NGHIEN CU'U K^T QUA OlEU TRj BENH LY VONG MAC OAI THAO DU'O'NG B A N G TIEM BEVACIZUMAB NOI NHAN
Trdn Thi Thu Hiin', Buong Anh Quan', Phan Vdn Nan^
(1) Benh vien Trung uang Hue (2) Tru&ng Dgi hgc YDugc Hue Tdm tdt
Muc tieu: Tim hieu cdc ddc dilm ldm sdng benh vdng mgc DTD. Ddnh gid kit qud diiu trj bfnh vdng mgc DTD bang tiim Bevacizumab ndi nhdn. Doi tirong va phuong phap: Md td tiln cuu cd can thifp ldm sang khdng ddi chftng trin 33 mdt cua 17 benh nhan benh vdng mgc dai thdo dudng dugc diiu tri bing tiim Bevacizumab ndi nhan tft 3/2014 din 6/2015. Kit qua: DO tudi trung binh Id 60,06 ± 13,108 nam. Thdi gian phat biln dai thdo dudng trung binh la 10,47 ± 6,145 ndm. HbAlc trung binh la 9,506
± 3,298 %. Trung binh cua thi lyc sau dieu tri 3 thang, 6 thdng ldn hon trung binh cua thj lyc trudc diiu trj. Trung binh cua dd day vdng mac trung tdm sau dilu trj thdp nhit d thdi diim 3 thdng, sau dd lgi tang trd Iai d cdc thang thft 5, thft 6. Khdng cd mdi tuong quan gifta thi lyc vd do day vong mgc trung tam do bang OCT trudc dieu tri, sau dieu trj. Ket luan: Tiem Bevacizumab dieu tri benh ly vdng mgc ddi thdo dudng cdi thien thi lyc vd mftc dd phu hodng diem tdt sau 3 thdng vd dn dinh ddn d cdc thdng sau.
Tu khoa: Bevacizumab npi nhan, binh vong mgc ddi thdo du&ng.
Abstract
THE TREATMENT RESULTS OF INTRAVITREAL BEVACIZUMAB ON DIABETIC RETINOPATHY
Tran Thi Thu Hien', Duong Anh Quan'. Phan Van Nam' (1) Hue Central Hospital (2) Hue University of Medicine and Pharmacy Objective: To study clinical features in diabetic retinopathy and to evaluate treatment outcomes of diabetic retinopathy by intravitreal Bevacizumab. Patients and methods: A descriptive prospective clinical intervention non-comparative study on 33 eyes of 17 patients diabetic retinopathy who were treated by intravitreal Bevacizumab from 3/2014 to 6/2015. Results: Average age: 60.06 ± 13.108 years.
Average diabetic duration; 6.145 ± 10.47 years. Average HbAlc: 9.506 ± 3.298%. The average of vision after treatment 3 month, 6 month was greater than before treatment. The average of central retinal thick- ness after treatment was lowest at 3 months, then back up again at the 5th, 6th. There was no correlation between visual acuity and retinal thickness measured by OCT center before treatment, after treatment.
Conclusion: Intravitreal Bevacizumab in treatment of diabetic retinopathy improve vision and macular edema after 3 months and gradually stabilize in the following months.
Key words: Intravitreal Bevacizumab, diabetic retinopathy.
1. D^iT VAN DE dudi 40, dgc biet d cdc nude phdt triln.
Bfnh ly vong mgc ddi thdo dudng (BVMDTD) Phu hoang dilm do ddi thao dudng hay ggp Id mpt nguyin nhan ddn din mii Ida vd ton hgi thi d giai dogn sdm cua bfnh dai thdo dudng. Cdc giac d hdu het bfnh nhdn nam trong dd tudi nghiin ciiru ngan hgn gan day da phdt hifn ra Igi
- Dja chiliin hi: Duong Anh Qudn, email: 'vji. 'P^ !«,!
' -Ngdy nhdn bdi: 23/1/2016 *Ngdy ddngy ddng: 26/4/2016 "Ngdyxudt bdn: 10/5/2016 ' f'- " -
Tgp chl Y Dupc hpc - Trudng Dgi hpc Y Dupc Hue - So 32 I37
ich khi tiim cac thudc ftc chl yiu t i phat triln ngi md mgch mdu anti-VEGF (VEGF = vascular epithelial growth factor) trong dd cd Bevacizumab vdo ndi nhan cd thi ngan ngfta su ri dich vd tinh ygng phii hodng dilm tft cac mgch mau.
Muc tiiu nghien cdu:
1. Khdo sdt cdc dgc diim ldm sdng cita benh ly vong mgc ddi thdo du&ng.
2. Bdnh gid kit qud dieu tri benh ly vong mgc ddi thdo duong bdng tiem Bevacizumab ngi nhan.
2. DOI TirOfNG VA P l W a N G PHAP NGHIEN c t r u
2.1. Ddi tupTig nghien ciru: Nghiin cftu 33 mdt cua 17 benh nhdn
2.1.1. Tiiu chudn chgn binh
Nhftng benh nhan dugc chdn dodn xdc dinh bfnh dai thdo dudng va cd BVMDTD.
Dugc diiu tri bdng tiem Bevacizumab ngi nhdn hang thang lien tyc tu thdng 3/2014dln thang 6/2015 tgi Khoa Mdt Benh vien Trung uong Hui.
2.1.2. Tiiu chuan logi trie
- VI todn than: bfnh nhdn qud gid ylu, khd hgp tac; bfnh nhan dj ung hodc nghi ngd di ftng vdi fluorescein.
- Tai mat:
-I- Bfnh nhdn bi due nhieu mdi trudng trong sudt ciia mdt d mftc dd cdn trd soi ddy mat, chyp mach hujnh quang va chup cat ldp vdng mac, ddng tu khdng gidn sau tra thudc.
+ Nhung mat bi BVMDTD tang sinh cd bien chung: xudt huyit djch kinh, bong vdng mac, tan mgch mdng mdt hay glocom tdn mach.
+ Cd benh ly hodng diem khac kem theo nhu thodi hda hodng diem tudi gid, tdc tinh mach vong mac cd thi dan tdi dnh hudng tdi kha ndng phyc hdi thj lyc.
. Benh nhdn DTD khdng ddng y tham gia nghien cuu.
2.2. Phuimg phap nghien cuu
2.2.1. Tiiiet ke nghiin cU'u: md td tiln cftu cd can thiep lam sang khdng ddi chung.
2.2.2. Cdc bu&c nghien cii-u
- Budc 1: Khai thdc lya chgn benh nhdn theo mau nghiin cuu.
- Budc 2: Khdo sat ddc diem ldm sdng benh
vdng mgc ddi thdo dudng bing sol ddy mat vd chup mgch hujnh quang.
- Budc 3: Can thilp diiu tri bing phuang phap tiim Bevacizumab ngi nhan.
- Budc 4: Danh gid kit qud sau dieu tri.
2.2.2.1. Tiim Bevacizumab npi nhan Chi dfnh tiim Bevacizumab npi nhan Phii hodng dilm DTD cd tdn thuong trung tam vd anh hudng den thi lyc. Phdn loai phu hodng dilm trin OCT dya vao do day vdng mac > 220 pm.
Ky thugt tiem Bevacizumab npi nhan:
- Tiem 0,05ml dung djch Bevacizumab tucmg duong 1,25 mg ngi nhan qua pars plana cdch ria 3,5mm.
2.2.2.2. Theo doi sau dieu tri
- Sau tiim 1 ngay va 1 tuan: ddnh gid cdc trifu chung lien quan din mui tiem (dau, cpm, chdi sang, chay nude mat, xung huyet kit mgc, xuat huyit kit mac, viem ngi nhan).
- Sau tiim 1 tudn, 1 thdng, 2 thdng, 3 thdng, 4 thdng, 5 thang, 6 thdng: thft thj lyc, nhan dp, kilm tra lai tinh trang vong mgc va dia thj bang soi ddy mdt va chup mgch huynh quang, do ddy vong mac trung tam bang OCT.
- Trudc khi tiem mui tiep theo bfnh nhdn dugc kiim tra thj lyc va OCT Ak ddnh gia do ddy ciia vdng mac trung tam.
2.2.3. Pltuang phdp xu ly sd liiu: EXCEL vd SPSS 22.0.
3. KET QUA NGHIEN CUU 3.1. Dac diem chung
Nghien cftu gdm 33 mit cua 17 benh nhdn, tudi tu 50 din han 70 tudi, yung binh Id 60,06 ± 13,10 tudi. Trong do cd 4 nam (23,4%), 13 nii (76,5%).
Thdi gian phdt hifn bfnh dai thao dudng bung binh Id 10,47 ± 6,14 tudi. 12 bfnh nhan (70,6%) trong nghien cuu cd mftc HbAlc tren 7%. HbAlc trung binh Id 9,506 ± 3,298%.
3.2. Dgc dilm lam sang benh vong mac dai thao dirdng
- 33 mdt trong nghien cihi cua chung tdi deu cd phii hoang dilm. Cdc tin thuang ddy mdt khac ciia bfnh 1^ vong mac dai thdo dudng chu yiu cd:
vi phinh mgch 29/33 mdt (87,9%), xuit huyit vdng mac 26/33 mdt (78,8%), xudt tiit cftng 23/33 mdt (69,7%).
138 Tap chf Y Dupc hpc - Trufrng Dgi hpc Y Dupc Hue '-"So 32
- Hinh thai tdn thuong chu ylu Id dgng khdng tdng sinh (60,6%).
- Khdng cd su khde bift vl thdi gian trung binh phat hifn benh ddi thao dudng, HbAlC trung binh, mftc dd phu hodng diim trung binh gifta nhdm cd tang sinh vd khdng tdng sinh.
3.3. Kit qua diiu trj BVMDTD bdng tiem Bevacizumab npi nhan
Bang 3.1. Mftc dg cai thifn thi lyc sau tiim ndi nhan Bevacizumab
Bang 3.2. Mftc dg cdi thien phu hoang diem saii 1 thdng, 2 thdng, 3 thdng, 4 thdng, 5 thdng, 6 thdng
Trudc diiu tri Sau 3 thang Sau 6 thdng
GTTB (log) 0,824 0,690 0,610
Dp lech chuSn
(los) 0,644 0,575 0,425
P
<0,01
<0,01 0,123 Truac dieu trj
Sau 1 thang Sau 2 thang Sau 3 thang Sau 4 thang Sau 5 thang Sau 6 thang
GTTB (lim) 280,36 277,06 273,42 261,85 261,88 262,67 263,36
Do lech chuan (^m)
20,986 21,830 20,505 16,489 15,449 15,157 16,269
P
<0,01
<0,01
<0,01
<0,01
<0,01
<0,01 Nhdn xet:
- Trung binh thi lyc sau dilu trj 3 thang, 6 thang Idn hon gid tri trung binh ciia thj lyc trudc dilu tri.
- Trung binh thi lyc sau dilu tri 3 thdng vd sau 6 thang Id nhu nhau.
- Thi lyc tdng them gifta 2 nhdm tang sinh vd khdng tang sinh la nhu nhau.
Nhdn xet:
- Trung binb dp phu hodng diem sau dilu tri thdp nhit d thdi diim 3 thdng (261,85 ± 16,489 pm), sau do tdng trd lai d cdc thdng thft 5 vol 262,67 ± 15,157 pm, thu 6 vdi 263,36 ±16,269 pm.
- Mftc dg giam phii hodng diem giua 2 nhdm tdng sinh vd khdng tdng smh la nhu nhau.
Bang 3.3. Tuong quan gifta thj lyc va dg ddy vdng mac trung tam
OCT
Thj lijc TO
r 0,291
P 0,101
Tl r 0,265
P 0,136
T2 r 0,278
P 0,117
T3 r 0,261
P 0,142
T4 r 0,261
P 0,143
T5 r 0,350
P 0,046
T6 . r 0,211
P 0,238 r: Hf sd tucmg quan p: Gia trj kha ndng - Mftc y nghTa
Nhgn xet:
Khdng cd moi tuong quan gifta thi lyc vd dg ddy vdng mgc trung tdm do bang OCT trudc dilu trj, sau dieu tri 1 thdng, 2 thdng, 3 thdng, 4 thdng va 6 thang. Cd moi tuang quan thudn gifta thi lyc va dg ddy vong mgc trung tam do bdng OCT sau dilu trj 5 thdng (r=0,350) nhung mftc dp tuong quan yeu.
BSng 3.4. Cac biin chftng trong va sau dieu tri tiim ngi nhan Bi^n
chii-n2 So mat Ty le %
Sau 23 69,7
Xuat huyet ket mac
22 66,7
Tang nhan ap
3 9,1
Viem nQl nhan
0 0
Tang huvet ap
2 6,1
Nghen mach huyet khoi
0 0 Nhdn xet.
Biin chftng trong vd sau diiu tri tiem ndi nhdn gap nhilu nhat Id dau vdi 23/33 mdt (69,7%.), xudt huyet kit mac tugng duong 22/33 mdt (66,7%). 3 yudng hgp tang nhan dp chiim 9,1% vd 2 trudng hgp tang huyit dp chiem 6,1 %..Khdng cd trudng ha^ ndo ghi nhgn biin chftng viim ngi nhdn hay nghen mgch huyit khdi xdy ra.
Tgp chl Y Dupc hpc - Trudng Dgi hpc Y Dupc Hue - s i 32 139
4. BAN LUAN
Chung tdi nghiin cftu thay khdng cd sy khde bift vl thdi gian trung binh phdt hifn bfnh dai thdo dudng va HbAlC trung binh gifta nhdm cd tang sinh vd khdng tdng sinh. Dilu nay cho thiy mdc du thdi gian mdc bfnh ddi thdo dudng vd mftc do kilm sodt dudng huyet la 2 ylu td nguy ca quan trgng cua BVMDTD nhung khdng thi dya vao dd di tien doan giai doan BVMDTD.
Hgn nfta, d nude ta do nhiiu ylu td vi ddi song kinh tl xa hdi, ve hieu biit y hgc cua ngudi dan, vi ca sd vdt chdt hf thong y tl dia phuang... anh hudng din thdi dilm phat hien benh ddi thdo dudng sdm hay mudn. Do dd, vifc kiem tra vd theo ddi BVMDTD nin dugc tien hanh ngay tft thdi dilm chin dodn xdc dinh mdt benh nhdn mdc ddi thdo dudng d nude ta. Chung tdi ciing thay khdng cd sy khde bift vi gid tri mftc do phii hodng diem trung binh gifta nhdm cd tdng sinh vd khdng tdng sinh. Hay ndi each khde phu hoang diem cd the ggp d tdt ca cdc giai doan ciia BVMDTD.
Theo nghien cftu cua chiing tdi, sau tiem Bevacizumab npi nhan dieu trj BVMDTD thi luc cdi thifn tdt nhit sau 3 thang, sau dd din dn djnh, khdng tang them d cac thang sau dd. Dilu ndy la diing theo muc tieu diiu tri BVMDTB gift Igi tbi lyc cho benh nhdn, trdnh dl thi luc xuong thap hon.
Mftc dp cdi thien thj lyc la nhu nhau d 2 nhdm BVMDTD tang sinh vd khdng tdng sinh. Chftng td dieu tri tiim Bevacizumab ngi nhan vdn cd tac dyng cdi thifn thj lyc d giai dogn mugn cua BVMDTD.
Trung binh do phii hoang diim sau dilu tri thip nhit d thdi diem 3 thang sau dd tang trd lai d cdc thdng thft 5, thu 6. Sy tdng gia trj trung binh ndy nay cung tuong tu nghien cuu ciia tac gia Atul Kumar vdi gid tri trung binh cfta dg phu hoang dilm sau diiu trj thip nhit d thdi diem 3 thdng, sau dd Iai tang nhe trd Igi d thdng thft 6.
Theo quy trinh tiem, nlu do ddy CSF tren OCT
> 250 |im hay thj lyc sau tiim < 20/20, tiim
> 6 thdng nhftng bfnh nhan ndy cd thi hoan tiem, xem xet laser khu trii/ludi niu do ddy CSF tren OCT > 250 pm va tai khdm sau 4 tuin. Nlu on djnh tuc (do day vdng mac trung tam qua
OCT hogc dilm chft thj lyc khdng cdi thien cung khdng xiu di) hay cdi thien (dd day vdng mac.
trung tdm qua OCT gidm > 10% hoac dilm chft thj lyc tang > 5 chft) thi nhdn ddi thdi gian theo doi lln 8 tudn. Niu xau di (dp ddy vdng mgc trung tdm qua OCT tang > 10%i hoac dilm chft thi lyc gidm > 5 chu) thi tiem tilp.
Theo nghiin cuu ndy, mftc dd gidm phu hodng dilm gifta 2 nhdm BVMDTD tdng sinh vd khdng tdng sinh sau dilu trj tiim Bevacizumab cdc thdng la nhu nhau. Nhu vdy, cung gidng nhu mftc dg cdi thipn thj lyc, diiu tri tiim Bevacizumab ngi nhan vdn cd tac dyng cdi thifn do phii vdng mgc trung tdm, do phu hoang dilm d giai doan muOn cua BVMDTD. Diiu nay md ra cho bac sJ nhan khoa vd cd nhftng bfnh nhdn cd BVMDTD nang nhieu ca hdi lya chgn phuang phap dilu tri phii hgp nhdt vdi tinh trang benh Iy vdng mgc ddi thdo dudng.
Chung tdi thiy khdng cd mdi tuang quan hogc tuong quan ylu gifta thi lyc vd dg day vdng mac trung tam do bdng OCT trudc dieu trj, sau dieu trj tiim Bevacizumab ngi nhan. Vi the, mac du OCT Id mdt xet nghifm quan trgng trong theo ddi phu hoang dilm do dai thao dudng nhung vdn khdng thi thay thi dugc gid trj thi luc. Dd ciing la 1;^ do trong quy trinh tiem va theo ddi anti-VEGF npi nhdn ludn dya trin 2 yiu to thj lyc va do ddy vong mgc trung tdm.
Tiim anti-VEGF ndi nhan Id mot thu thugt xam nhap nen bien chftng tgi chd Id khd tranh khdi nhung cd the chap nhgn dugc. Khdng cd trudng hgp nao ghi nhan bien chung viim ndi nhdn hay nghen mgch huyit khoi xdy ra. Day la mgt dau hifu tdt. Ky thudt tiim anti-VEGF kha don gian nhung ddi hdi mdi truong vd khuin tuyet doi cung nhu phdi dugc dao tag dl trdnh cdc bien chftng viem nhilm xdy ra.
5. KET L U ^
Dilu tri bpnh ly vdng mgc ddi thdo dudng bdng tiim Bevacizumab ngi nhan cdi thien thj lyc vd mftc do phii hodng diem sau 3 thdng va dan dn djnh d nhiing thang sau. Tuy nhiin hieu qud dilu tri niu cdn tdi phat trd lai thi cdn dugc nghien cuu thim.
140 Tgp chf Y Dupc hpc - Trudng Dgi hpc Y Dupc Hue r Si 32
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Tgp chi Y Dupc hpc - Trudng Dgi hpc Y Dirpc H u i - So 32
