Tap chf Tai Mui Hgng Viet Nam - Volume (59-21). N°3- October, 2014
XAC DINH CAC VAN DE LIEN QUAN DEN THUOC SAU PHAU THU A T N O I S O I MUI XOANG TAI BENH VIEN TAI MUI
HONG TRUNG iTONG
Phgm Thi Thity An\ Biii Van Dgm\
Vd Thanh Quang, Nguyin Thanh Thuy , Phgm Thi Thuy Van''
TOM TAT
Muc tiiu: Phdt Men mot so vdn de lien quan den thuoc (DRPs). Doi tuong vd phuffng phdp nghien cuu: Thu thap thong tin binh dn cua binh nhdn (BN)sau phdu thudt ngi soi mm xoang (PTNSMX), doi chiiu vdi thong tin tu cdc tdi lieu nghien cuu da chgn, tic do phdn tich vd tong hgp cdc vdn de phdt hien. Kit qud: Phdt hien 56 vdn di lien quan den su dung thuoc, trong do: 28 vdn de lien quan den lua chgn thuoc, 19 vdn di liin quan den cdch diing thuoc, 9 vdn di liin quan din liiu diing vd tdn sudt dua lieu. Kit luan: Cdc DRP thudng gap sau PTNSMX: Lua chgn thuoc chua phu hgp vai khuyen cao: 93%; Thdi diem diing thuoc chua phu hgp: 45%; Liiu diing vd tdn sudt dung chua chinh xdc: 100%.
SUMMARY
Objective Detect a number of problems related to drug use. Materials and Methods:
Gathering information from each patient after endoscopic sinus surgery and compare them with information from the selected to find DRPs. Results: The findings are 56 DRPs, in which 28 related to drug selection, 19 related to the use of drugs, 9 related to the dose and frequency of doses taken. Conclusion: The DRP after endoscopic sinus surgery: Option drugs not suitable for recommendation: 93%; Time of inappropriate drug use: 45%; The
z and frequency of use is not exactly. 100%.
Key Words: Drug related problems, DRPs, Dugc lam sdng.
I. DAT VAN DE nay da trd thanh mot khai niem quen thuoc Cac vin di lien quan din thudc (Drug ^"dc su dung rgng rai d nhiiu nude tren related problems - DRPs) la mot tinh hudng thi gidi nhu My, Uc, cung nhu d cac nude lien quan den dieu tri bang thudc cd the gay Chau Au.
trd ngai hoac tiim an moi nguy hai cho sire Nam 2011, Uc ban hanh mlu 'That khoe ngudi benh [8]. Tir nam 1990 khai hien va phan nhom cac vin di lien quan niem vi DRPs da dugc nhic din va cho tdi din thudc" trong hudng din thuc hanh dugc lam sang quoc gia. Tai Viet Nam,
;HOC vien cao hpc trtrarig Bai hoc Diroc Ha N6i nam 2012 B6 Y ti ban hanh mlu "Tom tit
'Khoa Din?c Benh vien Tai Mui Hong Trung uong
^Bac si Benh vien Tai MQi Hpng Trung uong
•'Giang vien Tni&ng Dai hpc Diroc Ha Npi „„
Tap chi Tai Mui Hong Vi6t Nam -Volume (59-21) N°3- October, 2014
cac van de can thiep thuc hien" kem theo thdng tu 31/2012/TT - BYT - Hudng din boat dong dugc lam sang trong benh vien.
Xuat phat tir thuc te do, chiing toi thuc hien de tai "Xac dinh cac van de lien quan den thuoc sau phau thuat noi soi miii xoang tai Benh vien Tai Mui Hong Trung U"o"ng" nham muc tieu phat hien cac van de lien quan den thudc thong qua danh gia viec sii dung thuoc tai Khoa Mui Xoang benh vien Tai Mui Hgng Trung LTong, tir do de xuat trien khai cac boat dong cua dugc sT lam sang.
2. D 6 I TU'ONG VA PHU*0NG PHAP NGHIEN Ctru
2.1. Doi tuong nghien cihi
32 benh an (BA) cua BN dieu tri ngi tni tai Khoa Miii Xoang benh vien Tai miii hgng Trung uong trong thdi gian tii 01/3/2014 din 24/03/2014.
Tieu chuan lua chon: BN dieu tri ngi khoa sau PTNSMX.
Tieu chuan loai tru: BN ding thdi cd benh ly khac d tai, hgng, amidan.
2.2. Phirong phap nghien cihi 2.2.1 Phuffng phdp nghien ciru
- Tien ciiu BA.
- Danh gia dua tren tieu chuan tong hgp tir cac thong tin trong cac tai lieu tham khao.
2.2.2 Cdc tieu chi nghien ciru - Dac diem benh nhan nghien ciiu.
- Cac thudc sii dung tren benh nhan.
- Danh gia sir dung thudc ve:
+ Lira chgn thuoc + Lieu dimg, each dimg
- Xac dinh cac vin di lien quan den thuoc.
2.2.3 Phuong phdp ddnh gid su dung thudc 2.2.3.1 Cdc tdi lieu sic dung de ddnh gid
+ Hudng dan dieu tri va thuc hanh lam sang cho benh ly viem miii xoang ciia:
Hiep hoi cac benh truyen nhiem My 2012, Canada 2011, va Vien phau thuat dau cd tai hgng Hoa Ky 2007; Antibiotic guidelines 2nd, Pharmacotherapy 8, Tai Miii Hgng (dimg cho dao tao bac sT da k h o a ) - B g Y t i 2012.
•I- Cac tai lieu tham khao chung vi thuoc: Dugc thu quic gia 2012, td hudng dan sii dung cua thudc phat minh (neu khong CO, sii dung hudng dan su dung ciia thudc thay the dang cd d benh vien), AHFS true tuyen, Martidale 36, Dugc thu Anh 66, va cuon Meyler's Side Effects of Drugs 15th Edition;
+ Cac chuyen luan rieng vi thuic:
Handbook on Injectable Drugs;
Stockley's drug interactions va Drug interaction facts 2012.
2.2.3.2. Cdch ddnh gid su dung thudc:
- Danh gia ve lua chon thuir.- + BA cd tieu chi lua chgn thudc phu hgp khi thuoc lira chgn dugc di cap din d 1
Tap chi Tai Mui Hgng Viet Nam -Volume (59-21). N°3- October, 2014
trong cac tai lieu hudng din dieu tri tren.
+ Cac lua chgn thuic khong phii hgp dugc xac dinh la vin di lien quan den lya chgn thuic. M6i lugt lua chgn thuic diu dugc danh gia vi tinh phii hgp va mot benh an cd the co nhiiu vin di lien quan den lira chon thuoc.
- Danh gia ve Heu dung, each dimg:
+ Cac BA dugc coi la co lieu dimg, each dimg phii hgp khi lieu dimg, each dimg dugc dS cap den d 1 trong cac tai lieu tham khao ve thuoc neu tren.
+ Cac BA CO lieu dimg, each dimg khdng phii hgp dugc xac dinh la c6 van de lien quan den lieu diing va each dimg cua thuic, Mdi lugt thay doi lieu dimg, each dimg dSu dugc danh gia ve tinh phii hgp va mot benh an co the co nliieu van de lien quan din liiu dimg, each dimg ciia thudc.
3. KET QUA NGHIEN ClTU 3.1 Dac diem benh nhSn nghien cihi
Bang 3.1: D§c diem v^ tu6i, gidi tinh, phan nhdm b^nh cua m^u nghien ctru
Gidi tinh
Do tu6i
Phan nhom benh
Nam Nu 14-18 tudi 19-40 41 - 60 tuoi
> 60 tudi VMXMT polyp mui VMXMT ngo nam Phan nhdm kh4c
(%)(n=32) 22 (68.75%) 10(31,25%) 1 (3,125%) 13(40,625%) 14 (43,75%) 4 (12,5%) 21 (65.625%)
6(18,75%)
5(15,625%)
03c diem chung SoBN
BN nam trong mau nghien ciiu chi8m tdi 68,75%. Nhom BN cd do tuii tir 19 - 60 chiim ty le cao nhat trong mau nghien ciiu (-84,4%). Benh nhan thuoc phan nhom VMXMT polyp mui chiem ty le cao trong mau nghien ciiu (~ 65%).
3.2 D|c diem sir dung thuoc
Bang 3 2: Thu6c, nhdm thudc dugc su dung va tin suit si> dung
STT
1
2 3
Nhdm thudc TSn nhdm
Khcing sinh
Corticoid Thudc c4m mSu
Thudc Amoxicillin + clavulanat
Cefamandol Cefuroxim Methyiprednisolon
Etamsylat Acid tranexamic
Tyle*
(n=32) 12,5 % 25%
62,5%
93,75%
93,75%
3,13%
Ty le (n=32)
100%
93,75%
96,88%
65
Tap chi Tai MiJi Hgng Vi#t Nam - Volume (59-21), N°3- October, 2014
4 5 6 7 8 9
Thuoc chdng phCi nd Thudc tieu nhdy rhudc giam dau, ha s6t
Thuoc chdng dj i>ng Thudc hudng than Thuoc nhd mui
Alpha chymotrypsin Acetylcystein Paracetamol Levocetirizin Fexofenadin Diazepam Fluticason furoat
Budesonid
100%
96,88%
96,88%
93,75%
3,13%
81,25%
9,38%
15.63%
100%
96,88%
96,88%
96,88%
81,25%
2 5 %
*Ty le: Ty liphdn trdm BA co ki don thuoc, nhdm thuoc.
Nhan xet: khang sinh va ching phii ni la 2 nhdm thudc dugc su dung 100% d cac BN trong miu nghien ciiu. Hai nhdm su dung vdi tin suat it hon la nhdm thuoc nho miii chiem 25% va nhdm thuoc hudng than chiem 81,25%.
3.3 Cac van de phat hien lien quan den thuoc
Bang 3.3: Cac van de phat hien Hen quan den thuoc
ST T 1
2
3
Nhom v i n de Lua chgn
thudc
Cach dCing
Lieu dung/tin s u i t dua
ll^U
Phan nh6m T&n
S u dung dang bao c h i chua d u g c khuyen c^o Khong ghi thai diem
dung thuoc
Ghi thdi diem dung thudc khong chinh xac Lieu dCing thuoc cao han
li^u khuyen c^o T i n suat dua thuoc t h i p
han khuyen c^o.
Thudc li&n quan Corticoid d u d n g
tiSm Amoxicillin +
clavulanat Corticoid u6ng
Corticoid u6ng Amoxicillin +
clavulanat Cefamandol
Tan s u i t "
28/30 (93,33%)
2/2 (100%)
3/20 (15%)
14/20 (70%) 1/1 (100%)
8/8 (100%)
Ty 16"
28/32 (87,5%)
19/32 (59,38%)
9/32 (28,13%)
Tdng s6 vin dS ph^t hien/so BA nghien cu-u: 56/32
* Tan suat: So van de/s6 lan ke don
**Ty le: Sd van de/sd BA nghien cuu Nhan xet: Van de "su dung dang bao che chua dugc khuyen cao", cu the la su dung corticoid dudng tiem cho BN sau PTNSMX chiera ty le cao trong mlu
nghien ciiu (87,5%) dong thdi ciing chiem ty le cao khi tinh tren tong sd lan chi dinh thuoc (93,33%). v i n di Hen quan din thdi diem uong, lieu dung vien nen amoxicillin -f- clavulanat; va tan suat dua thuic tiem cefamandol deu chiem 100% tdng sd lin chi dinh thudc. Cac van de con lai lien quan
Tap chi Tai Mui Hong Viet Nam -Volume (59-21). N°3- October. 2014
den thdi diem uing corticoid. Tong so van de phat hien la 56 tren 32 BA.
4. BAN LUAN
Cac van de dugc chia thanh 3 nhdm Idn tuong ling vdi 5 nhdm nho tap trung vao lira chgn thuic, each dimg va lieu diing. Dieu nay cho thiy tin suat lap lai vin de cao. Mat khac, cd tdi 3 nhdm van de cd tan suat gap 100%, tiic so lin chi dinh thuoc chinh la so lan phat hien vin di lien quan tdi sir dung thuoc ay. Dieu nay cd thi cho thay co sir thdng nhat ve each ke don thudc, each sii dung thudc giua cac bac si trong 1 khoa. Van de cd tan suit gap cao nhat la lira chgn thuoc, vdi 28 lan phat hien tren tong so 32 bSrih an.
4.1 Trong lura chon thuoc
Ty le su dung corticoid dang tiem cho BN sau PTNSMX chiim 93 % si lin chi dinh, nhung cac hudng din diiu tri hien tai chi khuyen cao sir dung dang xit tai cho va/hoac dang uong cho ddi tugng BN nay.
Hon the nua, chiing tdi chua tim dugc thir nghiem lam sang chiing minh hieu qua cua corticoid dudng tiem tren BN viem miii xoang (VMX).Trong khi dd, vdi corticoid dang uong, da cd rat nhieu bang chiing vi hieu qua cua thudc vdi chi dinh nay. Chi tinh tir nam 2010 tdi nay, cd hon 10 thii nghiem lam sang va ban 2 bai ting quan he thdng dugc thuc hien de danh gia hieu qua ciia corticoid dimg theo dudng udng. So vdi dang xjt tai cho, dgt dieu tri ngan ban corticoid dudng uong co hieu qua hon tren BN VMX man tinh c6 polyp mui hoac VMX di ling do nam cung nhu hieu qua trong giai doan PTNSMX tren nhung BN nay. Hien nay, viec sii dung corticoid
dudng uong cho BN VMX man tinh khdng polyp hay trong giai doan PTNSMX dii vdi BN nay chua he dugc khuyin cao do cdn thieu bang chiing.
Mat khac, so sanh giiia dudng uing va dudng tiem, viec sir dung corticoid dudng udng CO nhieu uu diem hon so vdi dudng tiem nhu [2]:De sii dung do BN co thi tu dimg thuoc; An toan hon so vdi dudng tiem .do it gay soc, gay dau, it bi nhilm tning; Re hon so vdi dudng tiem, dudng tiem con phai chi phi cho tien bom tiem, kim tiem;
Sinh kha dung cua corticoid dudng uing cao ~~ 80%, nong do thuic tdi da trong huyet tuong dat dugc sau 1 - 2 gid sau khi dimg thuoc [2] [9]. Do vay, corticoid dudng udng cho benh nhan la lua chgn dugc khuyen cao.
4.2Cach diing thuoc
Cdc DRP hen quan den cdch diing chii yeu Id vi thdi diim uong corticoid chua dugc ghi chinh xdc theo khuyin cdo. Dugc thu quoc gia va Hudng din su dung cua thuoc biet dugc goc khong khuyen cao sir dung corticoid sau an. Lien quan den tac dung khong mong muon tren dudng tieu hoa, da cd mot thdi gian dai glucocorticoid bi coi la thu pham gay loet dudng tieu hda.
Nhung trong nhiing nam gan day tong hgp lai cac bang chiing thir nghiem lam sang cho thay cd it bang chiing cho viec tang nguy CO loet dudng tieu hda khi sii dung corticoid don dgc. Viec phoi hgp sii dung corticoid vdi thudc giam dau chong viem NSAlDs mdi lam tang nguy co chay mau dudng tieu hoa [5][10]. Theo mot tai Heu khac, giai thich co che gay ra tac dung khong mong muon tren dudng tieu hda cua
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Tap chi Tai Mui HongViet N a m - V o l u m e (59-21). N°3-October, 2014
Methyiprednisolon (boat chat hien tai dang dugc su dung tai khoa lam sang) la do chat nay lic che tong hgp prostaglandin nen mat tac dung cua prostaglandin tren dudng tieu hda bao gom: lie che tiet acid va bao ve niem mac da day [1]. Nhu vay, neu methyiprednisolon cd tac dung phu gay loet dudng tieu hoa thi do ciing la tac dung phu cua thuoc sau khi thuoc da dugc hap thu vao he tuan hoan va khdng the han che dugc tac dung phu nay bang each uong thuoc sau an.Viec dua y lenh uong methyiprednisolon sau an la khong can thiet.
CUng lien quan tdi khuyin cdo thdi diim uong corticoid, nhu chiing ta da biet, mot nguyen tac quan trgng de han che tac dung phu do corticoid gay ra do la dung corticoid theo nhip tiet tir nhien glucocorticoid ciia co the, theo do corticoid chi nen uong 1 lan vao buoi sang hoac che do dieu tri each ngay vdi nhiing trudng hgp diing keo dai nhieu thang [2]. Do vay ma thdng tin udng thuoc vao buoi sang la thong tin quan trgng doi vdi nhom corticoid, va can dugc ghi day dii vao y lenh.
Vdn de thu lien quan den cdch dung cua thuoc Id vi thdi diem uong dgng phoi hgp amoxicillin + clavulanat (Biet dugc la Augmentin) khuyen cao nen udng vao diu bira an de giam thieu hien tugng khdng dung nap thuoc d da day, rugt. [1,4]. Do do bac SI nen bo sung thong tin nay vao trong y lenh ke don de dat dugc hieu qua diiu tri mong muon.
4.Z Lieu dung thuoc
Trudc hit, lien quan den lieu dimg cua vien nen bao phim amoxicillin + clavulanat
CO chiia 2 thanh phin amoxicillin va clavulanat theo ty le khdng gidng nhau thi khdng tuong duong vdi nhau do dd kliong thi thay thi dugc cho nhau [1]. Vi du 4 vien 625 mg (moi vien chiia 500mg amoxicilHn va 125 mg acid clavulanic) khong tuong duong vdi 2 vien 1 g (moi vien chiia 875 mg amoxicillin va 125 mg acid clavulanic). Chi dinh dieu tri ciia 2 dang bao che nay la khac nhau, 1 vien 625 mg x 2lin/ngay chi dinh cho trudng hgp nhiem khuan nhe den vira, con 1 viSn Ig x 2 lin/ngay dimg cho trudng hgp nhiem khuan nang [4]. Viec dimg 4 vien 625 mg chia 2 lin/ngay la khong hgp ly.
Thu hai, lien quan den tan suat dua Cefamandol dang bgt pha tiem.
Cefamandol la khang sinh cephalosporin the he thir 2, co thdi gian ban thai sau lieu tiem tinh mach la 32 phiit [3]. Do do, tan suat dua cefamandol thong thudng theo khuyen cao la mdi 4 den 8 gid, vdi nhiem triing nang tan suat dua thuoc tang len tdi moi 4 den 6 gid.
Nhu vay, neu cefamandol dugc dua vdi tan suat moi 2 lin/ngay nhu hien tai la chua phu hgp vdi khuyen cao.
5. KET LUAN
Qua nghien cuu 32 benh an ciia cac benh nhan phau thuat ngi soi miii xoang, di tai da thu dugc cac ket qua sau:
Ty le phan tram sd van de phat hien (tinh tren tong sd benh an nghien ciiu) lien quan tdi lira chgn thudc chua phii hgp, liiu dimg va each dimg chua phii hgp lin lugt la 87,5%; 28,13%; 59,38%.
Tap chi Tai Mui Hong Viet Nam -Volume (59-21). N°3- October, 2014
Cac DRP da gap chu vin la:
1. Lira chgn thuic chua phu hgp vdi khuyin cao: phat hien 28 vin di/30 lin chi dinh thuic chiim 93,33% s6 lin chi dinh thuoc.
2. Thdi diem dung thuoc; Phat hien 19 van de/42 lan chi dinh thuoc chiem 45,24%
so lan chi dinh thudc.
3. Lieu dimg thuoc va tan suat dua thuoc chua chinh xac: Phat hien 9 vin di/9 lan chi dinh thudc chiim 100% si lin chi dinh thuoc.
TAI LIEU THAM KHAO Tieng viet
1. Bg Y ti (2012), Dugc thu qudc gia Viet Nam.
2. Hoang Thi Kim Huyin (2006), Duac lam sdng, NXB Y hgc. Ha Ngi tr.205- 206, 130-134.
3. Tarchomin Pharma Polfa, Thong tin san pham Tarcefandole, Si dang ky VN-17603-13.
4. GSK, Thdng tin sdn phdm AUGMENTIN ® tablets, Si dang ky VN-5377-10.
Tieng Anh
5. David M. Poetker, MD, MA et al,
"Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations". International Forum of Allery & Rhinology, Vol.3, No.2. Ferbruary2013.
6. J.K.Aronson (2006), "MEYLER'S side effects of drugs - The international encyclopedia of adverse drug reactions and interactions", 930.
7. Martin Desrosiers et al (2011),
"Candian clinical practice guidelines for acute and chronic rhinosinusitis".
Journal of otolaryngology - head neck surgery, volum 40, number S2.
8. Pharmaceutical Care Network Europe Foundation (May 2006), "PCNE classification for drug related problems V5.01"
9. Sayed M.H.Ahabet & Howard J.Rogers (1989), "Methylprednisolone pharmacokinetics after intravenous and oral administration", 27,285-290.
10. Sean C Sweetman (2009), "Martindale - The complete drug reference".
Thirty-sixth edition, 1492.
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