Theo doi dieu tri ARV

Nguoi benh bat dau dieu tri ARV nen duoc kham bac sy theo lich trinh sau day:

- Mot den hai tuan mot lan trong thang dau tien de theo doi cac tac dung phu va duoc cung co ve tam quan trong cua viec tuan thu dieu tri.

- Trong khoang thoi gian 8 den 12 tuan sau khi bat dau dieu tri.

- Sau do 3 den 6 thang mot lan.

- Cac nhan vien y te, cac cong tac vien, nhom dong dang ho tro tuan thu dieu tri, cham soc tai nha nguoi benh, neu co the, cho cac doi tuong dieu tri theo che do DOT.

6.1. Theo doi su tuan thu dieu tri

Nguoi benh dieu tri ARV can duoc theo doi ve su tuan thu dieu tri. Can xac dinh nhung nguyen nhan khien nguoi benh khong tuan thu tot de ho tro.

Xem xet lai dieu tri voi ng­oi benh va ng­oi ho tro/giam sat:

- Kiem tra lai ve nhung thuoc nguoi benh duoc chi dinh dung va cach dung.

- Hoi ve thoi gian va cach nguoi benh dung thuoc trong thuc te, so lan nguoi benh bo hoac quen uong thuoc.

- Dem so thuoc con lai.

Neu nguoi benh tuan thu kem, can tim hieu ve nhung van de ma nguoi benh gap phai khi dung thuoc nhu:

- Cac tac dung phu cua thuoc hoac cac benh ly moi xuat hien?

- Do quen hoac khong hieu dung chi dinh?

- Do het thuoc hoac khong co kha nang tai chinh?

- Cac van de ve tam ly nh­ khong muon chap nhan tinh trang nhiem HIV cua minh, do khong muon de nguoi khac thay minh dieu tri thuoc HIV, do so bi phan biet doi xu?

- Do co su thay doi trong cuoc song?

- Thieu su ho tro (gia dinh, ban be, can bo y te)

Nguoi benh can duoc tu van lai mot cach can than. Nhung van de cua nguoi benh can duoc giai quyet de bao dam su tuan thu dieu tri.

6.2. Theo doi tien trien lam sang

Moi lan tham kham, nguoi benh dieu tri ARV can duoc danh gia can than ve lam sang:

- Toan trang, can nang, nhiet do.

- Phat hien cac tac dung phu cua thuoc va tinh trang ngo doc thuoc

- Danh gia lai giai doan lam sang

- Danh gia tien trien cua cac trieu chung lien quan den benh HIV

- Danh gia tien trien cua cac benh NTCH da co; phat hien cac nhiem trung co hoi moi xuat hien hoac tai phat.

- Phat hien hoi chung phuc hoi mien dich (xem muc 7).

- Xem xet kha nang mang thai.

Cac dau hieu sau chung to ng­oi benh co dap ung voi dieu tri ARV:

- Nguoi benh thay khoe hon, co nhieu suc luc hon de thuc hien cac hoat dong hang ngay.

- Toan trang kha hon, tang can.

- Cac trieu chung benh lien quan den HIV co tu truoc co duoc cai thien.

- Cac benh NTCH co tu truoc co duoc cai thien; giam tan suat mac va muc do nang cua cac NTCH.

6.3. Theo doi xet nghiem

Nguoi benh dieu tri ARV can duoc theo doi ve cac xet nghiem can lam sang de phat hien cac tac dung phu cua thuoc va danh gia dap ung dieu tri.

- Cong thuc mau toan bo va cong thuc bach cau 6 thang mot lan hoac khi nguoi benh su dung phac do ZDV co bieu hien thieu mau.

- Men gan ALT/SGPT - thuc hien 1 thang sau khi bat dau dieu tri NVP, sau do 6 thang mot lan hoac khi nguoi benh co bieu hien viem gan.

- Dem TCD4  6-12 thang mot lan khi dieu tri, neu co.

- Xet nghiem thai neu nguoi benh dang dieu tri EFV va co kha nang mang thai.

Bang 4

Theo doi can lam sang khi su dung cac phac do dieu tri ARV hang thu nhat






























Phac do
Xet nghiem truoc dieu tri
Xet nghiem can theo doi khi dieu tri

 

d4T/3TC/NVP
CTM, ALT (SGPT)

TCD4, neu co
ALT(SGPT) khi co dau hieu viem gan

TCD4 6-12 thang mot lan, neu co, de xac dinh hieu qua dieu tri

 

ZDV/3TC/NVP
CTM, ALT (SGPT)

TCD4, neu co
CTM (hoac it nhat Hgb), va ALT (SGPT) khi co dau hieu thieu mau hoac viem gan

TCD4 6-12 thang mot lan, neu co, de xac dinh hieu qua dieu tri

 

d4T/3TC/EFV
Xet nghiem thai

CTM, ALT (SGPT)

TCD4, neu co
Cac xet nghiem can thiet khi co cac dau hieu ngo doc thuoc

TCD4 6-12 thang mot lan, neu co, de xac dinh hieu qua dieu tri

 

ZDV/3TC/EFV
Xet nghiem thai

CTM, ALT (SGPT)

TCD4, neu co
CTM (hoac it nhat Hgb) khi co cac dau hieu thieu mau

TCD4 6-12 thang mot lan, neu co, de xac dinh hieu qua dieu tri


 

6.4. Theo doi doc tinh cua thuoc

- Nguoi benh dieu tri ARV can duoc cung cap thong tin ve cac tac dung phu cua thuoc va yeu cau phai thong bao cho bac sy dieu tri khi co cac bieu hien nay.

- Nhieu tac dung phu cua cac thuoc ARV co bieu hien nhe, xay ra chu yeu trong 2 tuan dau cua dieu tri dac hieu, chi can dieu tri ho tro va se giam dan trong vong 1 den 2 thang (Bang 5: Cac tac dung phu muc do nhe cua cac phac do hang thu nhat va huong xu tri). Tuy nhien, mot so truong hop co tac dung phu tram trong can phai duoc thay doi thuoc dieu tri (Bang 6: Cac doc tinh chu yeu cua cac thuoc ARV va xu tri).

- Cac tac dung phu cua cac thuoc ARV nen duoc theo doi va danh gia ca tren lam sang va cac xet nghiem can lam sang, neu can thiet va co the thuc hien duoc.

Bang 5

Cac tac dung phu muc do nhe cua cac phac do hang thu nhat va huong xu tri













































Cac tac dung phu muc nhe
Dieu tri thong thuong

Buon non
Dung cung thuc an

Tieu chay
Bu nuoc va dien giai.  Thuoc chong di ngoai nhu loperamide co the lam do tam thoi.

Dau dau
Paracetamol; neu lien tuc trong 2 tuan can phai tham kham lai

Met moi
Thuong chi keo dai 4-6 tuan, neu lau hon can tham kham lai

Kho chiu o bung
Neu lien tuc can tham kham lai

Noi man nhe
Dieu tri bang thuoc khang histamine hoac steroid.  Neu nang, xem xet kha nang di ung thuoc

Buon ngu
Uong thuoc truoc khi di ngu

Mat ngu
Co the dung thuoc ho tro

Ac mong, chong mat
Dung EFV vao buoi toi, thuong keo dai khong qua 3 tuan


 

Bang 6: Cac doc tinh chu yeu cua cac thuoc ARV va xu tri













































































Doc tinh
Thuoc co lien quan
Dac diem
Xu tri

 

Benh ly than kinh ngoai vi
d4T, ddI, cac NRTI khac
- Thuong xuat hien trong vong 1 nam dau.

- Bieu hien: roi loan cam giac ngoai vi, chu yeu o cac dau chi kieu deo gang; di lai kho khan do dau.
- Dieu tri bang amitriptyline 25mg 1 lan/ngay hoac vitamin B cac loai.

- Neu nang - thay d4T hoac ddI bang AZT.

Viem tuy
d4T, ddI
- Dau bung, buon non, non, sot…

- Tang amylase mau.
- Dung moi thuoc ARV

- Khi het cac trieu chung - bat dau lai voi AZT

Phan bo lai mo
NRTI (d4T), PI
- Tang tich tu mo o nguc, bung, lung va gay; teo mo mo o canh tay, cang chan, mong, va ma.

- Thuong ton tai vinh vien.
- Tu van cho ng­oi benh ve cac thay doi hinh dang co the lien quan den cac thuoc ARV. 

Doc tinh voi gan
NVP, EFV, ZDV, PI
- Nguy co cao: ng­oi co benh gan man tinh.

- Thuong xuat hien trong vong 3 thang dau sau khi bat dau dieu tri.

- Men gan tang ≥ 3 lan binh thuong co/khong co bieu hien lam sang.
- Dung moi thuoc ARV neu men gan tang gap 5 lan binh thuong.

- Bat dau lai ARV khi men gan ve binh th­ong. Dung han NVP. Thay cac thuoc gay doc voi gan bang cac thuoc khac.

Phat ban
NVP, EFV, ABC
- Thuong xuat hien som, trong vong 1-3 thang dau.

- Bieu hien co the nhe hoac nang, de doa tinh mang.

- Tai su dung ABC co the dan den shock phan ve.
- Dung moi thuoc ARV va dieu tri ho tro cho den khi het trieu chung.

- Dung han ABC neu co phat ban.  Dung NVP, EFV cho nhung tr­ong hop man da kem cac trieu chung toan than.

Toan lactic va thoai hoa mo gan
NRTI (d4T, ddI; hiem hon – ZDV, 3TC, ABC)
- Thuong xuat hien muon (sau vai thang).

- Bieu hien: met nang, buon non, non, sut can, dau co, gan to; tang acid lactic, men gan, amylase.

- Theo doi lactate th­ong quy o nguoi benh chua co trieu chung khong co tac dung.
- Dung moi thuoc ARV: cac trieu chung co the tiep tuc hoac tien trien xau di ngay ca sau khi dung thuoc.

- Dieu tri ho tro tho oxy, truyen dich va bo sung dien giai, dieu chinh toan mau. 

Doc tinh voi than kinh trung uong
EFV
- Thuong xuat hien som.

- Bieu hien: lan lon nang, roi loan tam than, tram cam
- Tham khao y kien chuyen khoa Tam than.

- Neu nang, dung EFV va thay the bang NVP.

Doc tinh voi tuy xuong
ZDV
- Thuong xuat hien trong vong 1 nam sau khi bat dau dieu tri.

- Bieu hien: thieu mau nang, co the kem ha bach cau
- Dung ZDV, thay bang mot thuoc NRTI khac.

Doc tinh voi co
NRTI: d4T, ddI, ZDV
- Thuong xuat hien muon.

- Bieu hien: dau co, tang creatinine kinase
- Neu bieu hien nhe - dieu tri thuoc giam dau.

- Neu nang - thay thuoc gay doc tinh voi co bang 3TC hoac ABC.

Tang duong huyet va roi loan mo mau
PI, EFV
- Thuong xuat hien muon.

- Bieu hien: tang d­ong mau va cholesterol mau
- Dieu tri ho tro insulin, che do an it mo, tiep tuc cac thuoc ARV.

- Neu khong dap ung va bieu hien nang - thay thuoc.

Soi than
IDV
- Xuat hien vao bat ky giai doan dieu tri nao, gap nhieu o tre em.

- Bieu hien cua soi than
- Khuyen benh nhan uong nhieu nuoc va tiep tuc IDV.

- Neu benh nhan khong uong duoc nhieu nuoc, xem xet thay IDV bang mot thuoc ARV khac.