Suygiap
- 1. C畉PNH畉T CH畉NON & I畛UTR畛 SUYGIP2016 TS. BS NGUY畛N TH畛 THU TH畉O TK N畛I TI畉T TH畉N - BVNDG
- 2. M畛c 鱈ch y棚u c畉u Hi畛u 動畛c sinh b畛nh h畛c, nguy棚n nh但n suy gi叩p Ch畉n o叩n v i畛u tr畛 動畛c suy gi叩p nguy棚n ph叩t Bi畉t 動畛c c叩c th畛 l但m sng v i畛u tr畛 動畛c: suy gi叩p d動畛i l但m sng, suy gi叩p v thai k畛, suy gi叩p 畛 ng動畛i l畛n tu畛i v c坦 b畛nh l箪 tim m畉ch Bi畉t 動畛c TSH m畛c ti棚u theo c叩 th畛 ho叩
- 3. SUY GIP Suy gi叩p l t狸nh tr畉ng gi畉m ch畛c nng tuy畉n gi叩p Gi畉m SX hormone gi叩p d動畛i m畛c b狸nh th動畛ng T畛n th動董稼g m担 v RL chuy畛n ho叩.
- 4. T4 T3 Chuy畛n h坦a c畛a Hormone tuy畉n gi叩p TUY畉N YN TUY畉N GIP VNG D働畛I 畛I TRH T4 T3 Gan T4 T3 TIM GAN X働NG H畛 TKTW Th畛th畛 C叩c m担 鱈ch TSH Adapted from Merck Manual of Medical Information. ed. R Berkow. 704:1997. C董 ch畉 feedback
- 5. T畉n su畉t suy gi叩p tng theo tu畛i Colorado research Canaris GJ et al. The Colorado Thyroid Disease Prevalence Study. Arch Intern Med 2000;160:526-534 T畉n su畉t SG/ c畛ng 畛ng DS chung 2%, SG DLS: 5 9% T畉n su畉t SG gia tng 畛 T t鱈p 1, 2, STM, B辿o ph狸
- 6. SUY GIP: Nguy棚n nh但n SG nguy棚n ph叩t (95% tr動畛ng h畛p) V挑nh vi畛n: VG Hashimoto, SG nguy棚n ph叩t th畛 s董 teo, SG sau i畛u tr畛 (m畛, 131I, chi畉u x畉) H畛i ph畛c: giai o畉n SG c畛a vi棚m gi叩p b叩n c畉p, VG th畛 y棚n l畉ng, do thu畛c (iod v担 c董, thu畛c kh叩ng gi叩p, lithium) SG th畛 ph叩t, SG tam ph叩t (SG trung 動董稼g 5%) B畛nh V湛ng h畉 畛i-Tuy畉n y棚n, ho畉i t畛 TY sau sinh, u, lo畉i kh叩c M担 ngo畉i vi 畛 kh叩ng v畛i hormon gi叩p (hi畉m)
- 7. Tri畛u ch畛ng c畛a suy gi叩p r畉t a d畉ng Tuy畉n gi叩p Tng LDL cholesterol2 Tng triglycerides2 Gan Ru畛t T叩o b坦n4 Gi畉m nhu 担ng ru畛t4 Gi畉m k/n sinh s畉n6 RL kinh nguy畛t6 H畛 sinh s畉n Tr畉m c畉m1 Gi畉m t畉p trung1 Gi畉m h畛ng th炭1 Suy gi畉m ph叩t tri畛n tr鱈 tu畛7 N達o Gi畉m ch畛c nng5 Gi畛 n動畛c v ph湛5 Th畉n Gi畉m nh畛p tim3 Tng HA3 Gi畉m cung l動畛ng tim3 Trn d畛ch mng tim RL ch畛c nng t但m tr動董稼g3 Tim 1. Nemeroff CB. Clinical significance of psychoneuroendocrinology in psychiatry: focus on the thyroid and adrenal. J Clin Psychiatry. 1989;50(suppl):13-20. 2. Klausen IC, Nielsen FE, Heged端s L, Gerdes LU, Charles P, Faergeman O.Treatment of hypothyroidism reduces low-density lipoproteins but not lipoprotein (a) Metabolism. 1992;41:911-914. 3. Polikar R, Burger AG, Scherrer U, Nicod P. The thyroid and the heart. Circulation. 1993;87:1435-1441. 4. Vassilopoulou-Sellin R, Sellin JH. The gastrointestinal tract and liver in hypothyroidism. In:Braverman LE, Utiger RD, eds. Werner and Ingbars The Thyroid. 7th ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1996:816-820. 5. Moses AM, Scheinman SJ. The kidneys and electrolyte metabolism. In:Braverman LE, Utiger RD, eds. Werner and Ingbars The Thyroid. 7th ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1996:812-815. 6. Emerson CH.Thyroid function and disease in the female. In: Gold JJ, Josimovich JB, eds. Gynecologic Endocrinology. 4th ed. New York, NY:Plenum Publishing Corp; 1987:109-133. 7. Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N Engl J Med. 1999;341:549-555.
- 8. Tri畛u ch畛ng suy gi叩p M畛t m畛i Tng c但n Da kh担 v s畛 l畉nh Xanh t叩i L動畛i l畛n v dy R畛ng l担ng, t坦c Gi畛ng khn i畉c Gi畉m t狸nh d畛c Braverman LE, et al. Werner & Ingbars The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000. M畉t t畉p trung Hay qu棚n Tr畉m c畉m Ch畉m ch畉p RL kinh nguy畛t v v担 sinh Nh畛p tim ch畉m T叩o b坦n H担n m棚 suy gi叩p
- 9. Ph湛 c畛ng Ph湛 c畛ng c坦 mu vng (th畛a Carotene)
- 10. C畉N LM SNG Tu畛 theo nguy棚n nh但n (SG nguy棚n ph叩t, th畛 ph叩t) Thi畉u m叩u Tng Lipid m叩u T: nh畛p ch畉m, i畛n th畉 th畉p, ST ch棚nh - T d畉t/畉o ng動畛c Trn d畛ch mng tim Gi畉m Natri m叩u
- 11. C畉P NH畉T M畛T S畛 KHUY畉NCO
- 12. C叩c x辿t nghi畛m 動畛c s畛 d畛ng 畛 ch畉n o叩n suy gi叩p 1. TSH v FT4 動畛c d湛ng 畛 ch畉n o叩n v theo d探i i畛u tr畛 suy gi叩p. (Khuy畉n c叩o 8) 2. Kh担ng s畛 d畛ng T3 ton ph畉n v FT3 畛 ch畉n o叩n SG (Khuy畉n c叩o 10) 3. C叩c kh叩ng th畛 kh叩ng tuy畉n gi叩p: Anti TPO, TRAb
- 13. Ch畛c nng tuy畉n gi叩p TSH Trung b狸nh N畉ngNh畉 Gi叩 tr畛 b狸nh th動畛ng FT4 FT3
- 14. Th畉 no l tr畛 s畛 TSH b狸nh th動畛ng ? 1. Demers LM, Spencer CA. Thyroid 2003;13:1-126 D但n s畛 b狸nh th動畛ng TSH trung b狸nh= 1.5 mIU/L Tng nguy c董 SG TPO-Ab + TG l畛n TC Suy gi叩p, n畛 95% ng動畛i kh畛e m畉nh, b狸nh gi叩p < 2.5 mIU/L 0.4 mIU/L 4.0 mIU/L > 2.5 mIU/L C但n c坦 kho畉ng tham chi畉u ri棚ng bi畛t cho t畛ng qu鱈 畛 ph畛 n畛 c坦 thai > 10 mIU/L TSH d動畛i m畛c BT c坦 th畛 g畉p 20 % thai k畛 b狸nh th動畛ng
- 15. Ai l b畛nh nh但n suy gi叩p 畉u ti棚n ? Gull (Myxedema 1874) When King David was old and advanced in years, though they spread covers over him, he could not keep warm. His servants therefore said to him, Let a young virgin be sought to attend you, lord King, and to nurse you. If she sleeps with your royal majesty, you will be kept warm The maiden, who was very beautiful, nursed the King and cared for him, but the King did not have relations with her. Some speculate that King David was afflicated with hypothyroidism Mc Dermott T. M. (2013). Endocrine secrets questions you will be asked. Mosby Elsevier , Ed: 6th, pp: 523
- 16. i畛u tr畛 1. Lo畉i b畛 nguy棚n nh但n: Thu畛c KGTTH, K gi叩p 2. Ch畛 m畛t thu畛c T: Levothyroxin, L- Thyroxin, Thyroxin 3. 動a TSH v畛 m畛c m畛c ti棚u 0,4 4 IU/L (KC 22.1) 4. B畉t 畉u li畛u th畉p tng li畛u ch畉m m畛i 2-4 tu畉n Ng動畛i kh畛e m畉nh, < 50t: Li畛u 100mcg/ngy Ng動畛i kh畛e m畉nh, 50 60t: Li畛u 50mcg/ngy Li畛u kh畛i 畉u tu畛 theo m畛c TSH, tu畛i, ch畛nh li畛u d畛a tr棚n 叩p 畛ng LS v m畛c TSH. Li畛u t畛i a: 150 - 300袖g/ kg/ngy (KC 22.8) 5. N棚n duy tr狸 c湛ng lo畉i bi畛t d動畛c, n畉u thay 畛i => x辿t nghi畛m TSH sau 4 - 6 tu畉n ( ATA, AACE)
- 17. Thu畛c i畛u tr畛 suy gi叩p Thyroxine L d畉ng t畛ng h畛p hormone T4 c畛a tuy畉n gi叩p 動畛c h畉p thu t畛 h畛ng trng v h畛i trng: 80% Khuy畉n c叩o 23: u畛ng L-thyroxine 30 60 ph炭t tr動畛c b畛a n s叩ng ho畉c 4 gi畛 sau n chi畛u, b畉o qu畉n thu畛c 炭ng c叩ch v kh担ng d湛ng chung v畛i c叩c ch畉t ho畉c thu畛c 畉nh h動畛ng h畉p thu L-thyroxine. B2 U畛ng bu畛i s叩ng 畛 g但y m畉t ng畛 h董稼 bu畛i t畛i Bolk N et al. 2010 Arch IM 170:1996-2003 (EL2). Bach-Huynh TG 2009 JCEM 94:3905-12 (EL2.)
- 18. Theo d探i i畛u tr畛 SG trung 動董稼g: FT4 動畛c d湛ng ch畉n o叩n v theo d探i i畛u tr畛 SG, (kh担ng d湛ng TSH). FT4 m畛c ti棚u 畉t tr棚n gi畛i h畉n gi畛a c畛a b狸nh th動畛ng. (khuy畉n c叩o 12 & 24) SG ang T: ki畛m tra TSH 4 -8 tu畉n sau khi b畉t 畉u T hay sau thay 畛i li畛u, sau 坦 m畛i 612 th叩ng khi x叩c 畛nh 動畛c li畛u thay th畉 (khuy畉n c叩o 13)
- 19. Khuy畉n c叩o ATA/AACE K. c叩o 20.2: T畉m so叩t SG 畛 ng動畛i > 60t. B1 K. c叩o 22.9: Suy gi叩p c坦 k竪m suy th動畛ng th畉n n棚n cho glucocorticoid tr動畛c L-thyroxine. B2 K. c叩o 17: SG kh担ng c坦 thai, c畉n 畉t TSH 畛 gh b狸nh th動畛ng c畛a TSH th畉 h畛 3 (0,4 -4mIU/L) v湛ng 畛 iod.
- 20. Nh畛ng tr動畛ng h畛p 畉c bi畛t Suy gi叩p d動畛i l但m sng Suy gi叩p v thai k畛 Suy gi叩p v b畛nh tim m畉ch Suy gi叩p ng動畛i gi
- 21. Suy gi叩p d動畛il但m sng(Subclinicalhypothyroidism) Suy gi叩p d動畛i l但m sng 動畛c 畛nh ngh挑a l tng TSH huy畉t thanh trong khi n畛ng 畛 FT4 b狸nh th動畛ng. Kh担ng c坦 tri畛u ch畛ng suy gi叩p N畉m gi畛a b狸nh gi叩p v suy gi叩p T畛 l畛 4-8.5%; c坦 th畛 t畛i 15% 畛 ph畛 n畛 > 60 tu畛i Nguy棚n nh但n: gi畛ng suy gi叩p th畛c s畛 i畛u tr畛: C嘆n tranh c達i Nguy c董: tng c但n, tr畉m c畉m, RL lipid m叩u, m畛t m畛i 1. MD Danese, et al. JAMA 1996; 276:285-292.
- 22. Suy gi叩p d動畛i l但m sng (TSHnh畉/v畛a/cao: SG LS 2%/20%/73%/nm) Khuy畉n c叩o 15: TSH > 10UI/ml tng nguy c董 suy tim v t畛 vong do TM Xem x辿t i畛u tr畛 Khuy畉n c叩o 16: n畉u TSH cao h董稼 gi叩 tr畛 tham chi畉u v < 10UI/ml xem x辿t T n畉u c坦: TC g畛i 箪 suy gi叩p, TPOAb+ Ho畉c c坦 b畛nh TM, suy tim
- 23. Wiersinga M.W (2014). Adult Hypothyroidism. In: De Groot J.L: Endotext.
- 24. UKGeneralPracticeResearchDatabase(10tri畛uh畛 s董) Nm 2001: C坦 322,291 k畉t qu畉 o TSH 4,735 ng動畛i > 40 tu畛i, TSH 5.0- 10.0 mU/l, FT4 b狸nh th動畛ng C坦 3093 ng動畛i tu畛i 40- 70 v 1642 ng動畛i > 70 tu畛i 達 lo畉i tr畛 BN ang i畛u tr畛 L-T4, thu畛c KGTTH, ti畛n s畛 b畛nh tuy畉n gi叩p, b畛nh m畉ch vnh, 畛t qu畛 ho畉c b畛nh tim m畉ch kh叩c Nh坦m kh担ng i畛u tr畛: Sau 7,6 nm 1.3% ph叩t tri畛n thnh suy gi叩p th畛c s畛: TSH >10, v/ho畉c FT4 58% v畉n c嘆n tng TSH 38% tr畛 l畉i b狸nh gi叩p 2.5% ti畉n tri畛n v畛 gi畉m TSH Razvi S et al. Arch Intern Med 2012
- 25. Suy gi叩p v thai k畛 Chi畉m 2 3% (15%) 畛 PN mang thai, th動畛ng l VG Hashimoto
- 26. Tng TSH c畛a thai ph畛 v IQ scores c畛a con Thai ph畛 c坦 SG kh担ng i畛u tr畛 c坦 nhi畛u kh畉 nng c坦 con v畛i IQs < 85 (c坦 箪 ngh挑a th畛ng k棚). Trong nh坦m con c畛a c叩c thai ph畛 i畛u tr畛 SG trong l炭c mang thai, % c坦 IQ < 85 kh担ng kh叩c bi畛t c坦 箪 ngh挑a th畛ng k棚 v畛i nh坦m ch畛ng Ch畛ng, n = 124 SG kh担ng i畛u tr畛, n = 48 T畛 l畛 c坦 IQ<85 0 5 10 15 20 25 Tr畉 nh坦m ch畛ng Tr畉 c坦 m畉 suy gi叩p kh担ng i畛u tr畛 Percent of children with IQ < 85 5 % 19 % P value = 0.007 1. Adapted from: JE Haddow et al., N Engl J Med. 1999;341:529-555
- 27. 10 20 30 40Tu畉n thai 0 +50 +100 % thay 畛i vs. Kh担ng c坦 thai -50 1st. Trimester 2nd. Trimester 3rd. Trimester TSH th畉p trong tam c叩 nguy畛t 畉u FT4 trong thai k畛 c坦 th畛 kh担ng tin c畉y E2 TBG hCG TT4 FT4 TSH
- 28. B畛nh tuy畉n gi叩p v thai ngh辿n c坦 nhi畛u tri畛u ch畛ng chung 1. S Mandel. Best Practice & Research Clinical Endocrinology & Metabolism 2004;18:213-224. Ch畉n o叩n suy gi叩p r畉t quan tr畛ng 畉nh h動畛ng x畉u l棚n thai k畛, Kh担ng c坦 tri畛u ch畛ng g狸 畉c bi畛t C叩c than phi畛n v畛 tng c但n, m畛t li棚n h畛 畉n thai ngh辿n. M畛t Bu畛n n担n Tng c但n Thay 畛i da, t坦c, m坦ng tay R畛i lo畉n gi畉c ng畛 B坦n Cho叩ng v叩ng/ch坦ng m畉t Thay 畛i t鱈nh t狸nh Nh畛c 畉u B畛nh Tuy畉n gi叩p Thai ngh辿n
- 29. Suy gi叩p li棚n h畛 v畛i tng bi畉n c畛 trong thai k畛 Tng bi畉n c畛 畛 m畉 THA thai k畛, ti畛n s畉n gi畉t Bong nhau Bng huy畉t sau sinh Tng t畛 l畛 m畛 cesarean Tng bi畉n c畛 cho con =20% Sanh non, sanh r畉t non ( tr動畛c 32 tu畉n) CN th畉p l炭c sinh, thai l動u, d畛 t畉t b畉m sinh Tng t畛 su畉t chu sinh Gi畉m nh畉n th畛c v t但m th畉n kinh, ch畛 s畛 IQ th畉p T畉m so叩t v T s畛m s畉 c畉i thi畛n c叩c bi畉n c畛
- 30. Suy gi叩p Hypothyroidism B畛nh l箪 tuy畉n gi叩p v 畉nh h動畛ng c坦 h畉i 畉n thai k畛 tr棚n nh坦m ph畛 n畛 c坦 thai. Ph但n t鱈ch h畛i c畛u tr棚n 223.512 thai k畛 t畉i M畛 (2002 2008). J Clin Endocrinol Metab 2013;98: 27252733
- 31. Suy gi叩p nguy棚n ph叩t lm tng nguy c董 c叩c bi畉n ch畛ng trong thai k畛 47% 57% 34% 15% 38% 208% 0% 30% 60% 90% 120% 150% 180% 210% 240% Tng nguy c董 Ti畛n s畉n gi畉t T thai k畛 Sinh non D畛c sanh M畛 b畉t con Nh畉p ICU J Clin Endocrinol Metab 2013;98: 27252733
- 32. C畉n t畉m so叩t suygi叩p 畛 nh畛ng 畛i t動畛ng no trong s畛 nh畛ng ph畛n畛 c坦 thai ho畉c d畛 畛nh c坦 thai? Khuy畉n c叩o 20.1.1 & 20.1.2: kh担ng khuy畉n c叩o sng l畛c hng lo畉t cho t畉t c畉 ph畛 n畛 ang c坦 thai ho畉c d畛 畛nh c坦 thai, ch畛 n棚n t畉m so叩t suy gi叩p c坦 ch畛 鱈ch
- 33. i畛u ch畛nhli畛u LT4 trong thai k畛 v sau sinh BN ang T suy gi叩p,khi c坦 thai c畉n tng li畛u L-T4 25% - 30%. Tng li畛u 董稼 gi畉n t畛 1vi棚n/ngy thnh 9vi棚n/tu畉n (tng 29%=tng g畉p 2 li畛u c畛a 2ngy/tu畉n) Suy gi叩p ang i畛u tr畛, d畛 畛nh c坦 thai c畉n ch畛nh li畛u 畛 TSH < 2,5 mIU/L Sau khi sinh, tr畛 v畛 li畛u tr動畛c khi c坦 thai, ki畛m tra TSH sau 6 tu畉n ATA 2011
- 34. Khuy畉n c叩o ATA/AACE Khuy畉n c叩o 25.1 v 25.2: BN suy gi叩p ang i畛u tr畛 L- thyroxine m c坦 thai, c畉n 畛nh l動畛ng TSH ngay khi c坦 thai v ch畛nh li畛u L-thyroxine 畛 : TSH trong 3 th叩ng 畉u < 2,5 袖UI/mL TSH trong 3 th叩ng gi畛a < 3,0 袖UI/mL TSH trong 3 th叩ng cu畛i < 3,5 袖UI/mL. Khuy畉n c叩o 25.3: BN suy gi叩p ang T Levothyroxin, theo d探i TSH v FT4 m畛i 4 tu畉n trong n畛a 畉u thai k畛, v 鱈t nh畉t m畛t l畉n 畛 tu畉n 26-32 c畛a thai k畛. i畛u ch畛nh li畛u L- thyroxine t動董稼g 畛ng.
- 35. Khi no c畉n 畛nh l動畛ng kh叩ng th畛 kh叩ng gi叩p? Khuy畉n c叩o 1: 畛nh l動畛ng TPO-Ab/BN suy gi叩p DLS B 1 Khuy畉n c叩o 2: TPOAb gi炭p ph叩t hi畛n VG t畛 mi畛n khi nghi ng畛 b畛nh l箪 nh但n gi叩p do b畛nh l箪 t畛 mi畛n gi叩p. D 4 Khuy畉n c叩o 3: 畛nh l動畛ng TPOAb 畛 b畛nh nh但n s畉y thai t叩i ph叩t c坦 k竪m ho畉c kh担ng k竪m v担 sinh. A 2 Khuy畉n c叩o 4: 畛nh l動畛ng TRAb 畛 ph畛 n畛 c坦 thai b畛 suy gi叩p v畛i ti畛n s畛 Basedow 動畛c i畛u tr畛 b畉ng ph畉u thu畉t hay iode ph坦ng x畉. Th畛c hi畛n TRAb 畛 3 th叩ng 畉u thai k畛 v vo tu畉n thai 20 26 n畉u TRAb tng tr畛 l畉i. A 2
- 36. T畉m so叩t suy gi叩p trong thai k畛 Hi畛p h畛i TG Hoa K畛 khuy畉n c叩o o TSH: - C坦 tri畛u ch畛ng SG ho畉c c坦 BG - > 30 tu畛i - Ti畛n cn gia 狸nh c坦 b畛nh TG - TPO Ab (+) - T t鱈p 1 ho畉c b畛nh t畛 mi畛n kh叩c - Ti畛n cn sanh non, s畉y thai - V担 sinh - X畉 tr畛 畉u c畛 - B辿o ph狸 b畛nh l箪 (BMI>40) - V湛ng thi畉u iod v畛a, n畉ng - D湛ng amiodaron, lithium ho畉c m畛i d湛ng c畉n quang iod American Thyroid Association 2016
- 37. B畛nh nh但n no v畛iTSH b狸nh th動畛ng c畉n i畛u tr畛 L-thyroxine? Khuy畉n c叩o 19.1: xem x辿t T b畉ng L-thyroxine 畛 ph畛 n畛 tu畛i sinh 畉, ho畉c d畛 畛nh c坦 thai, ho畉c ang c坦 thai c坦: TSH 2,5 袖UI/mL TSH 3,0 袖UI/mL 畛 3 th叩ng gi畛a thai k畛 TSH 3,5 袖UI/mL 畛 3 th叩ng cu畛i thai k畛
- 38. B畛nh nh但n no v畛i TSH b狸nh th動畛ng c畉n i畛u tr畛 L-thyroxine? Khuy畉n c叩o 19.2: xem x辿t T b畉ng L-thyroxine 畛 ph畛 n畛 c坦 TSH b狸nh th動畛ng, ang c坦 thai ho畉c d畛 畛nh c坦 thai, n畉u: TPOAb (+) ho畉c 達 t畛ng (+) v/ ho畉c C坦 ti畛n s畛 s畉y thai ho畉c b畛 suy gi叩p tr動畛c 但y B 2 Khuy畉n c叩o 19.3: N棚n i畛u tr畛 L-thyroxine 畛 ph畛 n畛 trong 畛 tu畛i sinh 畉 ang c坦 thai ho畉c d畛 畛nh c坦 thai, c坦 TPOAb (+) ho畉c 達 t畛ng (+) v TSH > 2,5 袖UI/mL. B2 Khuy畉n c叩o 19.4: Ph畛 n畛 c坦 TPOAb(+)ho畉c TSH> 2,5袖UI/mL n畉u kh担ng 動畛c i畛u tr畛 b畉ng L-thyroxine c畉n theo d探i m畛i 4 tu畉n trong 20 tu畉n 畉u c畛a thai k畛 畛 ph叩t hi畛n suy gi叩p B2
- 39. i畛u tr畛 suygi叩p cho BN c坦 b畛nh tim m畉ch i畛u tr畛 L-T4 cho BN c坦 TMCT=> nguy c董 b畛 NMCT, au th畉t ng畛c v lo畉n nh畛p tim. BN <50t: Li畛u kh畛i 畉u L-T4 25 50 g/ng, tng li畛u d畉n, theo d探i /4 tu畉n. BN >50t: Li畛u kh畛i 畉u 12,5 - 25g/ng, tng li畛u d畉n, theo d探i/4-6 tu畉n. Ch畛nh li畛u: ch畛 tng 12.5-25 g/l畉n Braverman LE, et al. Werner & Ingbars The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000. Kohno A, et al. Endocr J. 2001;48:565-572.
- 40. M畛c ti棚u d湛ng L-Thyroxin trong T suy gi叩p nguy棚n ph叩t C畉i thi畛n c叩c tri畛u ch畛ng suy gi叩p (c董 nng, th畛c th畛) 畉t b狸nh th動畛ng ho叩 TSH, c畉i thi畛n n畛ng 畛 hormon gi叩p Tr叩nh g但y nhi畛m 畛c gi叩p (do T qu叩 m畛c, nh畉t l BN l畛n tu畛i) Jonklaas J. et al (2014). Guidline for the treatment of hypothyroidism thyroid. Vol 24, pp: 1670
- 41. T畉i sao L-Thyroxin董稼tr畛 動畛c xem l chu畉n m畛c cho T suygi叩p? Gi畉i quy畉t c叩c TC suy gi叩p hi畛u qu畉 Kinh nghi畛m l但u di v畛 c叩c l畛i 鱈ch c畛a n坦 t t叩c d畛ng ph畛, h畉p thu t畛t 畛 ru畛t D畛 s畛 d畛ng Th畛i gian b叩n hu畛 k辿o di (7 10 ngy) Gi叩 thnh r畉 Khuy畉n c叩o AACE/ATA N棚n d湛ng ch鱈nh h達ng, tr叩nh chuy畛n 畛i t畛 1 d畉ng ny sang 1 d畉ng kh叩c, t畛 d畉ng g畛c sang d畉ng generic ho畉c t畛 d畉ng generic ny sang d畉ng generic kh叩c, v狸 c坦 th畛 g但y ra dao 畛ng v畛i li畛u s畛 d畛ng. N畉u c坦 thay 畛i th狸 n棚n ki畛m tra l畉i TSH sau 4 6 tu畉n 2004 AACE, TES, and ATA Joint Position Statement on the Use and Interchangeability ofThyroxine Products
- 42. KHUY畉N CO ATA/AACE S畛 d畛ng c叩c bi畛t d動畛c levothyroxin ch畉t l動畛ng t畛t v 畛n 畛nh, Nhi畛u levothyroxin kh担ng 動畛c so s叩nh v畛i Levothyroxin chu畉n. T動董稼g 動董稼g sinh h畛c kh担ng c坦 ngh挑a l t動董稼g 動董稼g v畛 hi畛u qu畉 i畛u tr畛. T動董稼g 動董稼g sinh h畛c c畛a c叩c thu畛c levothyroxin d畛a tr棚n t畛ng hm l動畛ng T4 Trong su畛t qu叩 tr狸nh i畛u tr畛, BN n棚n 動畛c s畛 d畛ng c湛ng m畛t lo畉i bi畛t d動畛c levothyroxin.
- 43. C叩c y畉u t畛 畉nh h動畛ng i畛u tr畛 TCLS v畉n c嘆n t畛n t畉i k辿o di sau T Levothyroxin? Nguy棚n nh但n: 1. Do b畛nh m畉n t鱈nh 2. C坦 b畛nh t畛 mi畛n k竪m theo, 3. C坦 b畛nh d畉 dy ru畛t 4. C叩c thu畛c d湛ng chung 畉nh h動畛ng s畛 h畉p thu L-T4 5. Li畛u L-T4 kh担ng 畛р (BN kh担ng tu但n th畛) 6. Ph動董稼g th畛c T kh担ng th鱈ch h畛p Wiersinga W.M. et al (2012). ETA T4/T3 Guidelines. Eur Thyroid J. V1, pp: 55 - 71
- 44. C叩c thu畛c lm gi畉m t叩c d畛ng c畛a L-T4 Gi畉m h畉p thu 畉nh h動畛ng 畉n chuy畛n h坦a Cholestyramine, Colestipol Sucralfate, Kayexalate Ferrous sulfate (s畉t) 畛c ch畉 b董m proton Aluminum hydroxide Ciproloxacin Multivitamins Rifampin Carbamazepine Phenytoin Phenobarbitol Amiodarone U畛ng l炭c n, ch畉 畛 n nhi畛u x董, 畉u nnh
- 45. C叩c nguy棚n nh但n 畉nh h動畛ng 畉n li畛u i畛u tr畛 畛 畉t TSH m畛c ti棚u C但n n畉ng ( m畉p, g畉y) L畛n tu畛i (li畛u kh畛i 畉u th畉p, m畛c ti棚u TSH cao h董稼) Mang thai (nhu c畉u cao h董稼, TSH m畛c ti棚u theo TCN) Nguy棚n nh但n suy gi叩p M畛c tng TSH T狸nh hu畛ng l但m sng chung (b畛nh tim m畉ch, K gi叩p) C畉n 畉t ra TSH m畛c ti棚u 畛 t畛ng nh坦m b畛nh nh但n kh叩c nhau Jonklaas J. et al (2014). Guidline for the treatment of hypothyroidism thyroid. Vol 24, pp: 1670
- 46. M畛t s畛 tr動畛ng h畛p 畉c bi畛t T畉n su畉t SG 畛 ng動畛i T, STM > ng動畛i kh担ng T, kh担ng STM T t鱈p 2: NC n= 120 (60 T t鱈p 2, 60 ch畛ng) SG 35%, SGDLS 11,66% vs 5,4% v 4,1% T t鱈p 1: 10% di畛n ti畉n VG m畉n v SG 20% di畛n ti畉n vi棚m gi叩p sau sinh Suy th畉n m畉n: t畉n su畉t SG tng g畉p 1,5 l畉n so v畛i ng動畛i kh担ng STM i畛utr畛 s畉 c畉i thi畛n LCT v ng動畛c l畉i Kh担ng T di畛n ti畉n nhanh 畉n l畛c th畉n, v t畛 vong V担 sinh, RLKN, x畉y thai: c坦 li棚n h畛 Vi棚m gi叩p m畉n, Suy gi叩p, SGDLS N畉u b狸nh gi叩p m AntiTPO (+) T Levothyroxin, s畉 c畉i thi畛n c叩c v畉n 畛 tr棚n.
- 47. M畛t s畛 tr動畛ng h畛p 畉c bi畛t 畛 b畛nh nh但n ung th動 gi叩p nguy c董 cao (達 c坦 di cn, sau ph畉u thu畉t v iode VPX ph畉i d湛ng L-thyroxin l但u di 畛 畛c ch畉 TSH) M畛c TSH m畛c ti棚u: 0,01mIU/L - <0,1mIU/L Ung th動 gi叩p nguy c董 th畉p (ch動a di cn, ch動a x但m l畉n v畛 bao) M畛c Tg th畉p: m畛c TSH m畛c ti棚u 0,1mIU/L 0,5mIU/L N畉u Tg 但m t鱈nh: duy tr狸 m畛c TSH 0,5mIU/L 2mIU/L.
- 48. T坦m t畉t i畛u tr畛 v theo d探i suy gi叩p TSH >3.0 IU/mL TSH <0.4 IU/mL Li畛u Levothyroxine kh畛i 畉u Tng th棚m li畛u Levothyroxine 12.5 - 25 g/ng XN l畉i TSH 6-8 tu畉n TSH 0.4- 2.0 IU/mL H畉t tri畛u ch畛ng XN l畉i TSH m畛i 6 th叩ng, sau 坦 hng nm ho畉c khi c坦 tri畛u ch畛ng Duy tr狸 li畛u Gi畉m b畛t li畛u Levothyroxine 12.5 - 25 g/ng Singer PA, et al. JAMA. 1995;273:808-812. Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site. Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.
- 49. TSH va淡 FT4 TSH ta棚ng, FT4 tha叩p TSH bt hay tha叩p, FT4 tha叩p hay gi担湛i ha誰n tha叩p SUY GIAP NP TPO-Ab (+) TPO-Ab (-) Hashimoto SG tho湛ang qua VG ba湛n ca叩p LT4 # 4 tha湛ng Gia短m 50% LT4 x 6 tha湛ng, TSH TSH ta棚ngTSH bt KHONG SG SG VNH VIEN LT4 LT4 SUY GIAP TW MRI B狸nh th旦担淡ng Ba叩t th旦担淡ng Sang th旦担ng ha誰 単oi, tuye叩n ye但n SG do nguye但n nha但n hie叩m ga谷p Ti畉p c畉n ch畉n o叩n v i畛u tr畛 suy gi叩p
- 50. BN n畛 34 tu畛i, i畛u tr畛 suy gi叩p b畉ng Levothyroxine 100 g/ngy Ch畉m kinh 10 ngy, Test th畛 thai (+) Thai l畉n 2. L畉n 1 b畛 thai l動u l炭c 10 tu畉n Ng畛ng Thyroxin 3 ngy v狸 s畛 thu畛c c坦 畉nh h動畛ng 畉n thai TSH = 13,1 mIU/ml FT4 = 8,7pg/ml Anti TPO > 600 Ph畉i lm g狸? Tng li畛u LT4 th棚m 50 g/ngy o l畉i FT4, TSH sau 4 tu畉n, m畛c ti棚u TSH < 2,5mIU/L Gi畉i th鱈ch: Thyroxine c畛c k畛 quan tr畛ng cho s畛 ph叩t tri畛n c畛a n達o b畛 nh動ng thai kh担ng t畛ng h畛p 動畛c hormone gi叩p cho 畉n tu畉n 12 Levothyroxine l thu畛c gi畛ng h畛t hormone tuy畉n gi叩p t畛 nhi棚n Ca l但m sng 1
- 51. Ca L但mSng 2 SP 32t, thai 11 tu畉n con so, 動畛c 畛ng nghi畛p S畉n g畛i 畉n: TSH: 6,5 IU/ml, FT4: trong gi畛i h畉n b狸nh th動畛ng Si棚u 但m: Tuy畉n gi叩p to nh畉 2 thu畛, kh担ng nh但n, kh担ng tng sinh m畉ch m叩u. BS to lan to畉 2 thu畛, kh担ng c坦 TC suy gi叩p BS Lm g狸? TSH l畉n 2: 6,1 IU/ml, FT4: 0,79ng/dl C畉n lm th棚m g狸 n畛a? Ch畉n o叩n? SG d動畛i l但m sng i畛u tr畛?
- 52. M畛T S畛 B畉Y C畉N BI畉T
- 53. Ca l但m sng 3 BN n畛 29 tu畛i, nh但n vi棚n vn ph嘆ng C畉t ton b畛 tuy畉n gi叩p do K gi叩p d畉ng nh炭 c叩ch 但y 4 nm GPB: ch動a di cn, ch動a x但m l畉n v畛 bao i畛u tr畛 thay th畉 Thyroxin 50 g/ngy X辿t nghi畛m: TSH = 4,12 IU/ml , Tg (-) Ch畉n o叩n: K gi叩p d畉ng nh炭 ch動a di cn M畛c ti棚u: TSH 0,5 - 2 IU/ml Tng li畛u 100g/ngy
- 54. Ca l但m sng4 BN n畛 32 tu畛i, i畛u d動畛ng, m畛t m畛i, tng c但n, v嘆ng c畛 to ra Basedow ang T th叩ng th畛 5 (XN l炭c i畛u tr畛: TSH < 0,005, FT4= 5,4ng/dl, FT3= 3,45pg/ml, TRAb >40, SA: TG to 2 thu畛, tng sinh m畉ch m叩u nhi畛u) Li畛u Thyrozol hi畛n t畉i 15mg/ng x 4 th叩ng X辿t nghi畛m: TSH = 15 IU/ml , FT4 = 0,9ng/dl, TRAb = 12UI/ml Ph畉i lm g狸? Basedow - SG do qu叩 li畛u KGTH M畛c ti棚u: TSH 0,4 - 4 IU/ml Gi畉m li畛u Thyrozol
- 55. K畉T LU畉N Suy gi叩p l b畛nh l箪 r畉t th動畛ng g畉p T畉n su畉t b畛nh gia tng theo tu畛i, 畛 ng動畛i c坦 b畛nh th畉n m畉n, 叩i th叩o 動畛ng, b辿o ph狸 v v担 sinh. .. N棚n s畛 d畛ng c湛ng m畛t lo畉i bi畛t d動畛c L - Thyroxin, d湛ng li畛u th畉p tng d畉n, th畉n tr畛ng 畛 ng動畛i l畛n tu畛i, c坦 b畛nh l箪 tim m畉ch. Suy gi叩p trong thai k畛 lm tng c叩c bi畉n c畛 cho m畉 v thai nhi, c畉n tng li畛u L -Thyroxin v gi畛 m畛c ti棚u TSH < 2,5mUI/L, < 3mUI/L v < 3,5mUI/L theo th畛 t畛 3 th叩ng 畉u, 3 th叩ng gi畛a v 3 th叩ng cu畛i c畛a thai k畛. C畉n c叩 th畛 ho叩 trong i畛u tr畛 v gi畛 TSH m畛c ti棚u theo c叩 th畛 ho叩: ng動畛i l畛n tu畛i, c坦 b畛nh m畉ch vnh, c坦 thai, ung th動 gi叩p
- 56. Ti li畛u tham kh畉o 1. Braverman LE, et al (2000). Werner & Ingbars The Thyroid. A Fundamental and Clinical Text. 8th ed. 2. Canaris GJ et al. (2000) The Colorado Thyroid Disease Prevalence Study. Arch Intern Med;160:526-534. 3. Demers LM, Spencer CA, eds (2003). The National Academy of Clinical Biochemistry Web site. Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1. 4. Garber JR. (2012) Clinical practice guidelines for hypothyroidism in adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 18 (6); pp: 989 -1019. 5. Haddow JE, et al. (1999) Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N Engl J Med.;341:549-555. 6. Kohno A, et al. Endocr J. 2001;48:565-572. 7. Vassilopoulou-Sellin R, Sellin JH. (1996) The gastrointestinal tract and liver in hypothyroidism. In:Braverman LE, Utiger RD, eds. Werner and Ingbars The Thyroid. 7th ed. Philadelphia, Pa: Lippincott-Raven Publishers; pp:816-820. 8. Stagnaro - Green A. et al (2011), Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid Vol 21 (10): 1081-1125
- 57. Ti li畛u tham kh畉o 9. Joan C. Lo et al (2005). Increased prevalence of subclinical and clinical hypothyroidism in persons with chronic kidney disease. Kidney International, Vol. 67, Issue 3, pp: 1047 1052. 10. Jonklaas J. et al (2014). Guidelines for the treatment of hypothyroidism Prepared by the American Thyroid Association Task Force on thyroid hormone replacement. Thyroid, Vol. 24 (12), pp: 1670 1751. 11. MIMS Endocrynology (2014/2015). Hypothyrodism, 4th Ed, Vietnam 2014/2015, tr. A147 A153. 12. Okosieme O. et al (2015). Management of primary hypothyroidism: Statement by the British Thyroid Association Executive Committee. Clinical Endocrinology, John Wiley & Sons Ltd, pp: 1 10. 13. Orlander P. R. et al (2016). Hypothyroidism Workup. Access date: 23/07/2016, http://emedicine.medscape.com/article/122393-workup#c7, 14. Pearce S. H. S. et al (2013). 2013 ETA Guideline: Management of subclinical hypothyroidism. Eur Thyroid J, Vol: 2, pp: 215 228 15. Haugen B. R. (2016). 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer The American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid, Vol 26, No. 1, pp: 64 65. 16. Wiersinga M.W (2014). Adult Hypothyroidism. In: De Groot J.L: Endotext. Access date: 23/07/2016: http://www.ncbi.nlm.nih.gov/books/NBK285561/
- 58. Ch但n thnh c叩m 董稼