 TC DNG KHNG MONG MUN
Mt trng hp au rng
Mt bui ti th su, anh C, 30 tui, cm thy au rng d di. Anh n nh
thuc mua mt loi thuc sc ming st khun v Toprec (ketoprofen). y l
loi thuc m mt ng nghip ca anh t vn v ngi ny khng nh vi anh
rng c th mua thuc ny khng cn n thuc.
C th bn thuc theo yu cu ca anh C.?
Khng. Trong trng hp nhim trng, cc NSAID c nguy c lm lan rng nhim
trng.
PHN TCH CA
* Nhim trng rng ming c th tin trin thnh vim m t bo mt v c. y
l mt nhim khun su, lan rng ti cc m m v c mt, thm ch cc m ti

ng ba hu hng. Nhim trng ny c nguy c gy t vong, bnh c th xy ra c

bnh nhn tr tui, c sc khe tt.
* S dng NSAID khng km khng sinh l yu t nguy c gy vim m t bo
nghim trng. Trn thc t, cc NSAID lm gim au, do c th che lp cc du
hiu tin trin ca p-xe rng. N cng c th lm nng thm tnh trng nhim
trng do lm thay i chc nng ca cc bch cu a nhn trung tnh.
X TR
* Dc s khng bn Toprec cho bnh nhn, ng thi khuyn anh C s dng
paracetamol kt hp codein sau khi m bo khng c chng ch nh vi cc
thuc ny.
* Nhn mnh vi bnh nhn phi n nha s khm rng ngay c sau khi cn au c
thuyn gim. Nu cn au khng thuyn gim nhanh chng, yu cu bnh nhn i
khm bc s c k n khng sinh.
* Ghi nh: Cc NSAID c nguy c lm nhim trng lan rng. c bit i vi
nhim trng rng ming khng c iu tr bng khng sinh, n lm tng nguy c
mc vim m t bo nghim trng mt v c.
3. CA LM SNG 3 TC DNG KHNG MONG MUN
Mt trng hp i tiu ra mu
B A, 4 tui (18kg), ang c iu tr mt bnh vim mn tnh do di truyn bng
colchicin. Gn y, b c ln nhp vin do vim khuu tay tri. Vi chn on
vim khuu tay v khun, b c xut vin vo 2 ngy trc vi ch nh
Voltarne (diclofenac) 25mg dng thuc n, 1 vin vo bui sng v ti, iu tr
ti a trong 5 ngy. Hm nay, m b bo rng phn ca b c ln mu.
Cn ngh g trong trng hp ny?
Sau khi loi tr tng tc gia colchicin v diclofenac, dc s nghi ng b b chy
mu trc trng do NSAID.
PHN TCH CA

* c tnh trn ng tiu ha ca NSAID c th xy ra rut non, rut gi v

trc trng. Cc bin chng trn rut chim 10-40% cc bin chng nghim trng
trn ng tiu ha lin quan ti NSAID. Tc ng trc tip ca NSAID trn
mng nhy ti rut l mt yu t nguy c. Thm vo , bin chng trn trc trng
thng xy ra hn khi iu tr bng cc dng thuc n.
* Thng thng, NSAID gy phn ng vim khng ng k ti trc trng, tuy
nhin cng c th gp cc tn thng nghim trng hn nh lot hoc vim trc
trng xut huyt. Thng, thm ch r trc trng m o cng c ghi nhn
khi iu tr ko di.
* c tnh trn rut kt ch yu xy ra dng thuc ung phng thch ko di.
X TR
* Dc s khuyn m b dng s dng NSAID cho b v a b i khm bc s
nhi.
* Bc s cho ngng iu tr bng diclofenac, thay bng paracetamol ng
ung, tin hnh cy phn loi tr nguyn nhn nhim trng v xt nghim cng
thc mu nh gi tnh trng thiu mu. Nu tip tc chy mu, cn tin hnh
ni soi trc trng.
* Ghi nh: c tnh trn h tiu ha ca NSAID khng ch xy ra d dy m cn
xy ra rut. NSAID dng thuc n c th gy vim trc trng xut huyt. Dng
iu tr ngay khi xy ra bin chng ny.
4. CA LM SNG 4 TC DNG KHNG MONG MUN
Ti sao khng s dng thuc gim au c qung co trn ti vi?
u tun, c H c mua mt n thuc gm famciclovir 500mg v
paracetamol/codein 500mg/30mg c k iu tr zona gian sn cho chng
c. Hm nay, c mun mua mt hp ibuprofen, m c thy qung co trn ti vi. C
gii thch vi dc s rng chng mnh vn cn au nhiu d s dng cc thuc
gim au c k trong n v hi rng dc s ngh th no v thuc gim au
m c thy qung co trn ti vi.

Dc s nn tr li th no?
Khng nn s dng ibuprofen trong trng hp nhim virus gy thy u zona
(VZV).
PHN TCH CA
* Cc NSAID c th lm trm trng thm mt s nhim trng trn da v m mm.
* Trn thc th, theo cc bo co cnh gic dc, cc NSAID c th lm tng nguy
c bin chng nhim trng nh chc l, p-xe di da v vim lot di da (vim
qung, vim m t bo...), thm ch vim cn mc hoi t (bi nhim xm ln do
lin cu v t cu)
* T thng 7 nm 2004, C quan quc gia an ton thuc v cc sn phm v sc
khe ca Php (ANSM) khuyn co khng s dng NSAID iu tr st v au
tr em b thy u.
* Cc d liu ti Php c cng c thm vo nm 2005 bi mt nghin cu ca
Anh c thc hin trn cc tr em b thy u v ngi ln b zona, c iu tr
bng NSAID (90% cc ca c iu tr bng ibuprofen). Nghin cu ny kt lun
rng nguy c mc bnh ngoi da nghim trng trong trng hp thy u v zona
tng ln tng ng l 5 v 1,6 ln sau khi s dng NSAID.
X TR
*Dc s khng bn ibuprofen cho c H v gii thch rng ibuprofen c th lm
nng thm cc vt lot do zona.
* Khuyn bnh nhn i khm li, v trong lc ch i, bnh nhn c th dng gc
m v mt ph trn cc mn rp.
* Ghi nh: Chng ch nh cc NSAID iu tr au v st do nhim virus gy
thy u zona do c th lm trm trng thm cc vt lot ngoi da.
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
* Ngun: Le Moniteur des pharmacies. Les AINS 17 cas cliniques. Cahier 2
n3056 du 22 novembre 2014.
* Dch: SVD5. Nguyn Th Minh Trang, H Dc H Ni