TAP CHJ KHOA HOC DAI HQC VAN LANG Hujinh Nguyen Thiiy Trang
TUAN THU Slf DUNG THUOC CUA BENH IVHAN BI ROI LOAN LIPID HUYET
STUDY OF MEDICATION ADHERENCE OF DYSLIPIDEMIA PATIENT HUYNH NGUYEN THUY TRANG<') TOM TAT: Mac dii dugc ke dan rdng rai ede logi thude hg lipid hiiu qud cao, mpt phdn l&n ddn s6 ed gid trf lipid huyet khong dgt mue tieu. Thdt bpi diiu tri duge cho la do nhiiu nguyen nhdn khde nhau, nhung diiu quan trpng nhdt ed le la viee tudn thu kem v&i ehi dp diing thudc la mpt yiu td chinh trong viic thiu thanh edng trong diiu trj tdng lipid mdu. Bdi viit cung edp tdng quan vi vdn di quan trpng ndy, tpp trung vdo vai trd cua binh nhdn trong viec xdc dfnh miic dp tudn thu diiu trj hg lipid huyit.
Tir khda: tudn thit sir dyng thude; tudn ihu thudc; diiu trj rdi logn lipid huyit
ABSTRACT: Despite the widespread prescription of highly effective lipid-lowering medications, a large portion of the population has lipid levels higher than the recommended goals. Treatment failures have been attributed to a variety of causes but the most importance is likely to be poor
adherence to a medication regimen, this is a major factor in the lack of success in treating hyperlipidaemia. The article provides an overview of ths critical issue, focusing on patient role in determining adherence level to lipid-lowering treatment.
Key words: medication using adherence; medication adherence; dyslipidemia treatment.
LDATVANDE
Thudc hg lipid huylt van dugc sir dung rpng rii, mic dii cd bing chiing thuyet phuc vd hi?u qua ciia chiing trong dilu tii va phdng ngira b?nh tim mach. Thit bai didu tii cd the la tuan thii dilu tii kem nhu dung thudc khdng deu hoic giin dogn va thudng xuydn ngung dung thudc hoic khdng cd su keo dii va duy tii. Tuan thii sii dung thudc la mot hidn tugng da chilu dugc xic dinh bdi sy tuang tac cua cac ydu td bdnh nhan, yeu td bie sT v i cic yeu to thupc he thdng chim sde sire khde. Kidn thire vi nilm tin eua benh nhan vd bpnh tit ciia hp, dOng lye dl quin ly nd, su ty tin trong khi ning tham gia vao cic hanh vi quin ly benh tgt va ky vpng ve ket qua didu tri v i hgu qua eua sy tuan thu kem tie dgng anh hudng ddn hinh vi tuin thii. Cic ydu td lidn quan din bpnh nhin la
yeu td giii thich gia tang Idn nhat trong vide du doan sy tuan thii sii dyng thudc. Bai vidt niy tip trung vao vai yd cua bdnh nhan trong sy tuin thii su: dung dilu tri rdi loan lipid huylt [I, y.805-814].
2.NOIDUNG
2.1. T i m quan trpng ciia tuan thii su- dung thuoc doi vdi benh nhin bi roi loan lipid huyet
Ndng dd cholesterol ting lam tang nguy CO benh tim va dot quy. Tren toan ciu, 1/3 bpnh thilu miu cue bg l i do cholesterol cao. Ndl ehung, cholesterol tang ldn udc tinh gay tii vong Ii 2,6 tiipu ngudi (4,5% tdng sd). Tgi My, trdn CO sd dii lieu Khao sat Siic khde v i Dinh dudng Qudc gia gin diy (NHANES), udc tinh cd 71 tiidu ngudi tmdng thanh cd LDL-C Idn hon myc tidu ciia NCEP ATP-III, nhung ehi cd 34 tiieu ngudi (48,1%) dupe dilu tij ha lipid (bao gdm dilu tri khdng dimg thude) v i 23
*' ThS. Tmdng Dai hpc Vin Lang, [email protected]. Mdsd: TCKH22-12-2020 107
JMS v^K,
IAI HOC VAN LANG yidu (33,2%) dgt dugc myc tieu NCEP ATP HI LDL-C. Theo sd lieu dilu ya cua EUROASPIRE III d ehau Au, ty Id bdnh nhan cd ndng do lipid khdng dat raye tieu li 46,2% [1, y.805-814].Bdnh tim mach ia nguydn nhan gay tii
^^^ hing diu, giy ra hon 4 tiidu tmcmg hgp tir vong sdm mdi nim, 18% benh vd mgch mau I (chu ydu la cie bidn co ididng gay tir vong) r56% bdnh thieu miu eye bg. Va tang lipid
|la^mdt tiong nhihig yeu td nguy ea quan
^Kilm soit eie ylu td nguy eo thdng I didu tri bing thudc ed thd lam giim ty Id I tit, tli vong v i giam ehi phi didu tri [3, I Cd bang ehiing tir cac thu nghidm lim sang ring lieu phap statin cd hieu qua trong
I
I lira giim bdnh suit va tii vong mgch miu va bdnh tim mgch. Cac nghidn ciiu gin diy thiy sy khdng tuan thii trong vide sii dung I bj anh hudng bdi ty Ip ngung ngay sau didu tii da dugc bit diu. Hon nira, nd da I chiing minh ring tuin thii giim ding kl sau 6 thing dau eiia lieu phip va 25-50% so ngudi radi sir dung statin ngiing didu tri trong nam diu tien. Nhieu ylu to cd lien quan din sy tuan thii kem nhu kiln thiie ve nilm tin siic khde, su khdng chic chin v l lgi ich ciia didu tri hg lipid, nhin thiie ve nguy co, mli quan tam hoic kinh nghiera vdi cae tie dyng phu cua thuoc, ehi phi thudc men vi sy bat tien. Sy tuin thii kem da Hen quan din hiu qua xiu, d^ bidt la tang ty Ip nim vidn vi tang ehi plti y tl [I, y.805- 814], [2].2.2. Cac yen to anh hudng den sy tuan thii thuoc Tuan thu l i mpt hidn tugng da chieu xac djnh bdi su tie dpng eiia cic yeu td anh hudng khac nhau. Nhung ydu to nay cd the dugc thinh ba ndi dung chinh nhu ydu td do bpnh nhin, ylu td do bic sT v i ylu to do he thdng chim sdc y te. Mac dii phin logi nay rat hiiu ich yong vipe hilu sy tuan thu statin nhung thudng ed sy tuong tic phiie tgp giiia eie ydu to inh hudng din vipc bpnh nhin ed dung thudc nay hay khdng diing thuoc. Vi dy, bpnh nhan ed thi
khdng tuan tiiu vi ly do khac nhau nhu tiiai dg ddi vdi thudc, chi phi yii tiln, tac dung phy, sy phirc tgp ciia phic dd dilu ni va sy giao tiep kem vdi bie sT ciia bpnh nhan. Cac rao cin ehung ddi vol vipc tuin thii khdng dd hidu qua dl kilra soat bdnh nhin, do dd su ehii y din cic ylu td anh hudng nay li mgt bude cin thidt va quan ygng d l cii thidn sy tuan thii. Trong cae cau y i ldi cho mot bang ciu hdi, cae ly do didn hinh cho thiy bdnh nhan khdng dimg thuoc bao gdm qudn diing thulc, uu tidn khie, quyet dinh bd qua lieu, thilu thdng tin, v i cic ydu td tim ly/hinh vi. Cae bie sT gdp phin vao su tuan thu kem ciia bdnh nhan bing cich ke dan cic phac do dieu trj phiic tgp, thit bgi tiong vide giai thieh diy dii eac lgi ieh va tae dyng phy ciia thudc, khdng xem xet ldi sdng ciia bpnh nhin hoge chi phi eiia thudc vi cd mdi quan he dieu tri kem vdi bdnh nhin eua hg. Ndi chung, h$
th6ng chim sde siic khde tgo ra cac rao cin dii vdi vide tuin thu bing cich hgn chd tiep CEIU eae co sd cham sdc y tl, sii dyng rapt logi thuoc hgn che hogc chuyen sang mgt logi thulc khac v i cd chi phi thudc cao, thude khdng dugc thanh toin bio hidra y td.
2.2.1. Cdc yeu io dnh hudng den vifc tudn thd sd" dung thuoc
Cac ylu td lidn quan din thudc, cac ylu t l lidn quan ddn ngudi dimg thudc, cic b^nh mic kem, lien quan din dpi ngii didu tri hay cac ylu t l kinh te xa hpi. Cac ylu td lidn quan din bpnh nhin la cic ydu td the ehit (co the sdng) hay ydu to tam ly/hanh vi. Ylu td the chit nhu khilm thj, khidm thinh, suy giim nhgn thirc, giim khi nang vgn dpng hoge giim sy khdo Ieo, khd khin khi nudt vidn thudc. Ylu to tiim ly/hinh vi nhu tiiilu kiln tiiuc vl bpnh tgt, thilu niem tin vao phac do dilu fri, thieu nh§n tiiiic yeu to nguy co sinh bpnh va lgi ich cua vi§c dilu yj, tiiieu ky vgng ho$c tiiii dp khdng hgp tie eiia bpnh nhan ddi vdi dieu yj, thidu dgng lye rd rang trong vipc ftian tiiu sir dyng tiiu6c Theo Healtii Belief Model. 33 bpnh nhin ed
TAP CHi KHOA HQC DAI HQC V A N LANG Huynh Nguygn Thiiy Trang cam giie can dieu tri cic tinh trgng ciia hp hidu
qua thi cd nhiiu khi ning sii dung eac logi thuoc dugc khuydn dimg. Kdt qui ciia vipc tiiieu cic tiidu chiing lidn quan ddn miic cholesterol eao, benh nhan tang cholesterol huylt khdng cam nhgn bdnh hoge nhan ra raiic dp benh ciia hp cin duge didu tij. Avom va cpng sy tiln hanh didu tra cic bpnh nhan dugc cho la da ngung dimg statin v i tim ra mpt tiong nhihig ly do phd biln nhat de ngung dung thulc li bdnh nhan khdng tiiuylt phye ve sy cin thilt phii didu trj (32%). Hiu hit cic bdnh nhan diu tin ring statin cd hieu qua lim giim miic cholesterol va mdc cholesterol cao la khdng an toin. Tuy nhidn, nhidu ngudi cung dit ciu hdi vd nhu ciu ca nhan eiia hg ddi vdi statin. Mgt sd ngudi tham gia cam thay ring miic cholesterol eiia hp da dd gin de nhim raye tieu ngudng ma statin ed the khdng cd nhieu lgi ich cho hg. Mdt sd benh nhin biy td mong mudn kiem soit cholesterol bang each thay ddi ili sdng, vi dy nhu tip thi dye va chi dg an udng hoic phuang phap dilu tii thay thd, bao gom cae lieu phip thio dugc.
Cic ydu td lidn quan den bdnh nhan ed the dugc phan thanh hai loai don gian: vd y va eo y khdng tuan thu. Khdng tuin tiiu thudc khdng do mong mudn ciia bpnh nhan ed lidn quan ddn k$' nSng ciia bfinh nhin h o ^ kha nang udng thudc cua hp (vi dy nhu cie vin dd vl kheo tay hoge qudn).
Ngupc lgi, su ed y khdng tuin thu thudc lidn quan den ddng co vi nidm tin ciia bpnh nhan ve vide dimg thuoc va la mpt quyet dinh cd y thuc ciia b^nh nhin dk "ty dilu tri thudc" nghTa ia quydt djnh dimg thudc, lilu lugng va tin suit didu tii.
2,2.2. Cdc nghiin cuu trin thi gi&i Trong mgt nghien eiiu tren bpnh nhan didu tij statin, 31 phan tieh eae phan ung didu tia bpnh nhan cho thiy cac 1^ do phd biln nhat khi ngung dimg statin la tic dyng phy (42,2%), cam tiiay ring didu yj khdng cin tiiilt (14,0%), lo ling ve vi^c eac tie dyng phy tang din (12,7%), khdng tidp tye theo Idi khuyen ciia bac sT didu frj
(8,5%), thich sir dung ehi dg an kieng va tip thi dye (8,5%), cim thiy ring hg diing qua nhidu thuoc (4,2%), hoic khac (28,2%).
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Hinh I. NguySn nhan ngung diing statin Nhieu ngudi ngung sir dung hon so vdi ngudi tilp tuc cho tiiay statin cd lgi ieh han chi hoic khdng chic chin vl lgi ich ciia statin (81,7% so vdi 46,8%). Vl tiidng kd kiln tiiiirc tdng hgp vd statin, nhiiu ngudi tidp tye hon nhiing ngudi ngung diing thudc bilt ring lipu phap statin cd the li liu dii (11,3% so vdi 2,3%) va nhgn thiic dugc lgi ieh ciia statin (72,5% so vdi 57,7%). Vl mdi quan he vdi cic nhan vien y tl, nhiiu ngudi tilp tue tuan thii sii thude hon nhiing ngudi khdng tuin thu tin tudng vd su ehim sdc siie khde cua nhin vien y te (95,3% so vdi 80,3%) va cam thiy nhin vidn y tl cd du kiln thiic dd tra ldi ciu hdi ciia hg (94,2% so vdi 75,9%). Nhirng ngudi tuin thii su dyng thudc ed khi ning tiep ein nhidu hon thdng tin ve statin dugc giii thieh bing nhiing each dd hilu (83,7% so vdi 64,8%).
Su tuan thii da duge chiing rainh li tdt hon khi bdnh nhan chip nhin miic dp nghiem tipng cua can bdnh eiia minh, tin tudng vao bie sT dieu trj va tin tudng vao phic dd didu tri. Tren thye td, Blenner va edng su d i phat hidn ra bpnh tim mach kit hgp (CVD Revascularization, suy tim sung huydt) va tien sii dot quy la do nhirng yeu td du bao ding ke vd tuan thii. Trong rapt phin tich eiia cic bpnh nhan chua timg diing statin, Ellis va cpng su da phit hipn thiy ty Ip khdng tuin thii eao trong sd cic bdnh nhin dy phdng khi so sanh vdi nhihig bdnh nhan dugc dilu tii du phdng thii phit, cho thiy ring mgt so miic do duy tii tang Idn xay ra
fKHOA HOC DAI HQC VAN LANG d nhirng benh nhin ed nhieu khi nang dugc
1
^ lgi tii lieu phip statin. Nhung dir lieu rphii hgp vdi cie nghidn ciiu khie chung I ring bdnh nhin ed nguy co tuan thu dilu nhidu hon sau khi trii qua cie biln chung nghiera trpng do benh tim mach, cd the la do su danh gia cao vd tim quan tigng cua vide quin ly: eac yeu td nguy ca ciia hg. Tuy nhidn, sy tuan thii dilu trj statin thip hem so vdi eac nhdm thuan tap dugc didu trj dd phdng ngCra^ ^ ^ ^ f p h i t v i thii phit. Miic dd cua vide khdng tuan thii ddi vdi cae ea nhan ed bdnh tim
I
I vinh do chin doin (CHD) cd nhidu kha fxiy ra eae bidn cd ddi vdi nhdm nguy co nay. Mgt nghidn ciiu hdi ciiu trdn 200.000 I nhan Canada da chirng minh ring 53,8%I nhin cd thdi ky khong tuan thu ddi vdi I keo dii it nhit 90 ngay. Tuy nhien, da cd
• biln ed rd rang thuylt phuc bdnh nhan tiep tyc dieu yi. Bidn cd ed inh hudng nhat la mgt con nhdi miu eo tim radi, kdt qui la y d lgi
^ ^ S d d didu yj. Thdng thudng, mgt cuge tham vidng vdi bac sT lam cho no tid lgi tii lieu gip
^ | l i n , vdi mdt ehuydn thira vdi bic sT ban diu da kd don statin chiing rainh ty Id cd thd tii yj lieu Ii 6:1, eho thiy vai yd quan tipng eua b$nh nhin - bie si tiong tuin thii.
Mdt nghidn eiiu didu tra da bio cio vao nam 2007 ggi y ring nhirng benh nhin lo ling vd tic dyng phy eiia statin hogc khdng chac chin vd loi ich tidm nang ed nhidu kha nang ngimg sir dyng statin. Trong nghidn eiiu nhdra tigng tim cua Fung va cpng su, 36 ngudi tham gia da biy td mdi quan nggi vd tie dpng liu dai tidm in ciia statin, bao gdm dgc bidt li tdn thuong gan va than va sy suy giim cua coenzyme QIO. Trong mpt phin tich thu vj cua Reaume va cdng su, da dugc khio sat inh hudng cua nhin thiic cua cdng chirng ddi vdi su an toin eiia thudc ddi vdi tuan thii dieu yj statin. Hg da nghidn eiiu khoing thdi gian ngay sau khi thu hdi eerivastatin tir thj tmdng vi cac mdi Io ngai vd an toan \a phit hidn ra, trong sd nhiing bdnh nhin hgi ehiing hgch
dpng mgch vanh cip, da cd sy syt giim tgm tiidi vd vide su dung tat ca eac statin ttong sudt tiidi ky dd nhung khdng sir dyng beta blocker - tiiuoc chen tiiu till angiotensin (tiiude lic chd ACE), eho thiy nhiing mdi quan tim dd li cic logi tiiuoc cy till va ed till bj inh hudng bdi edng khai xung quanh cerivastatm.
Mpt nghidn ciiu vd mgt nhdm ngudi Idn udng thudc theo toa statin hogc thudc hg huyet ap da cho thay su phue tap rit ldn cua cac b^nh nhan bi bdnh tim mgch. Trong thdi gian 3 thing, benh nhin kd don thudc eho trung binh 11,4 thudc; tuong duong vdi 5,9 lidu thude.
Dang chli y ban, tiong cimg khoang thdi gian nay, 10% bdnh nhan ke don thude eho 23 logi thudc trd len, 12 logi thudc ddc nhit vi 11 nhdm thude khae nhau, ed don thudc do hon bdn bac sT ke dan viet ra.
CJ nhidu nude, didu tii hg lipid ban diu bj chi phdi bdi lieu phap don trj lieu statin d lidu lugng thip den tmng binh v i thudng bao gdm cie lieu phip bd tig. Cic lidu statin nay thudng khdng phii hgp vdi nguy co tim mgch va nguy CO tim mgch eiia bdnh nhan va ehi tieu LDL-C.
Vide sit dyng cic lilu khdng day dii thudng dugc cdng nhin la rapt tiong nhiing ly do din ddn ty Id thinh edng thip yong viec dgt dupe LDL-C myc tieu. Trong cupc khao sit LIPI- WATCH, 77% benh nhan dugc duy yi d lilu khdi dau mac du hp khdng dgt dugc myc tidu.
Rit it bdnh nhin dugc didu yj bang lidu Iupng dugc thu nghidm tiong cie thii nghipm lim sing ngiu nhidn hogc lieu lugng cin thilt dl dgt dugc lipid huyet myc tidu.
2.2.3. Tde dung phu
Tic dyng phy eua statin ciing la mpt nguyen nhin quan trpng giy ra sy khdng tuan thu su dyng tiiudc. Mpt phin tich gin day vl eie phin img nghich tiiudc statin (ADR) trong hp tiiong bio cio phan img bit lgi AER ciia FDA (Food and Dmg Adminishation) da. phat hipn ra cac dau hipu eho Chung dau CO, tieu CO vi tang creatine phosphokinase va cac ADR co bip khie nhu
•HOC VAN LANG Huynh Nguyin Thuy Trang BiliB^BBJIiltt'MHi SSIsifl dm CO va chimg dau
lien quan den dieu trj xuydn hon tiong cic hudng Idn hon den thudng la suy nghT transaminase > 3 gidi ly^ilTOng cac nghie^cuu dimg atorvastatin i bing statin trong 4 nam gay ra 1 ea dai ungin ngua 5,4 lin bidn cd Chi phi thuoc van la mgt nguyen nhan giy tuan thu kem. Phin tich Idn nhit dinh gii chi phi thude v i tuin thii da cho thay rang trong 132 nghien eiiu, sy gia tang chia se chi phi lidn quan din vipc giam ty le dilu yi thudc, tuin thu kem hon vi ngimg su dyng thude nhidu hon.
Cac tie gii nhin thiy vide sti dyng thudc giam 2-6% cho vide chia se chi phi tang 10%.
3. KET LUAN
Nhihig \^ do khidn bdnh nhan khdng tuan thu dieu trj thudc statin gdm qudn udng thude, thai dp tieu cyc ddi vdi thudc, thit vpng vdi dip ling dieu tii kem, nhung niem tin ban dau vd siic khoe vi thudc raen, su hidu bidt kera vd phin tich chi phi va Ipi ich eiia mpt loai thuoc theo quy djnh, bao gdm vipc thilu hilu bilt vd lgi ich ciia thudc va lo nggi cac su kien bit lgi lien quan den thudc. Mdt sd can thidp nhim ting su tuan thii dilu tij statin nhu thay ddi lich trinh kd thuoc va hoic ddng gdi, kit hgp cic thudc hg lipid vdi eae thudc khac, sir dyng eac tii lidu
giio dye cho cic nha eung eip dich vy y td va/
hoic bdnh nhan, thu va ldi nhie dien thoai.
Muc tieu ehinh cua vide tiieo doi ehit ehe la Uieo ddi hidu qui cua lieu p h ^ diing thudc vi tiiiic diy sy tuin thii ciia bdnh nhin. Hudng dan khuydn bdnh nhan dinh gii lgi 6 din 8 tuin sau khi bit diu dieu yj va didu chmh lilu lugng va mdi 4 din 6 thing rapt lan khi dgt dupc eac mye tieu dilu tij.
Ky nang giao tidp ciia nhin vien y td gdp phan lim tang su hieu biet eua bdnn nhin vd phac do dieu tii. Su phu hgp giOa bic sT va benh nhan yong viec xac dinh tinh chit va mire dp y i m trgng ciia vin dd lam sang cd lien quan den vide eai thien v i giii quylt vin dl va sy tham gia ciia benh nhin cing lira tang sy hai ldng, tuin thii v i kit qua dilu tri. Bie sT ndn trau ddi kinh nghidm, hpe each ling nghe ti'ch eye, giai thich rd ring, kiem ha su hidu bidt ciia bdnh nhan, tu vin vd phic dd didu yj vi kidm ya su chii ^ ciia benh nhan ve su tuin thu. Xic dinh cic logi va ngudn thdng tin bpnh nhin sir dyng de tira hidu vd statins va nhin thiic cua hg ve cic ydu td nguy co tim rageh cung cd the cai thidn tmyen thdng lara sang va benh nhan vl statin. Nhan mgnh cae lgi ieh eiia lieu phap statin tai thdi dilm ke don, cung nhu thao lugn cic tic dyng phy ed hgi tiem an raiie dp v i mure dp nghidm trpng, cd the cai thien cieh thiie bdnh nhin loc thdng tin mi hp nhan duge tir cac ngudn khie.
TAI L l f U THAM KHAO
[1] Manuela Casula, Elena Tragni, Alberico Luigi Catapano (2012). Adherence to lipid-lowering treatment - the patient perspective; PMC3496534, Jounal List - Patient Prefer Adherence.
[2] Maribel Salas, The Most Effective Patient Adherence Interventions of Lipid Lowering Medications, Centerfor Clinical Epidemiology and Biostatistics, University of Pennsylvania, USA, and Patient Safety, AstraZeneca, Wilmington, Delaware.
[3] Gareia-Rodriguez, LA et al (2008), Pharmaeoepidemiol Drug Saf [4] Waters DD (2005), Safely of high-dose atorvastatin therapy. Am J Cardiol.
[5] Lancet (2010), https://www.ncbi.nlm.nih.gov/pubmed/20167359.
Ngay n h ^ bii: 09-01-2020. Ngay bien tip xong: 13-7-2020. Duyet ding: 24-7-2020
