Graves_病诊疗新进展

1、1会计学Graves_病诊疗新进展病诊疗新进展牛牛文库文档分享牛牛文库文档分享50/100,000 = 0.5/1000 = 1 out of every 2000 people everyyear牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享Antithyroid DrugsNonablativeLowfrequencyNot definitive, side-effects+RadioiodineDefinitive100%fear+SurgeryDefinitive100%complications, discomfort+Advanta

2、gesHypothyroidismOther DisadvantagesCost牛牛文库文档分享Glinoer et a.l 1987, Solomon et al. 1990, Walsh 2000, Tominaga et al.1997牛牛文库文档分享Tominaga et al. 1997牛牛文库文档分享Tominaga et al. 1997牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享NCNSOCH2CH2CH36-propyl, 2-thiouracil (PTU)CHNCNHS1 methyl, 2 mercaptoimidazole (MMI)-OCH2CH3 (CBZ)l

3、lO牛牛文库文档分享12Cooper DS NEJM 2005牛牛文库文档分享抗甲状腺药物不良反应:甲状腺之外甲状腺之外Thyroxine (T4)(T4)(T3)Cooper DS NEJM 2005BUT: This does nottranslate into PTUbeing a “better” drugfor sicker pateints牛牛文库文档分享牛牛文库文档分享需要讨论的问题牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享Nakamura et al. JCEM 2007Group B FT4 7 ng/dl牛牛文库文档分享010203040506070T4 21, CB

4、Z20T4 21, CBZ40T4 21, CBZ20T4 21, CBZ20T4 21, CBZ40T4 21, CBZ20T4 2x ULN)Skin RashDecr. WBC (1000)PTU 30051.9%*26.9%*22.1%4.8%*MMI 1513.9%*9%6.6%*0.7%MMI 3030%6.6%22.3%0%牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享 总结：选择哪种药物好？总结：选择哪种药物好？牛牛文库文档分享总结：选择哪种药物好？总结：选择哪种药物好？牛牛文库文档分享牛牛文库文档分享010203040506070Allannic1990Garcia1995

5、Weetman1994Maugendre1998% relapse*61812246121842牛牛文库文档分享3.8ng/dl 8Group A Group BGroup C牛牛文库文档分享需要讨论的问题需要讨论的问题：牛牛文库文档分享FactorChance of remissionATD as first line therapyLarge GoiterLowerNoSeverely abn. TFTs ( T3)LowerNoPrior relapsesLowerNoNeg TSIHigherYesSmoking?no effect-Eye Disease? no effect-Age

6、no effect-牛牛文库文档分享FactorChance of remissionATD as first line therapyLarge GoiterLowerNoSeverely abn. TFTs ( T3)LowerNoPrior relapsesLowerNoNeg TSIHigherYesSmoking?no effect-Eye Diseaseno effect-Ageno effect-牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享6.3 mCi9.4 mCi8.5 mCi12.3 mCiPercent牛牛文库文档分享 注意注意:牛牛文库文档分享牛牛文

7、库文档分享牛牛文库文档分享10/229/1945%47%Worse Pre-existing GOWorse New onset GO38%18%53/14123/131P700 ng/dl, very large goiter (4 times normal)Mild or moderate hyperthyroidism, small or modestly enlarged thyroid; Children or pregnant/lactating women; patients with severe eye diseaseDefinitive therapy with radio

8、iodine preferred in adultsNormalization of thyroid function with antithyroid drugs before therapy in the elderly or patients with heart diseasePrimary antithyroid drug therapy should beconsideredstart methimazole 5-30 mg/day after discussing side-effects and obtaining CBC and differential. PTU only

9、used in pregnancyMonitor thyroid functionevery 4-6 weeks until euthyroid state achievedDiscontinue drug therapy after 12-18 monthsMonitor thyroid function every 2 months for 6 months, then less frequentlyRelapseRemissionmonitor thyroid function every 6-12 months indefinitelyConsider restarting antit

10、hyroid drugs after therapyCooper 2005牛牛文库文档分享牛牛文库文档分享牛牛文库文档分享22 patients16 treated with embolization alone; 6 required surgery/ATDNo serious complicationsJ Clin Endocrinol Metab. 2002 Aug;87(8):3583-9 牛牛文库文档分享“然而，由于方法学的限制，我们尚无设计良好的临床试验为中药治疗甲亢提供较强的证据。因此，我们现在不能推荐任何中药的单方或复方制剂在临床使用。”牛牛文库文档分享20 patients1

11、0 received MMI + rituximab (RTX), 10 MMI onlyHigher remission rates after MMI withdrawal with RTX (P700 ng/dl, very large goiter (4 times normal)Mild or moderate hyperthyroidism, small or modestly enlarged thyroid; Children or pregnant/lactating women; patients with severe eye diseaseDefinitive ther

12、apy with radioiodine preferred in adultsNormalization of thyroid function with antithyroid drugs before therapy in the elderly or patients with heart diseasePrimary antithyroid drug therapy should beconsideredstart methimazole 5-30 mg/day after discussing side-effects and obtaining CBC and differential. PTU only used in pregnancyMonitor thyroid functionevery 4-6 weeks until euthyroid state achievedDiscontinue drug therapy after 12-18 monthsMonitor thyroid fu