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GLUCOCORTICOID
LM DNG V X TR CC BIN CHNG CAI

BS. TRN HU HIN


CAO HC NI 2014 2016
HYK PHM NGC THCH

NI DUNG

Lch s thuc corticocoid

Cu trc tuyn thng thn

Trc h i tuyn yn tuyn thng thn

C ch tc ng, cu trc, liu tng ng ca corticoid

Tc dng ca glucocorticoid

Ch nh ca glucocorticoid

Tc dng ph ca glucocorticoid

Km pht trin tr em do GC

Long xng do GC

Cai GC

LCH S THUC CORTICOID


1855 Bnh Addison
1856 Vai tr ca tuyn thng thn cho s sinh tn
1930 Cu trc tuyn thng thn
1932 Hi chng Cushing
1949 Hench v cng s (s dng corticoid trong vim
khp dng thp)

1952 Pht hin ra aldosterone

Cu trc tuyn
thng thn

Widmaier EP, Raff H, Strang KT:


Vander's Human Physiology: The
Mechanisms of Body Function, 11th
ed. McGraw-Hill, 2008

Trc h i
tuyn yn
tuyn thng
thn

J. Larry Jameson, editor.


Harrisons Endocrinology.
2nd Edition. 2010

C CH TC NG CA CORTICOID

Qu trnh
sinh tng
hp
glucocorti
coid

Dao ng nng ACTH v glucocorticoid


(11-OHCS) trong huyt tng c ngy

J Clin Endocrinol Metab.1971;32:266

Tc dng ca glucocorticoid: c ch min dch v khng vim

Goodman And Gilman's The Pharmacological Basis of Therapeutics 12th edition

C ch khng vim ca corticoid

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Tc dng ca glucocorticoid:
chuyn ha

- ngoi bin: gim s dng glucose, lm tng thoi ha


protein ( c) v lipid (m m) lc i.
- gan: to glucose t acid amin v glycerol, chuyn
glucose thnh glycogen.
- Tng d tr m v ti phn phi m khng ng u: m
tch t xng n, sau c v mt lm mt bnh nhn y
n nh mt trng trn (moon face) nhng li mt m chi.

- Tng gi Na+v nc, tng bi tit K+ (th th


mineralcorticoid) v tng lc cu thn, c ch tng hp v
bi tit vasopressin lm tng bi tit mui v nc qua thn
(th th GC)

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

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Dc lc v liu tng ng cc thuc corticoid

12

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

13

CH NH DNG
GLUCOCORTICOID

iu tr thay th khi thiu hormone

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Suy

v thng thn mn tnh (nguyn pht v th


pht)

Suy

v thng thn cp tnh

Tng

sn v thng thn bm sinh

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

iu tr vim
Vim

khp dng thp

Lupus
Hi

ban h thng

chng thn h

Hen

ph qun

COPD

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

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iu tr nhim khun
Vim

phi do Pneumocystis carinii trong bnh AIDS

Vim

mng no do Haemophilus influenza loi B

Vim

gan virus

Tng

bch cu n nhn do nhim khun

Sc

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nhim trng

Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

Bnh c tnh

Bnh Hodgkin

Bnh bch cu cp dong lymph

a u ty

U no nguyn pht

Nn do ha tr

Ph no do di cn

Bnh gim tiu cu

Ph hy hng cu t min

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Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

Cc bnh khc

Sc phn v

My ay

Bnh huyt thanh

Vim lot i trng

Bnh Crohn

Bnh u ht

Bnh v da v mt

Bnh vim a c

Tn thng ct sng v t qu

Chng thi ghp c quan

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Goodman And Gilman's The Pharmacological Basis of Therapeutics 11th edition

TC DNG PH CA GC

Suy gim min dch

Tng ng huyt do tng gluconeogenesis, khng insulin v dung np


glucose ("i tho ng steroid"); thn trng nhng ngi c bnh i
tho ng

Mng da, d bm tm

Gim canxi do gim hp thu canxi rut*

Long xng do steroid: gim mt xng (long xng, hoi t


xng, nguy c gy xng cao hn, lnh xng chm hn)

*Br J Rheumatol. 1993 May;32 Suppl 2:11-4

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TC DNG PH CA GC

Tng cn do tng lng ng cht bo tng v thn ngi (bo ph) v


kch thch s thm n

Tng cortisol mu vi vic s dng ko di v / hoc qu nhiu (cn c


gi l hi chng Cushing ngoi sinh)

Suy gim tr nh v s ch *

Suy thng thn (nu s dng trong thi gian di v dng li t ngt m
khng gim liu)

Thoi ha c (phn gii protein), yu c, gim khi lng c bp v sa


cha

U m (lipomatosis) trong khoang ngoi mng cng**


*Neurology 47 (6): 1396402 **Endocrinol. Metab. 11 (3): 8690

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TC DNG PH CA GC

Kch thch h thn kinh trung ng (hng phn, ri lon tm thn)

Ri lon chu k kinh nguyt

Chm tng trng, chm dy th

Tng axit amin huyt tng, tng hnh thnh ur, gim nit

Tng nhn p do tng p lc nhn cu

c thy tinh th

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KM PHT TRIN TR EM DO GC

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TM VC THP (SHORT STATURE)


TR EM

C ch: c ch tc dng pht trin xng v


sn ca somatomedin

Khc phc:

Hn ch k n glucocorticoid cho tr em

Ch dung liu thp trong thi gian ngn

Nu phi dung ko di th dng liu cao, cch


ngy thay th liu hng ngy gim r rt cc
tc dng ph tr*

*Endocrinol Metab Clin North Am. 1996 Sep;25(3):699-717.

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nh hng n pht trin no b


Dng glucocorticoid (GC) nhiu ln ca m lc mang
thai lm tng nguy c sinh non, nh hng xu n
tng trng thai nhi v gim chu vi vng u.

Acta Paediatr. 2011 Mar;100(3):364-9

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nh hng n pht trin no b


Thai nhi tip xc nhiu vi GC
trong giai on pht trin quan
trng ca no c th lm thay
i h vin (ch yu l vng hi
m - hippocampus), dn n
nh hng lu di i vi nhn
thc, hnh vi, b nh, s phi
hp ca h thng thn kinh
thc vt.

Korean J Pediatr. Mar 2014; 57(3): 101109.

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nh hng n pht trin no b

iu tr GC sau sinh cho bnh phi mn tnh tr non, c bit l


dexamethasone, c chng minh l gy ra s suy gim pht trin
thn kinh v lm tng nguy c mc bnh bi no.*

Ngc li vi nhng nghin cu lin quan n dexamethasone sau khi


sinh, cc nghin cu theo di di hn cho iu tr hydrocortisone khng
tit l nh hng xu n kt qu pht trin thn kinh.**

Nh vy, da trn cc nghin cu lm sng v thc nghim, c bng


chng khuyn thn trng vic s dng GC trong giai on chu sinh

*Neonatology. 2010;98(4):289-96. **J Pediatr. 2007 Apr;150(4):351-7.


Korean J Pediatr. Mar 2014; 57(3): 101109.

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LONG XNG DO GC

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C CH LONG XNG DO GC

Glucocorticoid tng ti hp
thu xng, lm gim s
hnh thnh xng, lm gim
hp thu canxi rut, thn
v lm tng bi tit canxi.

iu tr glucocorticoid c
lin quan nguy c ng k
cho s mt xng, gy
xng v gy xng xy ra
cc gi tr mt cht
khong trong xng cao
hn xy ra sau mn kinh
b long xng.

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NH GI LONG XNG DO GC

Cc nguy c gy xng c bo co: prednisone vi liu 2,5-7,5 mg


(dng hng ngy) hoc tng ng vi liu ny.*

Lm sng: long xng do GC cng ging nh cc nguyn nhn khc


ca bnh long xng. Thng thng, khng c biu hin lm sng cho
n khi c mt vt nt.

Bt c bnh nhn dng bt c liu glucocorticoid vi thi gian 3 thng


cn nh gi

nh gi cc yu t nguy c lm sng cho gy xng

Mt khong xng (DXA) ca hng v ct sng

o nng 25-hydroxyvitamin D
*J Bone Miner Res. 2001 Jan;16(1):104-12.

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D PHNG LONG XNG DO GC

Liu v thi gian iu tr GC cng thp v cng ngn cng tt, bi v


ngay c liu thay th c th gy ra mt xng.

Bnh nhn cn c khuyn khch cc bi tp chu trng ti chng li


s mt xng v teo c.

Bnh nhn nn trnh ht thuc, ung ru qu mc v c bin php


ngn nga t ng.

i vi bnh iu tr GC ko di vi thi gian 3 thng, nn b sung


canxi v vitamin D: 1.200 mg canxi nguyn t hng ngy, tng cng ch
n ung b sung, v 800 IU vitamin D mi ngy.*

*Arthritis Care Res (Hoboken). 2010 Nov;62(11):1515-26

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LA CHN THUC IU TR
LONG XNG DO GC

i vi nam gii v ph n sau mn kinh, la ch hng u


l bisphosphonates.

Nn chn alendronate* hoc risedronate** ung mi tun.


Cc d liu th nghim lm sng chng minh hiu qu ph
n v nam gii ca hai thuc ny so vi cc bisphosphonates
khc .

Axit zoledronic tim tnh mch l la chn cho bnh nhn


khng dung np c bisphosphonates ung
*J Rheumatol. 2009 Aug;36(8):1705-14 **Arthritis Rheum. 1999 Nov;42(11):2309-18.

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LA CHN THUC IU TR
LONG XNG DO GC

Hormone cn gip khng l thuc la chn u tay iu tr hoc


phng nga bnh long xng do glucocorticoid v chi ph cao v s sn
c ca cc thuc khc.

Estrogen khng cn c coi l mt loi thuc hng u phng chng


long xng sau mn kinh. Bi v:

Cc th nghim lm sng ph n sau mn kinh cho thy s dng lu di


kt hp estrogen-progestin ung khng lm gim nguy c bnh mch vnh
nh c mong i da trn cc nghin cu quan st.*

Ngoi ra, liu php phi hp lm tng nguy c ung th v, t qu, v huyt
khi tnh mch.
*JAMA. 2002 Jul 17;288(3):321-33.

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CAI GLUCOCORTICOID

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NH GI TRC H I TUYN YN TUYN


THNG THN (HPA) BNH NHN IU TR
GC

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TIU CHUN NH GI BNH NHN


C KH NNG SUY GIM TRC HPA
Bt

c ai nhn c mt liu
glucocorticoid tng ng vi hn 20 mg
prednisone mt ngy trong hn ba tun

Bt

c ai nhn c mt liu bui ti /


trc i ng prednisone trong mt vi tun

Bt

k bnh nhn c xut hin dng Cushing

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CC YU T CN NH GI KHI
CAI GC

Cc yu t tui tc, bnh ng pht,


mc nguy him v kh nng bng
pht ca bnh nn

Cc bnh phi n nh gim liu dn


n liu thch hp

Cc yu t tm l

Nu thi gian dung thuc di 3 tun


c th ngng t ngt

Dng liu thp nhng ko di nhiu


thng vn phi gim liu trc khi
ngng

Ann Intern Med. 1976 Mar;84(3):304-15.

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CH NH CAI GC

Tc dng ph, chng hn nh bnh long xng ct sng tht lng hoc
tng huyt p, tr nn nghim trng hoc khng kim sot c bng
thuc

Hai bin chng cn ngng GC hoc gim vi liu sinh l, ch khng gim
dn:

Lon tm thn cp tnh do GC khng p ng vi thuc chng lon thn

Herpesvirus gy ra vim lot gic mc, c th nhanh chng dn thng gic


mc v m la vnh vin

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CH GIM LIU GC

5-10 mg / ngy mi 1-2 tun t mt liu ban u trn 40 mg


prednisone hoc tng ng cho mi ngy.

5 mg / ngy mi 1-2 tun liu prednisone gia 40 v 20 mg /


ngy.

2,5 mg / ngy mi 2-3 tun liu prednisone gia 20 v 10 mg /


ngy.

1 mg / ngy mi 2-4 tun liu prednisone gia 10 v 5 mg /


ngy.

0,5 mg / ngy mi 2-4 tun liu prednisone t 5 mg / ngy


xung.

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SO SNH GIM LIU PREDNISOLONE


KO DI V GIN ON TR EM MC
HC THN H

Mt th nghim nh gi 46 tr em b hi chng thn h v c iu tr vi liu cao


prednisolone (60 mg /m2 mi ngy)

Gim liu dn c thc hin hn tm tun hoc nm thng.

29 tr trong nhm gim liu ngn nhn 60 mg / m2 mi ngy trong bn tun, tip theo
l 40 mg / m2 mi ngy ba ngy mt tun trong bn tun. Prednisolone sau b
dng.

17 tr trong nhm gim liu di nhn c 60 mg / m2 mi ngy trong bn tun, 60


mg / m2 mi ngy cch ngy trong bn tun, sau gim dn bng 10 mg / m2 mi ngy
mi bn tun qua nm thng.

Kt qu: s bnh nhn b ti pht vi cc hi chng thn h trong vng su thng sau
khi gim liu cao hn ng k nhm gim liu nhanh chng.
J Pediatr. 1988 Jan;112(1):122-6.

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GII QUYT TI PHT BNH


NN KHI GIM LIU GC

Bnh nhn b bnh thp khp c th phn nn v cc triu chng ti pht


ca bn khi gim liu GC

Cn phn bit gia cc triu chng cai GC (tc l, au khp v au c


hay gi thp khp - pseudorheumatism) hoc l ti pht ca bnh thp
khp

Nu cc triu chng khng nng, i 7-10 ngy, v s dng mt loi thuc


khng vim khng steroid hoc thuc gim au khc. Gii quyt ca cc triu
chng trong thi gian ny cho thy l pseudorheumatism.

Nu cc triu chng khng gim dn trong khong thi gian ny, cn tng liu
prednisone 10-15 phn trm v duy tr liu 2-4 tun.

Sau khi cc triu chng ti pht c gii quyt, cn tip tc li ch gim


liu

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GII QUYT TI PHT BNH


NN KHI GIM LIU GC

Nu xut hin cc trng hp cp tnh (nh ti pht cp tnh ca vim


thn lupus, tn huyt nng, vim a c cp tnh, hoc vim mch) cn
dng li liu ban u, liu cao nht ca GC c th thc hin.

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THANK YOU SO MUCH

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