?t v?n ??

          H?i ch?ng Stevens-Johnson l ph?n ?ng c h?i trn da, hi?m g?p nh?ng nguy hi?m c?a thu?c. ?c tr?ng c?a h?i ch?ng StevensJohnson l lot cc h?c t? nhin (th??ng g?p ? m?t v mi?ng) v c nhi?u d?ng t?n th??ng da: b?ng n??c, di?n tch da t?n th??ng <10% di?n tch da c? th?, c th? km theo t?n th??ng gan th?n, th? n?ng c th? gy t? vong [1]. C nhi?u y?u t? ???c cho l nguyn nhn gy ra h?i ch?ng Stevens-Johnson nh? virus, k sinh trng s?t rt ho?c do thu?c.

          N?m 2010, Trung tm Qu?c gia v? Thng tin thu?c v Theo di ph?n ?ng c h?i c?a thu?c ? nh?n ???c 4 bo co t? cc c? s? khm, ch?a b?nh v? h?i ch?ng Stevens-Johnson c lin quan ??n carbamazepin. Cc b?nh nhn ny ???c ch? ??nh carbamazepin ?? ?i?u tr? ?au dy th?n kinh tam thoa ho?c ?i?u tr? ??ng kinh. Cc b?nh nhn khi nh?p vi?n c bi?u hi?n chung l m?n ng?a, lot tr?t ? mi?ng, m?t, m?i hay c? quan sinh d?c. Hai trong 4 b?nh nhn c xu?t hi?n b?ng n??c trn da. Ba trong 4 bo co ???c cc chuyn gia k?t lu?n ch?c ch?n r?ng h?i ch?ng Stevens-Johnson l ph?n ?ng c h?i lin quan ??n carbamazepin.

          Trong y v?n, h?i ch?ng Stevens-Johnson ???c ?? c?p nh? m?t ph?n ?ng c h?i trn da c?a carbamazepin [2]. M?t tr??ng h?p ?i?n hnh ???c m t? l b?nh nhn nam, 6 tu?i, b? ??ng kinh. Sau vi tu?n ?i?u tr? b?ng acid  valproic, b?nh nhn ???c ch? ??nh b? sung carbamazepin. H?i ch?ng Stevens-Johnson xu?t hi?n sau 5 tu?n dng k?t h?p 2 thu?c. Khi ng?ng s? d?ng carbamazepin, h?i ch?ng  Stevens-Johnson ? thoi lui, do ? acid  valproic v?n ???c ch? ??nh ti?p cho b?nh nhn [3]. Cc bo co ??c l?p c?ng cho th?y carbamazepin v phenobarbital l nguyn nhn gy ra h?i ch?ng Stevens-Johnson ? nh?ng b?nh nhn ???c ?i?u tr? b?ng tia x? [4].

          Theo s? li?u ???c phn tch t? c? s? d? li?u l?u tr? ph?n ?ng c h?i c?a T? ch?c Y t? th? gi?i WHO, t? n?m 2000 ??n n?m 2011 c 1377 ca bo co lin quan ??n h?i ch?ng Stevens-Johnson v carbamazepin trn ton th? gi?i. Ring n?m 2011, s? bo co ???c ghi nh?n l 342 ca, cao nh?t trong t?t c? cc n?m, t?ng ?ng k? h?n so v?i 2 n?m tr??c ? (195 bo co n?m 2010 v 109 bo co n?m 2009).

          Y?u t? nguy c? xu?t hi?n h?i ch?ng Stevens-Johnson khi s? d?ng carbamazepin

          Nguy c? x?y ra h?i ch?ng Stevens-Johnson t?ng ?ng k? ? nh?ng b?nh nhn c gen HLA-B*1502, h?u nh? ch? xu?t hi?n ? ng??i g?c chu . Nh?ng b?nh nhn ny ???c khuy?n co xt nghi?m gen tr??c khi b?t ??u dng carbamazepin. 
          Tuy nhin, h?i ch?ng Stevens-Johnson v?n c nguy c? x?y ra ? b?nh nhn khng c gen HLA-B*1502, d nguy c? ny th?p [5].

          Vi?t Nam n?m trong nhm cc n??c chu c nguy c? cao xu?t hi?n h?i ch?ng Stevens-Johnson ? b?nh nhn. Vi?c ti?n hnh xt nghi?m gen cho b?nh nhn tr??c khi ch? ??nh carbamazepin ch?a kh? thi trong ?i?u ki?n hi?n t?i. ? gi?m thi?u h?u qu? c?a h?i ch?ng Stevens-Johnson c th? x?y ra do 
carbamazepin v thu?c ni chung, b?nh nhn c?n ???c t? v?n ?? c th?:

-         Bi?t cch nh?n bi?t cc d?u hi?u s?m c?a h?i ch?ng Stevens-Johnson ?? t? theo di trong qu trnh ?i?u tr?.

-         Khng t? dng thu?c khi ch?a c h??ng d?n c?a bc s?, d??c s?.

-         Khi pht hi?n b?t th??ng khi dng thu?c, c?n thng bo ngay cho bc s?, d??c s? ?? ???c h??ng d?n v x? tr k?p th?i.

 X? tr khi xu?t hi?n h?i ch?ng Stevens-Johnson trong qu trnh ?i?u tr? b?ng carbamazepin

          - B n??c: truy?n dung d?ch glucose 5%, Lactate Ringer hay natri clorid 0,9% t? 500 - 2000ml/ngy, th??ng trong 5 - 7 ngy.

          - B ?i?n gi?i d?a theo ?i?n gi?i ??.

          - Dinh d??ng: b? sung dinh d??ng qua ???ng mi?ng ho?c qua sonde m?i - th?c qu?n - d? dy (n?u ch?a lot tr?t ???ng tiu ha); ho?c truy?n plasma t??i, albumin, lipovenoes (??m, m?) ??n khi r?i lo?n dinh d??ng ? ???c c?i thi?n.

          - Ch?ng nhi?m trng:

+ Ch?ng nhi?m trng t?i ch?:

          Ch?m sc da: trnh lm tu?t da b?nh nhn, thay v?i tr?i gi??ng hng ngy. V? sinh da b?ng thu?c st trng t?i ch? (nitrat b?c 0,5%, 
clorhexidin 0,05%). B?ng b b?ng g?c v?i m? citrat b?c, polyvidon iod hay cc hydrogel. Bi dung d?ch Castellani ho?c xanh methylen vo nh?ng vng da b? lot tr?t.

          Ch?m sc m?t: khm m?t th??ng xuyn. Dng ??u d?t c?a ??a th?y tinh ?? tch 2 m m?t th??ng xuyn khi b? lot, dnh mi m?t. R?a m?t nhi?u l?n hng ngy b?ng n??c m?t nhn t?o ho?c dung d?ch natri clorid 0,9%.

V? sinh cc h?c t? nhin hng ngy b?ng dung d?ch natri clorid 0,9%.

+ Ch?ng nhi?m trng ton thn: th??ng dng khng sinh t gy d? ?ng nh? h? macrolid.

          - Glucocorticoid:

+ Li?u ban ??u 1-3 mg/kg/24 gi?: Methylprednisolon (Solu-Medrol) 40mg ho?c Depersolon 30mg tim t?nh m?ch 2-4 ?ng/ngy trong 3-5 ngy ??u. Sau ? dng methylprednisolon (Medrol) 16mg d?ng u?ng 2 vin/ngy trong 3-5 ngy.

+ Tr??ng h?p b?nh r?t n?ng c t?n th??ng no, tim m?ch, suy ?a ph? t?ng dng 
methylprednisolon 500-1000mg, pha d?ch truy?n dung d?ch natri clorid 0,9% 250ml (ho?c glucose 5% 250ml), truy?n t?nh m?ch XXX gi?t/pht x 3 ngy. Sau ? gi?m li?u (1-3 mg/kg/24 gi?): Methylprednisolon 40mg (Solu-Medrol) ho?c Depersolon 30mg tim t?nh m?ch 2-4 ?ng/ngy trong 3-5 ngy. Cu?i cng s? d?ng methylprednisolon (Medrol) 16mg d?ng u?ng 2 vin/ngy trong 3-5 ngy.

          -  Khng histamin H1: ban ??u tim b?p dimedrol 10mg x 2-4 ?ng/ngy trong 3-5 ngy do c t?n th??ng nim m?c mi?ng v ???ng tiu ha. Sau ? chuy?n sang d?ng u?ng: levocetirizin 5mg (Xyzal) ho?c desloratadin 5mg (Aerius), fexofenadin 180mg (Telfast), loratadin 10mg (Clarityn), cetirizin 10mg (Zyrtec) u?ng 1 vin/ngy trong 3-5 ngy [6].

K?t lu?n

          H?i ch?ng Stevens-Johnson l ph?n ?ng c h?i trn da c?a carbamazepin tuy hi?m g?p nh?ng nghim tr?ng v c th? gy t? vong cho b?nh nhn. Vi?c pht hi?n s?m v x? tr k?p th?i ?ng vai tr quy?t ??nh ??n tin l??ng v k?t qu? ?i?u tr? c?a b?nh nhn. Bc s? nn t? v?n k? v? h?i ch?ng Stevens-Johnson cho b?nh nhn tr??c khi ch? ??nh carbamazepin ?? ?i?u tr?.

Ti li?u tham kh?o

1. Nguy?n Qu?c Anh, Ng Qu Chu (2011), H??ng d?n ch?n ?on v ?i?u tr? b?nh N?i khoa, Nh xu?t b?n Y h?c. Tr 771-773.

2. B? Y t? (2009), D??c th? Qu?c gia Vi?t Nam. Chuyn lu?n carbamazepin. 2009.

3. Thomson Reuters Healthcare. Micromedex 2.0. Monograph Carbamazepine, accessed on 14th April, 2012.

4. J.K. Aronson, Meyler's Side Effects of Drugs. 15th Edition, p. 283.

5. U.S. Food and Drugs Administration. Information for healthcare professionals: dangerous or even fatal skin reactionscarbamazepine (marketed as Carbatrol, Equetro, Tegretol, and generics) (issued 12th December, 2007).

6. Nguy?n V?n ?on (2011), D? ?ng thu?c, Nh xu?t b?n Y h?c. Tr 203-207.

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