Corticoid trong NT 2018

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SỬDỤNGCORTICOIDTRONG VIÊMLTGIÁCMẠCNHIỄMTRÙNG TS.BS Nguyễn Đình Ngân HọcViệnQnY Nộidung • Đạicươngvềcorticoid • CorticoidtrongviêmloétGMNT – Trongloétgiácmạcdovikhuẩn – Trongviêmloétgiácmạcdovirus – TrongviêmloétgiácmạcdoAncathamoeba – Trongviêmltgiácmạcdonấm Glucocorticoid • Hormonvỏthượngthận: – Tácđộnglênnhiềuqtrìnhsinhlý • Chuyển hóa Đường,Protein,Lipid • Kiểm sốt chất điện giảI • Đáp ứng miễn dịch • Điều hòa viêm • Kiểm sốt hành vi • Đáp ứng với Stress Glucocorticoid The new england journal CH2OH • Chốngviêm Cytokines Bacteria Viruses Free radicals Ultraviolet radiation HO C O OH O Cortisol IkB IkB kinase of medicine Repression by means of negative glucocorticoid-responsive elements Corticotropin-releasing hormone Pro-opiomelanocortin Cytokines Osteocalcin Cytokine receptors Proliferin Chemotactic proteins Keratins Adhesion molecules Interleukin-1b Collagenases Matrix metalloproteinases c-Jun Fos Glucocorticoid receptor NF-kB MAPK phosphatase I Jun N-terminal kinase Cytokines Growth factors Mitogens Bacteria Viruses Ultraviolet radiation Annexin I Cytokines Cytokine receptors Chemotactic proteins Adhesion molecules Cytokines Hormones Mitogens Endotoxin Antigen MAPKs Phospholipids cPLA2a COX-2 MAPK-interacting kinase Arachidonic acid 5-LOX Calcium kinase II Calcium/calmodulin– dependent kinase II Calcium Minor pathways Prostaglandins Leukotrienes Inflammation Core pathways Enzyme Protein kinase Inflammatory transcription factor Protein phosphatase Inhibitory protein Figure Partial Molecular Architecture Underlying the Glucocorticoid-Induced Antagonism of Inflammation Inflammatory pathways are characterized by positive feedback loops (i.e., cytokines activate NF-kB, which in turn stimulates the synthesis of more Glucocorticoid • Chốngviêm:mọinguyênnhân – Ức chế́ huy động bạch cầu đến ổ viêm – Giảm sản xuất và hoạt ~nh nhiều chất TGHH viêm: histamin, serotonin, bradykinin – Giảm tổng hợp và sản xuất Leucotriens, Protaglandins – Ức chế giải phóng men tiêu thể, gốc tự giảm hóa ứng động, hoạt tính men collagenases, plasminogen, elastase – Giảm hoạt động thực bào Macrophage (đại thực bào), tế bào đa nhân trung ~nh và giảm sản xuất cytokin – Tăng sức bền thành mạch, giảm thấm dịch vào khoang gian bào Glucocorticoid • Chốngviêm:mộtsốthuốcthườnggặp Tên T/dchống viêm T/dgiữ muối Hydrocortison 1 Prednisolon 0,8 Methylprednisolon 0,5 Triamcinolon 0,5 Betamethason 25-30 Dexamethason 25-30 Glucocorticoid • ỨcchếMD: – Trên tế bào: • Gắn vào receptorở bào tương phức hợp gắn AND • Tác động lên AMPc sinh trưởng TBLympho – Trên quần thể tế bào: • Huỷ TBLympho (đặc biệt TBtuyến ức) • Giảm tập trung TBviêm – Trên đáp ứng miễn dịch: • Ức chế phản ứng mẫn muộn • Giảm Lympho Tgây độc Glucocorticoid • ỨcchếMD: Đại thực bào Kháng nguyên giải phóng (-) Corticoid Interleukin 1,6 giải phóng Lympho T Interleukin (-) Cyclosporin A Lympho T Lympho T hoạt hoá Glucocorticoid • Tác dụng chống viêm GMcủa số dạng thuốc tra thường gặp Thuốc tra mắt Tác dụng chống viêm (giảm biểu mơ GM) Prednisolon Acetate 1% 51% Dexamethasone 0.1% 40% Fluorometholone 0.1% 31% Prednisolone phosphate 1% 28% Dexamethasone phosphate 0.1% 18% Glucocorticoid Nồng độ thuốc tiền phòng theo thời gian (ng/ml) Dexamethason alcohol0,1%và Fluorometholone alcohol0,1%nhũ tương Prednisoloneacetat 1%nhũ tương,Prenisolone phosphate 0,5%dungdịch 10 VLGMdovirus • ViêmgiácmạcdoAdenovirus • ViêmgiácmạcdoHerpes – Viêmbiểumơ – Viêmnhumơ – Viêmnộimơ 44 VLGMdovirus:Herpes • Viêmbiểumơ • Viêmnhumơ – ViêmGMchấm – KhơngltGM – LtGMhìnhcànhcây • Viêmnhumơkhơnghoạitử – LtGMhìnhđịađồ • Viêmnhumơhoạitử – LtGMrìa • Viêmnhumơmiễndịch combination of antiviral and topical corticosteroid–therapy CóltGM:viêmnhumơhoạitử • Viêmnộimơ: viêmhìnhđĩa Table HSV KERATITIS: CLASSIFICATION Corneal Layer Epithelium Nomenclature HSV epithelial keratitis Stroma HSV stromal keratitis without ulceration Endothelium HSV stromal keratitis with ulceration HSV endothelial keratitis Alternate Terms Dendritic epithelial ulcer Geographic epithelial ulcer Non-necrotizing keratitis Interstitial keratitis Immune stromal keratitis Necrotizing keratitis Disciform keratitis 45 VLGMdovirus:Herpes • Viêmbiểumơ – Lthìnhcànhcây • Acyclovir400mgx3-5lần/ngàyx7- 10ngày • Valacyclovir 500mgx2lần/ngàyx 7–10ngày • MỡAcyclovirx4-5lần/ngàyđếnkhiliền,dùngtiếp3lần/ngàyx7ngày – Lthìnhđịađồ • Acyclovir800mgx5lần/ngày x14–21ngày • Valacyclovir 1gx3lần dailyfor14–21days • MỡAcyclovirx4-5lần/ngàyđếnkhiliền,dùngtiếp3lần/ngàyx7ngày 46 VLGMdovirus:Herpes • Viêmnhumơ (Therapeutic dose of topical corticosteroid PLUS prophylactic dose of oral antiviral agent) – Khơngkèmtheolt • Prednisolone1%x6– 8lần/ngày,giảmliều dần,kéodàitrên8tuầnvà • Acyclovir400mgx2lần/ngày • Valacyclovir 500mgx1lần/ngàyx 7–10ngày 47 VLGMdovirus:Herpes • Viêmnhumơ (Limited dose of topical corticosteroid PLUS therapeutic dose of oral antiviral agent) – Kèmtheoloét • Prednisolone1%x1-2lần/ngày,giảmliềudần,kéodàitrên8tuầnvà • Acyclovir800mgx3-5lần/ngàyx7-10ngày • Valacyclovir 500mgx1lần/ngàyx 7–10ngày • Điềuchỉnhliềusteroidtheođápứngcủabệnhnhân,sửdụngliều khángvirusdựphòngkhicòndùngsteroid 48 VLGMdovirus:Herpes • Viêmnộimơ – CótủamặtsauGM • Prednisolone1%x6– 8lần/ngàyvà • Acyclovir400mgx3-5lần/ngày • Valacyclovir 500mgx2lần/ngày • Thuốckhángvirusdùng7– 10ngàyrồi chuyểnsangliềudựphòng,steroidgiảm liềuchậm 49 VLGMdovirus:Herpes Herpes Simplex Virus Keratitis: A Treatment Guideline Michelle Lee White, M.D., M.P.H., and James Chodosh, M.D., M.P.H Massachusetts Eye and Ear Infirmary Department of Ophthalmology Harvard Medical School 243 Charles Street Boston, MA 02114 617-573-6398 Acknowledgments: This study was supported by a Senior Scientific Investigator Award to JC from Research to Prevent Blindness, NY, NY 50 The authors gratefully acknowledge the insightful reviews of this guideline by the following protozoan presents 2.1.The Clinical findings of AK2 morphologic cellular forms: trophozoites and cysts (Fig 1).125 Trophozoites, active cells at the metabolic, physiologic, morphologic are Corneal infections caused by and Acanthamoeba spp levels, can cause responsibleThe for the infective stagesdescribed and virulence of the problindness most frequently symptoms are tozoan pathogen, whereas cysts are characterized by foreign body sensation, redness, tearing, photophobia, dormancy and resistance to antimicrobial agents Both forms decreased visual acuity, and in some cases, severe pain not 23,26,91,130 are immunogenic, but may have mechanisms to evade imClinical signs include predicted by clinical findings 94 The pathophysiology of AK lesions is triggered by mune attack punctate epithelial erosions, pseudodendritic (Fig 2A), initial adhesionorof stromal trophozoites to the corneal epithelial cells subepithelial infiltrates and perineural in23,112,130 mediated by mannose-binding a cellular surface reThe presenceprotein, of a ring-shaped corneal filtrates ceptor composed of 130-kDa subunits belonging to the lectin family.106 Subsequent steps in the infectious cascade of amoebic keratitis involve deeper stromal invasion, degradation of extracellular matrix components, and induction of host cellular death.106,121 Extracellular proteins secreted by virulent Acanthamoeba strains, designated as secretomes or exoproteomes, are comprised mainly of proteases and phospholipases.89,103 The enzymatic activities of these proteins are related to the corneal tissue digestive process and the different patterns of infectious severity observed in patients.27 aims to apply the knowledge and technologies from method (Fig 3) This technique allows the direct m research to improve laboratory diagnostic procw visualization of double-walled cellular structures early therapeutic interventions, while the selec morphological characteristics of Acanthamoeba cy appropriate with minimal side effects for e cific stainingtherapy of Acanthamoeba cysts and trophozo and maximum efficacy againsttechniques, the pathogen accomplished by antibody-based such infection is an essential aspect to be provided by immunofluorescence and immunoperoxidase st ized medicine development of recrudescen In vivo confocal The microscopy is a clinical diagnos episodes treatment failure also may of be AK assoa that may after be helpful in the management acquired resistance of the antimicro observing a wide range of protozoan structural to changes in increased risk visualofloss, and need for cora tissue from theofonset protozoan infection plantation.37,62,74,138 Alternatively, other procedur physicochemical inactivation of ocular pathoge cross-linking, photodynamic therapy, and exc phototherapeutic keratectomy) have been propos vant treatments for infectious keratitis, AK56,63,120,129; however, controversies exist conc application and standardization of these techniq and optimized therapeutic procedures in the ro ment of AK.13,57,114 Keratoplasty may be necessary therapeutic purposes to avoid corneal perforat VLGMdoAcanthamoeba • Điềutrịkhókhăn • Hìnhảnhđadạng • Thuốcđặchiệu??? Fig e Clinical signs of Acanthamoeba keratitis A: Corneal pseudodendrite B: Typical ring infiltrate C: Perineural (radial keratoneuritis) • Corticoid: – BÀNCÃI 51 Fig e Morphologic characteristics of cysts and trophozoites of Acanthamoeba species isolated from cases of se VLGMdoAcanthamoeba • Chốngviêm – Corticoid: • Làmsuygiảmsứcđềkháng:bệnhpháttriển • Làmthểkémà chuyểnthểhoạtđộngà cácthuốcdiệtamiptốthơn • Chlorhexidine+ dexamethasoneà lắngđọngthểkính(glass-likeprecipitate) trênKHVđồngtrục • Khơngđượcdùngbanđầu,nếudùng:khibệnhgầnkhỏi – NSAIDs: • Giảmđau,giảmviêm,khơnggiảmsứcđềkháng • Cóthểdùngtốt - Loét tạo vảy, có sắc tố VLGMdonấm - Mủ tiền phòng: Có thể tăng, giảm - Dạng xuất tiết bông, bắc cầu từ Khám bệnh: Viêm GM nấm 13 mặt sau giác mạc đến mống mắt • Chốngviêm – Corticoid: • KHƠNGĐƯỢCDÙNG Khám bệnh: Viêm GM nấm 11 – NSAIDs: • Giảmđau,giảmviêm,khơnggiảmsứcđề Khám bệnh: Viêm GM nấm kháng • Cóthểdùngtốt 14 operative inflammation perative inflammation of the anterior segment was obd by slit-lamp microscopy Inflammation resolution was ed as no ciliary congestion, donor edema, or flare and in the anterior chamber infection b A small amount of bleeding and inflammatory infiltration in the anterior chamber at days after penetrating keratoplasty c Photophobia, redness, ocular congestion, graft edema, and graft endothelial folds at week after surgery d The signs and symptoms disappeared, and the graft became clear after days of steroid use VLGMdonấm Discussion Graefes Arch Clin Exp Ophthalmol (2016) 254:1585–1589 DOI 10.1007/s00417-016-3412-0 Immune rejection and fungal recurrence are both serious comCORNEA plications that can occur in the early period after corneal transplantation for fungal keratitis Surgical intervention can re44 patients completed the scheduled 6-month follow-up – SaughépGMđiềutrị: move the infected corneal tissue, but cannot immediately conFungal hyphae were found in 208 eyes (85.25 %) onTherapeutic dilemma in fungal keratitis: administration trol the of steroids forexisting immune anterior rejection segment early afterinflammation keratoplasty ination of corneal scrapings and in 230 eyes (94.26 %) by • Corticoids??? Neovascularization and edema are typically present in the 1587 cal microscopy A total of 224 specimens (91.80 %) hadTing Wang & Suxia Li & Hua Gao & Weiyun Shi 1,2 ve culture results for fungi, among which 165 (73.66 %) gens were identified as Fusarium species, 30 (13.39 %) as gillus species, 20 (8.93 %) as Alternaria species, and %) as other species PK was performed in 118 patients Received: July 2015 / Revised: June 2016 / Accepted: June 2016 / Published online: 24 June 2016 K in 126 patients Fungal hyphae were found in all partial# Springer-Verlag Berlin Heidelberg 2016 al buttons obtained from the 244 patients by histopatholog-Abstract Conclusions Initiating the use of topical cor Purpose To investigate the timing and dosage of topical corwith fungal keratitis week after kera xamination Anterior segment inflammation was aggravat-ticosteroid use after keratoplasty for fungal keratitis, and to tients rapid control of anterior segment inflamma thin week after surgery, with ocular pain, photophobia,evaluate the results with regard to anterior segment inflamma- of immune rejection, with no increase in tion, immune rejection, and fungal recurrence recurrence ss, and tearing, but was alleviated at 7.51 ± 1.76 days afterMethods This prospective observational study included a total 244 patients (244 eyes) who underwent penetrating keratoKeywords Corticosteroid Keratoplasty F d use (Figs 1, 2, and 3) In patients with no fungal recur-of plasty (PK, 118 patients) or lamellar keratoplasty (LK, 126 Immune rejection Fungal recurrence , vision at months post-surgery was improved by two topatients) for fungal keratitis at the Shandong Eye Hospital between January 2009 and April 2014 Topical administration lines from presurgical measurements of steroid eye drops was initiated at week after surgery Introduction Changes in ocular inflammation before and after steroid use, ngal recurrence was observed in three eyes (1.23 %) at to percentages of eyes with fungal recurrence and immune rejecFungal keratitis in patients who not resp s after administration of fluorometholone, including twotion, and the relationship between the timing of local admin- systemic antifungal medications 54 can cause d istration of steroids and therapeutic anti-inflammatory effects tions, leading to corneal perforation To that underwent PK and one eye that underwent LK Theafter keratoplasty were evaluated The follow-up period was penetrating keratoplasty (PK) or lamellar ke ults • Chốngviêm: Kếtluận • CorticoidstrongVLGMNT: – Khơngphảichốngchỉđịnh100% – Sửdụng • Kiếnthứcvàkinhnghiệm • Đặcđiểmtổnthương • Theodõisátbệnhnhân • Dùngchủyếuđườngtạichỗ • Liều:thấpà trungbình 55 XINCHÂNTHÀNHCẢMƠN Q&A? 56 ...Nộidung • Đạicươngvề corticoid • Corticoid trong viêmloétGM NT – Trong loétgiácmạcdovikhuẩn – Trong viêmloétgiácmạcdovirus – Trong viêmltgiácmạcdoAncathamoeba – Trong viêmltgiácmạcdonấm... trò corticoids 250 Allocated to placebo 250 Received allocated intervention 250 Allocated to corticosteroid 250 Received allocated intervention 10 Lost to follow-up 11 Discontinued intervention... Tgây độc Glucocorticoid • ỨcchếMD: Đại thực bào Kháng nguyên giải phóng (-) Corticoid Interleukin 1,6 giải phóng Lympho T Interleukin (-) Cyclosporin A Lympho T Lympho T hoạt hố Glucocorticoid
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