HYK PHM NGC THCH

IU TR LAO

1
2
 Quy nh ghi kt qu xt nghim AFB nhum ZN
S lng AFB Kt qu Phn loi
0 AFB / 100 vi trng m tnh

1 - 9 AFB / 100 vi Dng tnh Ghi s lng AFB c

trng th

HYK PHM NGC THCH

10 - 99 AFB / 100 vi Dng tnh 1+
trng
Dng tnh 2+
1 -10 AFB /1 vi trng
(soi t nht 50 vi
trng)

Dng tnh 3+
>10 AFB / 1 vi trng
(soi t nht 20 vi
trng)
3
 Quy nh ghi kt qu xt nghim AFB nhum
hunh quang
S lng AFB
quan st bng vt Kt qu Kt qu
knh 20 X

HYK PHM NGC THCH

0 AFB/ 1 dng m tnh m tnh
129 AFB/ 1 dng Dng tnh Ghi s lng AFB
c th
30299 AFB/ 1 dng Dng tnh 1+
10100 AFB/ 1
VT Dng tnh 2+
(soi t nht 10 VT)
>100 AFB/ 1 VT
(soi t nht 4 VT) Dng tnh 3+
4
 So snh ghi kt qu xt nghim AFB 2
phng php nhum
Nhum ZN (phng Nhum hunh quang Nhum hunh quang

Kt qu i 1000 ln) (phng i 200 ln) (phng i 400 ln)

HYK PHM NGC THCH

1 dng = 2cm = 1 dng = 2cm = 20VT 1 dng = 2cm = 40VT
100VT
m tnh 0 AFB / 100 VT 0 AFB/ 20 VT 0 AFB / t nht 40 VT
Ghi s
lng AFB 1 - 9 AFB / 100 VT 129 AFB/ 20 VT 1-19 AFB / 40 VT
c th
20-199 AFB/ 40 VT
1+ 10 - 99 AFB / 100 VT 30299 AFB/ 20 VT (Soi t nht 40 VT)
1 -10 AFB /1 VT 10100 AFB/ 1 VT 5-50 AFB/ 1 VT
2+ (soi t nht 50 VT) (soi t nht 10 VT) (Soi t nht 20 VT)
>10 AFB / 1 VT >100 AFB/ 1 VT >50 AFB/ 1 VT
3+ (soi t nht 20 VT) (soi t nht 4 VT) (Soi t nht 8 VT) 5
6

6
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 MC TIU IU TR LAO
1. Cha lnh bnh nhn v em li cht lng
cuc sng cho bnh nhn.
2. Trnh t vong trong cc trng hp lao tin
trin hay cc bin chng ca lao gy nn.
3. Trnh ti pht lao.
4. Gim ly truyn lao cho nhng ngi khc
5. Ngn chn pht trin v gim ly truyn
lao khng thuc.

9
 NGUYN TC IU TR LAO
1. Phi hp thuc : phi phi hp t nht 3 th
thuc trnh hin tng chn lc vi trng
khng thuc.
2. ng liu lng: Liu lng thuc cn
dit vi trng lao, liu cao s gy ng c v
liu thp s khng c tc dng dn n khng
thuc
3. Thi gian : thi gian ti thu 6 thng trong
giai on tn cng ko di hai hay ba thng.
4. Dng thuc phi lin tc mi ngy nu khng
s gy tht bi iu tr.
 NHNG XT NGHIM CN LM KHI
QUYT NH IU TR LAO

- XT NGHIM:
TPTTBM, GLYCEMIE

AST, ALT, BILIRUBIN TP/TT

URE, CREATININ

HIV

- KHM TH GIC V THNH GIC

- TM HIU THUC BN ANG DNG
- PHT HIN CC BNH L I KM
- PHT HIN CC D NG
 CAC LOAI THUOC CHA LAO

Thuc hng 1 Thuc hng 2

Isoniazid Fluoquinolones
Rifampicin Aminoglycosides
Pyrazinamide Ethionamide
Ethambutol P-Amino salicylic acid
(PAS)
Streptomycin Cycloserine

12
 PHC IU TR LAO
Phc IA: 2RHZE(S)/4RHE
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy.
Giai on duy tr ko di 4 thng, gm 3 loi thuc l R, H v E dng
hng ngy.
- Ch nh: cho cc trng hp bnh lao mi ngi ln (cha iu tr lao
bao gi hoc tng iu tr lao nhng di 1 thng). iu tr lao mng tim
c th s dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng
u tin.
Phc IB: 2RHZE/4RH
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy.
Giai on duy tr ko di 4 thng, gm 2 loi thuc l R v H dng
hng ngy.
- Ch nh: cho cc trng hp bnh lao mi tr em (cha iu tr lao bao
gi hoc tng iu tr lao nhng di 1 thng). iu tr lao mng tim c
th s dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng u
tin.
 PHC IU TR LAO
Phc II: 2SRHZE/1RHZE/5RHE hoc
2SRHZE/1RHZE/5R3H3E3
- Hng dn:
Giai on tn cng ko di 3 thng, 2 thng u tin vi c 5
loi thuc chng lao thit yu S, H, R, Z, E dng hng ngy, 1
thng tip theo vi 4 loi thuc (HRZE) dng hng ngy.
Giai on duy tr ko di 5 thng vi 3 loi thuc H, R v E
dng hng ngy. (hoc dng cch qung 3 ln/tun).
- Ch nh:
Cho cc trng hp bnh lao ti pht, tht bi, iu tr li sau
b tr, tin s iu tr khc, khng r tin s iu tr m
khng c iu kin lm xt nghim chn on lao a khng
nhanh.
Cho cc trng hp bnh lao ti pht, tht bi, iu tr li sau
b tr, tin s iu tr khc, khng r tin s iu tr c lm
xt nghim chn on lao a khng nhanh, nhng kt qu
khng khng a thuc.
 PHC IU TR LAO
Phc III A: 2RHZE/10RHE
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc H, R, Z, E dng
hng ngy.
Giai on duy tr ko di 10 thng, gm 3 loi thuc l R, H, E dng
hng ngy.
- Ch nh: Lao mng no v lao xng khp ngi ln. iu tr lao mng no
c th s dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng
u tin v dng Streptomycin trong giai on tn cng.
Phc III B: 2RHZE/10RH
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc H, R, Z, E dng
hng ngy.
Giai on duy tr ko di 10 thng, gm 2 loi thuc l R, H dng hng
ngy.
- Ch nh: Lao mng no v lao xng khp tr em. iu tr lao mng no c
th s dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng u
tin v dng Streptomycin trong giai on tn cng.
 PHC IU TR LAO
Phc c nhn cho ngi bnh lao siu khng thuc
- Hng dn: Theo nguyn tc
S dng Pyrazinamide v cc thuc thuc nhm I cn hiu lc.
S dng mt thuc tim cn nhy cm v c th s dng trong thi gian
di (12 thng hoc trong sut liu trnh). Nu c khng vi tt c cc
thuc tim th khuyn co s dng loi thuc m ngi bnh cha tng

HYK PHM NGC THCH

s dng hoc khng s dng thuc tim.
Nu ngi bnh c nguy c d ng vi thuc tim c hiu lc, cn nhc
vic s dng theo ng kh dung.
S dng Fluoroquinolone th h sau nh Moxifloxacin hoc Gatifloxacin.
S dng tt c cc thuc nhm IV cha c s dng rng ri trong phc
iu tr trc y c th c hiu lc.
B sung hai hoc nhiu thuc nhm V (xem xt vic b sung
Bedaquiline).
Xem xt vic b sung cc thuc c th s dng di dng cu tr khn
cp (compassionate use) nu c TCYTTG ph duyt. 16
Cn nhc vic s dng Isoniazid liu cao nu kt qu KS khng khng
hoc khng t vi gen kat G.
 PHC IU TR LAO
iu tr lao tim n
- Hng dn:
Ngi ln: Isoniazid (INH) liu dng 300 mg/ngy, ung
mt ln hng ngy trong 9 thng, phi hp Vitamin B6 liu
lng 25mg hng ngy.

HYK PHM NGC THCH

Tr em: Isoniazid (INH) liu dng 10 mg/kg/ngy, ung mt
ln vo mt gi nht nh (thng ung trc ba n 1 gi),
ung hng ngy trong 6 thng (tng s 180 liu INH).
- Ch nh:
Tt c nhng ngi nhim HIV (ngi ln) c sng lc
hin khng mc bnh lao.
Tr em di 5 tui v tr 0-14 tui c HIV sng cng nh
vi ngi bnh lao phi, nhng tr ny c xc nh khng
17
mc lao.
 IU TR LAO CHO NHNG TRNG
HP C BIT
iu tr lao ph n c thai hoc cho con b
Cc loi thuc Isoniazid, Rifampicin, Ethambutol v Pyrazinamid, c
hp thu d dng qua ng tiu ha v c kh nng i qua nhau thai.
Nn dng vitamin B6 liu 25mg hng ngy nu c dng INH.

HYK PHM NGC THCH

Kh nng tng nguy c nhim c gan trong khi mang thai v trong 2-3
thng u ca thi k hu sn.
Streptomycin c kh nng c cho tai thai nhi, Ethionamide v PAS (gy
d tt bm sinh) khng s dng trong thai k.
Vic iu tr bnh lao khng thuc, c bit l lao a khng, trong khi
mang thai v qun l chm sc tr s sinh cn phi xem xt cn thn,
qun l c hng dn ca thy thuc chuyn khoa lao l bt buc.
ang dng thuc trnh thai: Rifampicin tng tc vi thuc trnh thai,
lm gim tc dng ca thuc trnh thai. V vy nu ph n ang ung
thuc trnh thai iu tr lao bng phc c c Rifampicin c th chn
mt trong hai gii php: hoc dng thuc trnh thai c cha liu lng 18
Estrogen cao hn hoc dng bin php trnh thai khc
 IU TR LAO TRN BNH NHN C BNH L GAN
Nu ngi bnh c tn thng gan nng t
trc
Phi c iu tr ni tr ti bnh vin v theo
di chc nng gan trc v trong qu trnh iu

HYK PHM NGC THCH

tr.
Phc iu tr s do bc s chuyn khoa quyt
nh tu kh nng dung np thuc ca ngi
bnh.
Sau khi ngi bnh dung np thuc tt, men gan
khng tng v c p ng tt v lm sng, c th
chuyn iu tr ngoi tr v theo di st.
19
 IU TR LAO TRN BNH NHN C BNH L GAN

Nu chc nng gan l bnh thng: c th tip tc iu tr v
khng cn thit xt nghim tr khi ngi bnh c triu chng
ca nhim c gan.
Nu men gan cao t hn 2 ln gii hn trn ca bnh thng

HYK PHM NGC THCH

v khng km triu chng nhim c gan, ngi bnh c
th c bt u iu tr nhng phi theo di nh gi triu
chng ca nhim c gan v cc ch s men gan hng thng.
Nu men gan cao > 2 ln gii hn trn ca mc bnh thng,
ngng iu tr lao v phi tip tc qun l ti bnh vin.
Ngi bnh c bnh gan mn tnh khng nn dng
Pyrazinamid, Isoniazid v Rifampicin c th kt hp mt
hoc hai loi thuc khng c vi gan nh Streptomycin v
Ethambutol. Hoc kt hp vi mt thuc nhm
20
Fluoroquinilone
 IU TR LAO TRN BNH NHN C BNH L GAN
Ngi bnh lao c vim gan cp tnh
Ngi bnh c bnh lao v ng thi bnh vim gan cp
tnh (v d nh vim gan siu vi cp tnh) khng lin quan
n lao hoc iu tr lao. nh gi lm sng l cn thit
trong vic a ra quyt nh iu tr. Trong mt s trng

HYK PHM NGC THCH

hp c th tr hon vic iu tr lao cho n khi bnh vim
gan cp tnh iu tr n nh.
Trong trng hp cn thit phi iu tr bnh lao trong
vim gan cp tnh, s kt hp ca Streptomycin v
Ethambutol trong 3 thng u tin l la chn an ton nht.
Nu vim gan n nh, sau ngi bnh c th dng
Isoniazid v Rifampicin tip tc giai on 6 thng. Nu
vim gan khng n nh, Streptomycin v Ethambutol nn
tip tc cho tng cng 12 thng. Do , la chn iu tr l
3SE/6RH hoc 12SE. Hoc c th cn nhc kt hp vi
mt thuc nhm Fluoroquinilone (Lfx hoc Mfx). 21
 IU TR LAO TRN BNH NHN C BNH L GAN

Trng hp ngi bnh c xc nh c tn

thng gan do thuc lao
Ngng s dng nhng thuc lao gy c cho
gan, xem xt s dng thuc Fluroquinolones nu

HYK PHM NGC THCH

vic iu tr lao cn thit, iu tr h tr chc
nng gan cho n khi men gan v bnh thng,
ht vng da. Cn theo di lm sng v men gan.
Nu khng p ng hoc c biu hin vim gan
do thuc, chuyn n c s chuyn khoa iu
tr. (xem phn pht hin, nh gi v x tr tc
dng khng mong mun ca thuc chng lao).
22
 IU TR LAO TRN BNH NHN C BNH
L THN
Phc 2RHZ/4RH.
Cc loi thuc u tay (Rifampicin, Isoniazid, Pyrazinamid) v Ethionamide,
Prothionamide hon ton chuyn ha qua gan, c th c s dng mt cch an
ton vi liu bnh thng nhng ngi bnh c suy thn. Tuy nhin, c th thay
i phc iu tr v liu lng khi c suy thn nng.
Ethionamide/Prothionamide cng c la chn trong phc iu tr ngi

HYK PHM NGC THCH

bnh a khng thuc c suy thn (hiu chnh liu khi c suy thn nng).
i vi ngi bnh suy thn nng, chy thn nhn to: Trong suy thn nng
hiu chnh liu thuc lao iu tr l cn thit c tnh theo thanh thi ca
creatinin. Isoniazid i khi gy ra bnh no nhng ngi bnh c suy thn v
trong nhng ngy chy thn (b sung iu tr Pyridoxine ngn chn bnh thn
kinh ngoi vi).
Trng hp bnh lao nng nguy c cao, e da tnh mng: la chn li ch v
nguy c, c th la chn Streptomycin v Ethambutol iu chnh liu l cn thit
trong suy thn, liu iu tr c tnh theo thanh thi ca creatinin.
Trong trng hp cn thit phi iu tr lao a khng, vic dng thuc chng lao
hng 2 cho ngi bnh suy thn phi ht sc ch liu lng v thi gian gia
cc liu.
23
 IU TR LAO TRN BNH NHN I THO
NG
- iu tr cng ging nh i vi tt c cc ngi bnh khc, ngi
bnh T c nguy c tn thng thn kinh ngoi vi, thuc INH c
nguy c cao vim thn kinh ngoi vi, do nn dng thm
Pyridoxine (10-25mg/ngy).
- Kt hp cht ch vi thy thuc chuyn khoa kim sot ng

HYK PHM NGC THCH

huyt, cc bin chng ca T. m bo ti u kim sot ng
huyt, khi ng huyt n nh theo di lng ng trong mu
hng thng, gio dc ngi bnh tun th iu tr, ch n ung,
hot ng th cht.
- Xem xt n tng tc thuc trong vic kt hp iu tr lao v iu
tr T (Rifampicin vi nhm Sulphonylurea), cn nhc s dng
thuc h ng mu bng insulin, nhm thuc t gy tng tc vi
thuc lao: Biguanide (v d: Metformin, khng c tng tc vi
Rifampicin, tuy nhin, Metformin gy tc dng ph n h tiu ha
khi kt hp vi thuc lao v thn trng nhng trng hp suy gan,
thn).
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 IU TR LAO TRN BNH NHN HIV/AIDS

- Cc thuc chng lao c tc dng tt vi bnh lao ngi bnh

lao/HIV. iu tr lao cho ngi bnh HIV/AIDS ni chung khng
khc bit so vi ngi bnh khng nhim HIV/AIDS. Khi iu tr
cn lu mt s im sau:
Tin hnh iu tr lao sm ngi HIV c chn on lao.

HYK PHM NGC THCH

Phi hp iu tr thuc chng lao vi iu tr d phng nhim
trng c hi khc bng Cotrimoxazol v ARV cng sm cng tt,
ngay sau khi ngi bnh dung np thuc chng lao (sau 2 tun u
tin).
Thn trng khi iu tr phi hp ARV v c hin tng tng tc
thuc gia Rifampicin vi cc thuc c ch men sao chp ngc
Non-nucleocide v cc thuc c ch men Protease.
Hi chng phc hi min dch c th xy ra mt s ngi bnh
nhim HIV iu tr lao c s dng thuc khng virus biu hin
bng cc triu chng lm sng, cn lm sng nng ln iu tr 25
triu chng, trong trng hp nng c th s dng Corticosteroid
vi liu lng 1mg/kg trong 1-2 tun.
 THEO DI IU TR LAO

Trong qu trnh iu tr ngi bnh cn c theo di nh

sau:
Ngi bnh cn c theo di kim sot vic dng thuc.

Theo di nh gi p ng lm sng, Xquang v tc dng

ph ca thuc. i vi tr em phi cn hng thng iu

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chnh liu thuc theo cn nng.
Xt nghim m theo di: ngi bnh lao phi cn phi
xt nghim m theo di 3 ln
Phc 6 thng: Xt nghim m vo cui thng th
2, 5 v 6.
Phc 8 thng: Xt nghim m vo cui thng th
3, 5,7 (hoc 8).

26
 X TR KT QU XT NGHIM
M THEO DI
Vi P I (bao gm c P IA v P IB), m cn
AFB(+) cui thng th 2, chuyn iu tr duy tr, lm
xt nghim nhum soi trc tip cui thng th 3. Nu

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cui thng th 3 cn AFB(+), cn chuyn m lm Hain
test, Xpert MTB/RIF (hoc nui cy v KS).
Vi P II, nu AFB (+) cui thng th 3 th chuyn m
lm Hain test, Xpert MTB/RIF (hoc nui cy v KS).
C P I v II, nu AFB(+) cui giai on tn cng th
vn chuyn iu tr duy tr m khng ko di tn cng
thm 1 thng nh trc y.
Lu : bt k thi im iu tr no vi thuc chng
lao hng 1, khi xc nh c chng vi khun lao khng
27
a thuc th ngi bnh cn c ch nh P IV.
 nh gi kt qu iu tr theo khuyn co mi ca WHO:
Khi: ngi bnh lao phi c bng chng vi khun hc ti thi im bt
u iu tr, c kt qu xt nghim m trc tip hoc nui cy m tnh
thng cui ca qu trnh iu tr v t nht 1 ln trc .
Hon thnh iu tr: ngi bnh lao hon thnh liu trnh iu tr,
khng c bng chng tht bi, nhng cng khng c xt nghim m trc
tip hoc nui cy m tnh vo thng cui ca qu trnh iu tr v t nht
1 ln trc , bt k khng lm xt nghim hay khng c kt qu xt

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nghim.
Tht bi: ngi bnh lao c kt qu xt nghim m trc tip hoc nui
cy dng tnh t thng th 5 tr i ca qu trnh iu tr.
Cht: ngi bnh lao cht do bt c nguyn nhn g trc hoc trong qu
trnh iu tr lao.
Khng theo di c: ngi bnh lao ngng iu tr lin tc t 2 thng
tr ln.
Khng nh gi: ngi bnh lao khng c nh gi kt qu iu tr.
Bao gm cc trng hp chuyn ti n v iu tr khc v khng c phn
hi kt qu iu tr, cng nh cc trng hp n v bo co khng bit
28
kt qu iu tr ca ngi bnh.
iu tr thnh cng: tng s khi v hon thnh iu tr.
 RIF: RIFAMPICIN

- Liu dng: tr em v ngi trng thnh

liu dng l 08 12 mg/kg trong ngy.
- Ung trc ba n 1h hay sau ba n 2h.
- Trong trng hp suy thn khng cn iu
chnh liu do RIF c chuyn ha gan.
- Cn thn trn bnh nhn suy gan v RIF c
th gy c tnh gan v nguy c tng ln
khi dng chung vi INH.
- Dng an ton cho ph n c thai.
 TC DNG PH

Tc dng ph quan trng: gim tiu cu, thiu

mu tn huyt do RIF chim t l 0,1%, suy thn
cp (do vim i b thn cp hay hoi t ng
thn cp).
Tc dng ph khc: d ng da, bun nn, nn
 INH: ISONIAZIDE

Liu dng: ngi trng thnh liu dng

l 4 6 mg/kg n 300mg trong ngy.
Ung trc ba n 1h hay sau ba n 2h.
Nn dng km vi vitamin B6 10 -20mg.
Trong trng hp suy thn khng cn iu
chnh liu tuy nhin nn cho sau lc thn
trnh ly b thuc trong qu trnh lc.
Cn thn trn bnh nhn suy gan v INH
c th gy c tnh gan
Dng an ton cho ph n c thai.
 TC DNG PH
Tc dng ph quan trng:
- Vim gan khng biu hin lm sng chim
10% bnh nhn dng INH.
- INH tng thi vitamin B6 qua nc tiu
lm gim tr lng vit B6 gy ra hi
chng Pellagra: pht ban ngoi da, thiu
mu, vim thn kinh ngoi bin.
- INH qu liu nh hng TKTW gy ra ri
lon tm thn, l m, hn m, ng
kinh
 PZA: PYRAZINAMIDE
Liu dng: ngi trng thnh liu
dng 20-30 mg/kg n 2g trong
ngy hay 50mg/kg hai ln/tun.
Tc dng ph: gy bun nn, nn,
au khp, tng nng acid uric,
tng c tnh gan, d ng da
Ghi nhn thy khi dng chung vi
RIF v INH lm gim hp thu RIF
13%.
 EMB: ETHAMBUTOL
Liu dng: ngi trng thnh liu dng l
15 -20 mg/kg trong ngy.
Tc dng ph: vim dy thn kinh th gic,
vng da mt, gim tiu cu, gim bch cu
tng acid uric hay phn ng da do thuc.
 SM: STREPTOMYCIN
Liu dng: ngi trng thnh liu
dng l 15mg/kg v 20mg/kg tr em
trong ngy ti a 1g/ngy.
Tc dng ph: gy c tnh thn v
c tnh tai c 2 nhnh.
 TC DNG PH THUC KHNG LAO
Tc dng khng mong mun - Phn ng c hi ca
thuc (ADR: Adverse Drug Reaction): Phn ng c
hi ca thuc l mt phn ng c hi, khng nh trc
v xut hin liu thng dng cho ngi phng

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bnh, chn on, cha bnh hoc lm thay i mt chc
nng sinh l (T chc Y t Th gii - WHO).
Gnh nng do tc dng khng mun ca thuc: Bnh
nhn b tr, thay th thuc iu tr, b bt thuc iu tr
hoc thay i phc dn ti ko di liu trnh iu tr,
tng chi ph iu tr hoc gp tht bi iu tr v tnh trng
khng thuc gia tng v c th li di chng nng n
Tc dng khng mong mun ca thuc lao thng
gp: Triu chng tng men gan, cc biu hin trn da, ri
lon tiu ha, au khp, vim dy thn kinh, ri lon tin 39

nh
 TC DNG PH THUC KHNG LAO
Cc yu t nguy c lm tng tn sut xut hin ADR ngi
bnh lao:
Phc iu tr ko di, s dng nhiu thuc ng thi, m
rng cc phc lao a khng thuc.
T l bnh mc km (HIV, vim gan nghin ru, i tho

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ng)
Ngi bnh khng tun th iu tr, thi quen t dng
thuc ca ngi bnh, hiu bit v kinh nghim hn ch ca
Cn b Y t.
Ln tui tng nguy c tn thng gan, thn, ung nhiu ru
v nghin ru lm tng tn thng gan..
Tnh trng dinh dng, suy dinh dng c bit thiu vitamin
B1 lm tng tc dng ca thuc lao vi thn kinh ngoi vi.
Nhim vi rt nh vim gan, HIV, CMV, EBV lm tng
40
nguy c gy ra cc phn ng d ng chm vi thuc, tn
thng gan.
 X tr mt s tc dng khng mong mun do
thuc lao
Ngi bnh lao c tn thng gan do thuc lao
- Theo di thng quy cc ch s men gan c bn:
ngi bnh < 35 tui nu c cc ch s men gan bnh thng v khng c tin s
bnh gan: khng yu cu bt buc theo di cc ch s men gan nh k mi 4 - 6 tun,
tr khi ngi bnh c triu chng biu hin.
ngi bnh > 35 tui, ngi bnh ung ru hng ngy, c ch s men gan khng

HYK PHM NGC THCH

bnh thng hoc c tin s bnh gan: cn theo di cc ch s men gan nh k mi 4-6
tun.
- Nguyn nhn: INH+Rifampicin > INH mt mnh >> Pyrazinamid mt mnh >
Rifampicin mt mnh > Ethionamide.
- Biu hin lm sng: Chn n, mt mi, bun nn, nn, au bng, au h sn phi,
vng da, vng mt. Du hiu: gan to, tng men gan.
X tr:
Ngng s dng thuc lao, iu tr h tr chc nng gan cho n khi men gan v bnh
thng, ht vng da. Cn theo di triu chng nng lin quan n suy gan.
Nu chc nng gan khng ci thin hoc tin trin nng hn, cn chuyn n c s
chuyn khoa iu tr.
Chn on phn bit vi vim gan A, B, C., vim gan t min v bnh l ng mt, 41
cc yu t tim tng lm tng nguy c c tnh trn gan, v d: lm dng ru, tin s s
dng cc thuc c c tnh vi gan.
HNG X TR DA TRN TRIU CHNG NHIM C
GAN V TNG MEN GAN

Men gan tng nh hn 5 ln gii hn trn bnh

thng khng km triu chng lm sng:
iu tr h tr chc nng gan.

HYK PHM NGC THCH

C th khng cn phi ngng thuc hoc thay i
iu tr v men gan c th t tr li mc bnh
thng.
Duy tr s dng thuc chng lao cn phi theo di
cht ch, pht hin cc du hiu gi sm trn
lm sng (mt mi, suy nhc, chn n, bun nn,
au bng), xt nghim nh gi chc nng gan sau
3 5 ngy. 42
HNG X TR DA TRN TRIU CHNG NHIM C
GAN V TNG MEN GAN
Men gan tng ln hn 5 ln v di 10 ln gii
hn trn bnh thng (c km hoc khng km triu
chng lm sng) hoc ln hn 2,5 ln gii hn trn
bnh thng c km triu chng lm sng:

HYK PHM NGC THCH

Cn nhc ngng ton b hoc mt s thuc lao gy
c cho t bo gan gm Rifampicin, Isoniazid,
Pyrazinamid.
iu tr h tr chc nng gan tch cc, nh gi tnh
trng lm sng chi tit v ton din, xc nh cc yu
t tin lng xu: tng bilirubin v ri lon cc yu
t ng mu (nh lng fibrinogen v t l
43
prothrompin).
HNG X TR DA TRN TRIU CHNG NHIM C
GAN V TNG MEN GAN

Men gan tng ln hn 10 ln gii hn trn bnh

thng:
Ngng ton b thuc lao, ngi bnh c iu tr tch

HYK PHM NGC THCH

cc ti bnh vin, cn kt hp vi chuyn khoa tiu ha.
Nu bilirubin ton phn trong mu huyt thanh tng km
triu chng lm sng nng, cn xem xt mc can thip
hoc iu tr bng thuc, s dng bin php thay huyt
tng, iu tr h tr gan tch cc ngi bnh suy gan
cp nng (Bilirubin ton phn > 250 mol/l).
nh gi lm sng chi tit v ton din, xem xt cc yu
t tin lng xu: tng bilirubin v ri lon cc yu t
ng mu (nh lng fibrinogen v t l prothrombin). 44
 LA CHN PHC IU TR LAO
Nu mc vim gan c kh nng e da tnh mng v cn
nguyn khng phi do virus hoc ngi bnh mc th lao nng
m vic ngng tm thi vic iu tr lao l khng an ton th
cn nhc la chn phc iu tr lao gm cc thuc t c nguy
c c vi gan nh SE + Fluoroquinilone.

HYK PHM NGC THCH

Nu vic iu tr lao c th tm ngng th nn ch cho cc triu
chng lm sng v xt nghim nh gi chc nng gan v bnh
thng, nn tin hnh s dng li cc thuc chng lao. Thng
iu tr t nht 3 thuc khng c vi gan n khi c th xc
nh c nguyn nhn gy vim gan v cn ko di thi gian
iu tr cho ph hp. Nn bt u s dng li tng thuc nghi
ng mi thi im sau khi nng men gan gim xung
di 2 ln gii hn bnh thng trn
Cc thuc ln lt c cn nhc ch nh s dng li:
RMP/INH/PZA nu men gan khng tng c th sau mi 3 ngy 45
1 tun iu tr.
Phc iu tr thay th ph thuc vo thuc no c th
l nguyn nhn gy vim gan v phi loi tr khi phc
, c th cn nhc la chn phc sau cho ngi bnh
khng mc lao a khng:
Nu vim gan lin quan n Rifampicin, phc ngh:
2SHE /10 HE.

HYK PHM NGC THCH

Nu khng th s dng INH, cn c cn nhc s dng
phc 9 thng gm RMP, PZA, EMB.
Nu cn ngng iu tr PZA trong khi cha kt thc giai
on tn cng th ko di iu tr bng RMP, INH ti 9
thng.
Nu c 2 thuc INH, RMP u khng th s dng li th
phc khuyn co phi hp SM, EMB v mt
fluoroquinolon (c th ko di ti 18-24 thng).
46
 Tc dng khng mong mun trn da mc va n nng
(phn ng qu mn)
Biu hin lm sng: Pht ban c th km theo st.
Nguyn nhn: C th gp cc thuc vi mc thng gp
xy ra nh sau: INH < RMP < PZA < Ethionamid < EMB <
PAS < SM
X tr

HYK PHM NGC THCH

Trn tr em:
Ngng tt c cc loi thuc ang dng.
Kim tra cn nguyn virus (cc test xt nghim, cng thc
mu...).
Nu l cn nguyn do nhim mt loi virus no th tip tc
s dng li tt c cc thuc lao.
Nu loi tr cn nguyn nhim virus th theo di nguyn tc
thay i liu ngi ln, hiu chnh li liu theo tui v cn
nng.
Trn ngi ln: Dng tt c cc thuc n khi ht phn ng 47
 Ch nh v chng ch nh gii mn cm
- Ch nh gii mn cm:
Thuc gy d ng l thuc khng th thay th bng thuc khc
trong qu trnh iu tr (iu tr c hiu).
Thuc gy d ng l thuc c hiu qu tt nht cho la chn
liu php iu tr (first line) v d: thuc iu tr lao,

HYK PHM NGC THCH

Cotrimoxazol cho ngi bnh HIV.
- Chng ch nh gii mn cm:
Ngi bnh c nguy c cao bnh phi hp: Hen ph qun
(FEV1<70%), ang iu tr bta block, tin s Shock phn v
nng v bnh gan thn nng.
Chng ch nh tuyt i ngi bnh nng, phn ng c t
bo min dch nng hoc e da mng sng (hi chng Steven-
Jhonson), hi chng Lyell, Dress.
Gii mn cm ch nn cn nhc sau khi nh gi gia yu t
nguy c/ li ch 48
 TC DNG KHNG MONG MUN TRN
THN
Biu hin:
au tht lng t ngt, st, gim niu, v niu cp.
Tng nng creatinin/huyt thanh trong 7-10 ngy u iu tr.
S thiu ht magie, kali c th xy ra.

HYK PHM NGC THCH

Nguyn nhn:
Thng nguyn nhn gy c trn thn gp Kanamycin=
Amikacin>Streptomycin, c ch gy c l hy t bo ng thn
cp.
Ngoi ra c th gp phn ng suy thn cp do Rifampicin, thng
him gp, theo c ch min dch trung gian.
Yu t nguy c: nng Aminoglycosid/huyt thanh cao, s dng
Aminoglycosid ko di, iu tr ngt qung hoc iu tr tht
thng Rifampicin, s dng ng thi vi cc thuc c c vi
thn, bnh gan, tui cao, gim huyt p, gim th tch tun hon, 49
c tin s suy gim chc nng thn, c bnh thn t trc, ung th,
i tho ng.
 TC DNG KHNG MONG MUN TRN
THN
X tr:
Ngng s dng thuc nghi ng.
Kim sot cc yu t nguy c c lin quan.
Phc 2RHZ/4RH c th p dng iu tr cho ngi

HYK PHM NGC THCH

bnh lao c suy thn.
Suy thn cp l mt chng ch nh xa hn ca
Kanamycin, Amikacin, Streptomycin v Rifampicin.
Trng hp bnh lao nng nguy c cao, e da tnh
mng: cn nhc li ch v nguy c, c th s dng
Streptomycin v Ethambutol, hiu chnh thuc lao theo
thanh thi ca creatinin.
Trong phc iu tr ngi bnh a khng thuc c
suy thn Ethionamide/ Prothionamide cng c u tin 50
la chn (hiu chnh liu khi c suy thn nng).
 AU KHP DO THUC LAO

Tp 1
- Nguyn nhn: Pyrazinamid >> Ethambutol >
Isoniazid.

HYK PHM NGC THCH

- Biu hin lm sng: au khp chn, vai, u
gi(thng mc nh).
- X tr:
Khng bt buc phi dng thuc chng lao.

Liu thp NSAID c th s dng trong trng

hp au nh.
Nu cc triu chng vn cn dai dng, cn nhc
chuyn n chuyn khoa xng khp nh gi.
51
 AU KHP DO THUC LAO

Tp 2 (b Gout)
-Nguyn nhn: Pyrazinamid >> Ethambutol.

-Biu hin lm sng: au v sng cc khp: chn, vai,

HYK PHM NGC THCH

u gi, thng l nng v tng acid uric mu.
X tr:

Thng thng, khng bt buc phi dng thuc

chng lao.
Nu sng khp cp vn tn ti, m thanh ca khp
khng t nhin v xt nghim c tinh th urat th ngh
n triu chng ca t gt cp.
52
 iu tr
S dng mt NSAID: indomethacin 50mg x 3-4 ln/ngy n khi gim
bt au, sau dng 25mg x 3-4 ln/ngy hoc ibuprofen 800mg ngy 3
ln hoc naproxen 750mg/ln u v sau 250mg mi 8h.Colchicin
c s dng nh mt tc nhn thay th NSAID
Liu: 0,5-1,2mg/ln u, sau 0,5-0,6mg mi 1-2h n khi au

khp gim hoc c biu hin bun nn, nn hoc tiu chy.

HYK PHM NGC THCH

Triu chng au thng ht sau tng liu 4-8mg.

Liu ti a 8mg

S dng Corticoid gim dn liu c th c s dng trong trng hp

cn gt nng.
C th xy ra nhng t ti din trong qu trnh s dng phc c
Pyrazinamid hoc Ethambutol.
Cn nhc s dng d phng bng Colchicin vi liu 0,6mg: 1 - 2
ln/hng ngy.
Tip tc s dng n khi dng s dng thuc gy triu chng au.
Cn nhc chuyn n chuyn khoa xng khp lng gi t gout 53
cp.
 ST DO THUC LAO
St do thuc lao thng xut hin li nhng ngi bnh
c iu tr vi tun, c bit ngi bnh c ci thin v vi
khun hc v trn hnh nh Xquang. Tuy nhin cn ch
rng: st do bnh lao c th ko di ti 2 thng sau khi bt u
iu tr.

HYK PHM NGC THCH

Khng c chun c bit cho ghi nhn du hiu st. Biu hin
tng bch cu eosin c th c hoc khng.
Cn phn bit nguyn nhn nhim trng, bnh lao ang din
bin xu hn, thuc iu tr lao k cha liu, chn on
nhm cn nguyn. St cng c th l biu hin ca hi chng
phc hi min dch (IRIS Immune reconstitution), c bit
trn ngi bnh ng nhim HIV.
Cn ngng tm thi tt c cc thuc. Biu hin st do thuc s
t ht trong vng 24gi sau khi ngng thuc v s dng li
thuc c th thc hin tng t nh phn x tr triu chng 54
pht ban.
 Hng ngy cho ngi ln Hng ngy cho tr em (*)
Loi Thuc

Liu lng (khong cch liu) tnh Liu lng (khong cch liu) tnh
theo mg/kg cn nng theo mg/kg cn nng

Isoniazid 5 (4-6) Ti a 300mg 10 (1015) Ti a 300mg

HYK PHM NGC THCH

Rifampicin 10 (8-12) 15 (1020)

Pyrazinamid 25 (20-30) 35 (3040)

Ethambutol 15 (15-20) 20 (1525)

Streptomycin 15 (12-18)

Liu lng cc thuc chng lao theo cn nng

55
 Cn nng ca ngi bnh (kg)
25-39 40-54 55-70 >70
Giai on tn cng hng ngy S lng vin hoc l
H 100 mg (vin) 2 3 3 3
R 150 mg (vin) 2 3 4 5
Z 400 mg (vin) 2 3 4 5
E 400 mg (vin) 2 2 3 4

HYK PHM NGC THCH

S 1g (l) 0,5 0,75 1 1
Giai on duy tr hng ngy
H 100mg (vin) 2 3 3 3
R 150 mg (vin) 2 3 4 5
E 400 mg(vin) 2 2 3 4
Giai on duy tr tun 3 ln
H 300 mg(vin) 1 2 2 3
R 150 mg(vin) 2 3 4 5
E 400mg(vin) 2 4 6 6

S lng vin, l thuc n l dng hng ngy cho ngi 56

ln theo cn nng
 Cn nng (kg)
Thuc hn hp liu c nh
25-39 kg 40-54 kg 55-70 kg >70 kg
Giai on tn cng hng ngy Svin
HRZE (vin) 2 3 4 5
(75mg+150mg+400mg+275mg)
HRZ (vin)
(75mg+150mg+400mg) 2 3 4 5

HYK PHM NGC THCH

Giai on duy tr hng ngy
HR (75mg+150mg), vin 2 3 4 5
HE (150mg + 400mg), vin 1,5 2 3 3
Giai on duy tr - tun 3 ln
HR (150mg + 100mg) (vin)
HR (150mg + 150mg) (vin) 2 3 4 5

S vin hn hp liu c nh dng hng ngy cho ngi

ln theo cn nng
57
 ADR Thng s cn Mc 1 (nh ) Mc 2 (va) Mc 3 (nng) Mc 4
lm sng
(nng e tnh mng)
Cc biu hin Hot ng ca ngi Hot ng ca ngi Gii hn hot ng ca ngi
thong qua hoc bnh c b hn ch bnh b hn ch ng bnh rt nghim trng, c s
nh, hot ng ca t nh n trung k, thng cn n h tr ng k can thip y t /
ngi bnh khng b bnh, c th cn n s tr gip, i hi liu php iu tr ng k, yu
hn ch, khng i mt vi s tr gip, can thip hoc iu cu phi nhp
hi phi can thip khng yu cu can tr bng thuc, c th vin hoc iu tr cp cu, tch
hoc iu tr bng thip iu tr, hoc phi nhp vin cc.
thuc can thip v iu tr
mc ti thiu
Hgb 80-94 g/l 70-79 g/l 65-69g/l <65 g/l
Gim tiu cu 100.000 124.999/mm 50.000 99.999/mm 25.000 49.999/mm < 25.000/mm
Gim tiu
cu, thiu
Gim bch 2.000 2.500/mm 1.500 1.999/mm 1.000 1.400/mm <1.000/mm
mu tn

HYK PHM NGC THCH

cu
huyt, gim
bch cu, ri
lon ng Gim Fib 1 -2 g/l 0,75 0,99 g/l 0,5 0,74 g/l < 0,5g/l
mu
Gim 1,1 1,25 ln 1,26- 1,5 ln bnh thng 1,51 3,0 ln >3,0 ln bnh thng
Prothrombin bnh thng bnh thng
(PT)

1,25-2,5 ln
Tng AST AST (SGOT) gii hn bnh thng >2,5-5,0 ln gii hn bnh >5,0-10,0 ln gii hn bnh >10,0 ln gii hn bnh thng
thng thng
1,25-2,5 ln
Tng ALT ALT (SGPT) gii hn bnh thng >2,5-5,0 ln gii hn bnh >5,0-10,0 ln gii hn bnh >10,0 ln gii hn bnh thng
thng thng
1,25-2,5 ln
Tng GGT GGT gii hn bnh thng >2,5-5,0 ln gii hn bnh >5,0-10,0 ln gii hn bnh >10,0 ln gii hn bnh thng
thng thng
>1,0-1,5 ln
Tng bilirubin gii hn bnh thng >1,5-2,5 ln gii hn bnh >2,5-5 ln gii hn bnh >5,0 ln gii hn bnh thng
huyt thanh Bilirubin thng thng
58

Phn loi mc nghim trng v hng x tr tc dng

khng mong mun ca thuc lao
 >1,0-1,5 ln
Tng Creatinine gii hn bnh >1,5-3,0 ln gii hn bnh thng >3,0-6,0 ln gii hn bnh >6,0 ln gii hn bnh
creatinine thng thng thng
3,0-3,4 meq/l hoc 2,5-2,9 meq/l hoc 2,0-2,4 meq/l hoc <2,0 meq/l hoc
H Kali mu
3,0-3,4 mmol/l 2,5-2,9 mmol/l 2,0-2,4 mmol/l <2,0 mmol/l
Kali
ADR Thng s Mc 1 (nh ) Mc 2 (va) Mc 3 (nng)
lm sng Mc 4
(nng e tnh mng)
Bun nn Nh hoc thong qua, Kh chu va phi, lng nc vo Lng nc u vo khng Yu cu nhp vin
duy tr lng nc vo gim ng k, hn ch mt s hot ng k, yu cu truyn
hp l ng dch tnh mch

HYK PHM NGC THCH

Nn 1 ln trong 24h 2-5 ln trong 24h >6 ln trong 24h hoc cn
Hu qu sinh l yu cu
truyn dch tnh mch nhp vin hoc yu cu
dinh dng ngoi rut
Tiu chy Nh hoc thong qua: Va phi hoc dai dng: 5-7 ln, phn >7 ln, phn lng/ngy Sc h huyt p hoc hu
3- lng/ngy hoc tiu chy ko di trn hoc tiu chy mu hoc h qu sinh l, yu cu nhp
4 ln, phn lng/ngy 1 tun huyt p t th hoc mt vin
Tiu ha
hoc tiu chy nh cn bng in gii hoc yu
ko di < 1 tun cu truyn dch tnh mch >
2 ln
Lo u va phi hoc trm cm, yu Thay i tm trng nng, Ri lon tm thn cp
cu iu tr, thay i trong sinh hot yu cu iu tr, hoc tnh, yu cu nhp vin,
Tm thn Bnh tm Lo u nh hoc trm bnh thng nh t t, nh gy g hoc c ch/c gng t t
thn cm hoc o gic
au nh khng gy au va phi, mt cm gic v/hoc au nng, au v/hoc mt au khng lm g c
nh hng ti chc au nh hng ti chc nng nhng cm gic lm nh hng ti
nng khng nh hng ti hot ng sng hot ng sng thng
au khp thng ngy ngy
Xng khp
au nh vi vim, ban au va phi vi vim, ban hoc au nng vi vim, ban hoc Cng v/hoc mt kh nng vn

Phn loi mc nghim trng v hng x tr tc dng 59

khng mong mun ca thuc lao
 hoc sng khp sng khp, nh sng khp, nh ng khp.
nhng khng nh hng ti chc nng hng ti hot
hng ti chc nng nhng khng nh ng sng thng
Vim khp hng ti hot ng ngy
sng thng ngy

Phn ng ca Ban chm khu tr Ban chm, nt sn ri Ban chm, nt sn Cc tn thng

da- ni ban rc hoc ban dng si ri rc hoc ban lan rng hoc ton
dng si vi cc nt thn hoc hi
phng nc hoc tn chng Stevens-
thng lot b mt Jhonson, hoc hi
ca nim mc gii chng Lyell,
hn ti mt v tr DRESS, AGEP...

HYK PHM NGC THCH

Phn ng d ng Ni my ay khu tr Ni my ay khu tr Ni my ay ton Shock phn v
Phn ng d ton thn cp nhng khng cn ch nhng cn ch nh thn hoc ph mch hoc co tht ph
ng tnh nh can thip y khoa can thip y khoa hoc cn ch nh can qun nng e da
ph mch nh khng thip y khoa hoc b tnh mng hoc
cn ch nh can thip co tht ph qun nh ph thanh qun,
y khoa tn thng vim
cu thn/ hi
chng thn h,
vin mch, Lupus
St 37,70C- 38,60C 38,8 0C - 39,30C 39,40C 40,50C >40,50C

60

Phn loi mc nghim trng v hng x tr tc dng

khng mong mun ca thuc lao
 Hng dn th thch liu
Thuc Liu th thch
Ngy 1 Ngy 2
Isoniazid 50mg 300mg

HYK PHM NGC THCH

Rifampicin 75mg 300mg
Pyrazinamid 250mg 1g
Ethionamid 125mg 375mg
Cycloserin 125mg 250mg
Ethambutol 100mg 500mg
PAS 1g 5g 61
CM N CH LNG NGHE

HYK PHM NGC THCH

62