đặc điểm điều trị, phác đồ điều trị từng thể lâm sàng bệnh viêm khớp thiếu niên theo acr 2011

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BỘ GIÁO DỤC VÀ ĐÀO TẠO BỘ Y TẾ
TRƯỜNG ĐẠI HỌC Y HÀ NỘI
LÊ QUỲNH CHI
Chuyên đề 3:
ĐIỀU TRỊ VIÊM KHỚP TỰ PHÁT THIẾU NIÊN
THUỘC ĐỀ TÀI:
GIÁ TRỊ CỦA MỘT SỐ YẾU TỐ MIỄN DỊCH
TRONG CHẨN ĐOÁN, PHÂN LOẠI, TIÊN LỰỢNG
BỆNH VIÊM KHỚP TỰ PHÁT THIẾU NIÊN
Chuyên ngành: Nhi
Mã số: 62.72.16.25
Người hướng dẫn khoa học:
PGS.TS. Nguyễn Thị Ngọc Lan
HÀ NỘI - 2013
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ĐẶT VẤN ĐỀ

 !"#$%&''()*+,)-
./&0".1."2,3.'4!)5'"*,6
'786'59&'):)*+,;"<,=,.'4>=,(
?@,A&.B(CCC"#$!,=,*,(D..,%'
$;E2>'E):,%.A,FG.>4"&H'="0I;E
,;)"#*,9&.'.*JD.,%.K*!.
)H'="0="G,L&"#, *+.,',9M.,%,3.N)1.
)1.>4(O; )P,Q);=9,R=,,S.
*T.=)P'"-,+" ,5"*,,FE.
1P*T.1.GU,7VW
X3YYC,=,,N)P'"-$;<.*,$;
&.&)5'9ZEU.,=,[\]^9=,&',;",;9$";EE5E5
 ,=, ;'M,=,( '4   ,=,.,%'"*,)>4 ,;"_.

 *J.'! '"*!.  1.,R=,( 
*T."`H'&."*,)>4)*+,,;RK4"&'";.H'="0
E,L&*.,.a!5',=,>-
M.)&";.b.3";.b.c3!D.
>G(*T.9U9)*+,,%."
0K,U,.*!.<(cCd)eCd>-G
M.;a,)&fCd)cCd>G
U,,F;).*,9&.'.*J(;K.gCdhfCd
>,F'4Na.I;E&;.7,K .cdhcCd
>,5Ki''N";.)F,F,K&4(>
G*J.R'49F9="G1.,>_.P,P'E
g
,>,F$;,TH'&(?Z;.Cfd)dRK4"&,L4'
!D.>GM..'4>,D.
,%.;=F&E.,%.;F&),;VW(
XP'"-):&4)"2"";.c3H'&'4P'
"#$i1.)*+,)P'"-!,=,=,9jVW(_0G'"2
TP ,=,,N+k)G)P'"-,=, G>9. =,&',L&
,l.1,,'4)P“Điều trị viêm khớp tự phát thiếu
niên”gU,'m
( O=,'M,ES.";.)P'"-'
( Xa,)G)P'"-=,)7)P'"-<.G>9.$;\OnC(
g( XP'"-1.ES.'M,
f
1. CÁC THUỐC ĐIỀU TRỊ VIÊM KHỚP THIẾU NIÊN
1.1. Thuốc giảm đau (paracetamol)
&"&,$&;,&P'A)G)P'"-D."*J.+)&'
<&K(O59ZEU.P'*+.,R=,$;,>a.,L&"#(o"#$
<&,>ES."p.*+.,TGk*!.,%1.E&;"p.*+.
,)G;=P')P'"-(qP'A C.B.B5P'M)&6C

.B.B.4,;"#AE*6=."#P'YC.B.B.4)M
)&f.B.4)G)P'"-)&'E&Er.VgW(
OK=;
s &"&,$&;  ,F =,EU.U *. ,FG .>4 ),.&(
1.E&;P','., !,=,9KR' t0R'*.ES.P'
Au(1.9ZEU.,=,,Q'M,.KF.,N,;"#9T9
"#$(";.H'Kk)&',;,=,>'.*J&
i, N&"b,L&'M,.K)&')T.Ka,ES,=,_.,%.
R=,'H'K)a,,L&'M,',b
,( ".,=,,'4.&    '4 ES. &"&,$&;
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"&(OQN=,EU.U,L&'M,*3."M;. ,.L)&'U.
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VcW(
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-D.>F'>LES.'M,$;H'4)-VcW(
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‚
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3."*!..:4R*T.)U,L4G.&3.4,K
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;>=,>H'&"p.'H'K)G)P'"-D.G'a.
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F,F9…VcW(
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;0.'4,T.>49'4*+.N, (1Z&;a,',K4,L&"#
)&.)*+,)P'"-9$";E)bAKP'.',;,;",;E*T.)*T.
)a,,F, *T.."p.;a,9"$99(9'.9$";E,5
Y
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"*,;).4E";,;"9;$/,";.9'MH'="0)F(
•KP',;",;E*J.F09,.,L&"#)P'"-
,;",;E):>'(O;",;E,b.>4"&9%,KE<.'M,;a,
N,)&..KP',w.,FG.>43.),%.)&'
9M,,F,-'('M,,FG)*+,.KMG'.;a,T
H'="0E"&1.*J.R'4x•'5(
Liệu pháp Steroid liều xung (Pulse therapy)
XP'"-.',;,;",;EP'R'.)*J./,,=,,N=,
";."*J.+."p.1.)=%.(y'H'K.&4N%,
4p.),>'E9v)(~$4"$E9;;$'M,)*+,&
,pP'*+.<C)gCB.B.x5T/,x)+)P'
"-g.4,=,&'=.(q'=41.K1.,F),
."p.> K!)*+,.=9=E '' ,
";."'4PJ.&9&')F,5,lkP,>_.).K
)7*'*+.'5;.'4,T"M;-;a,3.'4=
, VcW(
Glucocorticoid tiêm nội khớp
'M, )*+,,z)-,;>G)=%.
1.,+[\]^9;a,*)P'"-+)G,M.(

Oz)-";.G)&,F;a,1.)=%.
,=,'M,[\]^9,=,'M,,M.VW('49M5,z)-
";.,z ,F .t,z &5  ";.3u(
"&,;;$$R&,$";E$ 'M,)*+,&,p!P'ChfC.,;
([ZEU..>4,x!E;,&5'"#$"e',FG
+=,L'N("#$D.>,F*T.
C
=.;a, D.  ."p.)*+,P€,
L'N4j'N1"S.K)*+,)KK;(
y'H'K&;,L&9$";E):)*+,.,%'
!9M=,.K(y5'* ,K>)P')=%.M6Cd>
)'H'K)P'"-I;E 6=.fcd1.,F_.,%.
):";.b.3(.'4,T$;1E*E&$; 9@,M
E&,x,FG"=;a,.KG'_.,=,.3,a"b"z,L&
'M,"&1R'.H'&(1F&&4H'&RK4"&
;K.cd>):)P'"-)*+,,%."`H'&.(=,EU.
U;>" a,ES,FG.>4'H'K)P'"-"
=,1.)*+,(D.,F=,";.0 4"
9'>.>4,K"!9>M,L&.',;,;,;E";..3
,a)=%.)P'"-;;VceW(
1.5. Nhóm thuốc chống thấp khớp tác dụng chậm (DMARD)
Các thuốc chống thấp khớp tác dụng chậm cũ, ít dùng:
* Các hợp chất vàng dùng đường tiêm Parenteral Gold Compounds.
O=,  +  ,  'M  . )*J.  t&" &'";;&&$ 
&'";;.',;9$u )*+,,z )- !"#$ )& 1.)=%.
[\]^"G!".("*,'=)P'"-.)*+,
3)5'"#,5)*+,G"&,=,,%,3.'4p,N.&t)
;=';5>,*,G''","$&$='7.)
$.&u(~P'@Zc.)*+,!)5'.'59&')FP'
)*+,3.E5);K.C(ec.h.B.B'5tM)&cC.B'5u(')

U,',KA&)=.;a,'4.K";.b.6=.
E'4"0P')F,%x'55";.;K.g=.9&')Fxg
'5";.g=.(',FE '',KU,.K;K.J.&

 R'M. E5f'59&')F 9)P',z )-† E& " 93.
"*!.="G,L&"#VcW(
"*,x5ES.'M,"#,5)*+,)=.=R$,F †),
H'&;,r.*.E&.%&.K;
,L& =' G'=' ;a, ";$'( ' .K 9M*+.,,5' R'M.
E*gcCC;B
g
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 K.=);'=)P'"-(q'=,FG)*+,U,N
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):(OM.,z)-)P'"-..K,,5'a.;a,.K,
,5'";$'"F,E&;I.)=.G"M;)1.=''
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='E&(
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'M..&'"&;}."$4;9$ ";.)F,FZ.
.i',F)M,%.9;.9;.S)1";.b.6=.!TCC"#
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 ,Fv1.MT)=.G9;F.KE*+,(O=,.,%'
,; 4&;,L&+, .'M.P'!)5'ChC
.B.B.4tM)&Y.B.4u),*T.)M€
* D- penicillamine
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:G<.*J&N 4'H'K,&;,L&$;"$R&$F

'M,,M. =,EU.,N([&'g53.P';K.J.&‚•
'5B5))*+,P'C.B.B.4tM)&ecC.B.4u('M,K
'M.l,)FEE4"M."x.)G.3,a;a.";.%,3
,;F1.'H'K(O5>,;='*,G')54)L

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H'&)a,,FGRK4"&ES.'M,*,%..K''9E&
.KG',5'";$'(),^h$,&$1. 
U',;P'  ,FG H'& 9E,L& yq\h^‡gg
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,=,,'4.& p,;&(=,9/,F&"bH'&"p.";.
,.=9=9'>L)P'"-,=,^~\n^'%.,L&,l.(=,
EU.U,L&)P'"-$;"$R&$&;.7'711 ;I
.F,-'!U.T&4),%,3..&t3.
"&9&&9$u"S.;a,&$&;;.,;R,4(O=,^~\n^*J.
)*+,9ZEU.=,&;.74E";R4,;";H'$9'}&9&&„$q$}';E$
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* Thuốc gây độc tế bào và thuốc ức chế miễn dịch
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Ga..>4;b."p.),9$";E>
,F,%.)$Ep&.&;.7m
6-mercaptopurine, azathioprine và cyclophosphamide và chlorambucil(
O=,,%.,L& )P'"- ,;"&', &;.7 19  3.
.'4,T@,,=,=,(XG)P'"-,1.;=F&E.
!"#$'*J.4',5'9ZEU.,;"&',(
";..,%'$;E2c36‚d"#$-:,F
,%.;=F&E. )*+,)P'"-_. ,;"&',tCC‚h
Cc.B.B.4u,b9M.?Z;.";.F1.)*+,)P'"-
CCd( q$}';E$ , %,, .+ 4"E )&.)*+,Z

.!"#$):,FH'K)=.,!.*JE.
 VcW(
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Cyclosporine
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$ ):)*+,=;,=;('M,)*+,ES.)*J. 'M. P' <g)c
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'59&')F)=.=)-†'4=,%,3.N>,*,
G'('M,,FG,F.'4,TA>'E,L&'.*,(
{9$9$)7..):)P'"-,;f"#$P'fhc.B.
B.4";.6hC=.(g>,FG.KP'.',;,;",;Ef"#,F
)+, ,L&)&.ES.'M,7.),"$&$'4&3.
";.>3.p,1. *J.RK4"&!f>3.
'4= !  "#( '=' RK4"&! Y >  g>K
.<.)P'"-(&"b,L&'M,4";.)P'"-!"#$0
1.,@,,@ *. ,Fv ,,†H'&"p. ";.)P'"- ~\[
t$;&.;,4;99 K%.u( "-'+  $;"$R&$ ):)*+,
'4,=;"9M"# )-Vc6W(
^;),,L&F'M,4,FD.'4,=;,5,
,9ZEU.'M,('4,;)&4F'M,4i,b&
,p%&,;,=,"#,F)=%.(
Các thuốc chống thấp khớp tác dụng chậm cổ điển (DMARD cổ điểm)
Methotrexate
q;'M,9@)5',F'H'K)P'"-), ,FG, 
N)*+,&,p%&)G)P'"-5'"#$-:
(ˆ')G,L&'M,4  ES.)*J.'M. x'5ES.  5(
y5'>,F)=%.'M,9&'g=.*.)1"#,5
J.&>'T('M,.>4),,L4'L4R*T..&" 
!(`T.&1.K),,L&'M,P'ES..'5(
['4EE*‰..&9')==;)*J.I;0'M."*+'9v

f
3..'4,TRT.&(^;)F'4,=;,L&\On$;E2,%,3.
.&*J.R'49.&1.,F,z)-Vgfc6W(
,=,K*!.",%,3.E;~$;"$R&$.>4"&.a!"#$(
~9M[\]^,FG.>4K*!.),.@,=,";$
,L&$;"$R&$P'*+.,L&'M,.D)-";.9'MH'=
"0)P'"-(\R};,.B.4;a,};,&,EES.+ES.
,S.$;"$R&$)G.K),!)*J.'F&*.1..K'
H'K)P'"-V‚W(
 •=9=),,L&'M,m$;E29M*+.,=,;='.K
,,5'>;,=, ; ,,5' 9M*+.G',5'$.&
&'V‚W(
'M,)*+,ES.P'.'5E'4 "*,39=.fcl;a,
,=,=,"*,).L .J9&'3M;.4%9=';a,
%K4"=H';D..4)p,(^'.E-,'M.,F9…E.c
B,FG)*+,9ZEU.!"#$P'):9…,R=,(qP'
'M.!)5'MG'C.B

E&.'5t*T.)*T.Cg.B.u(
')=%.'M,1.S+;a,''M."#'711,FG
ES.E.E*E&P'&4)C6chC.B.M)&gC)cC
.B'5(~$;"$R&$)*+, '!EE4h"'<cCd)‚Cd!P'E*
C.B'5*.1.M!P'C.;a,P'Tx'5(^<.)P'
"-~`'1.,F)=%.;a,),,L&'M,3.a,ES):)*+,
.KP'(@,w.,F'H'K*.1.,5(
OK>9.,L&),*T.)M ,L&~`
):)*+,=;,=;";.9M.,%'(X=.=&;.79M*+.
-9*.,%.'9=."',%.;>,L&P'"'.0
..4,L&.',;,;",;ERI.OnM,)='@.(.,%'
c

!Š&&,$,.9,; 4)=%.~`! ,K,=,"#";.)F
Z&9M"#))*+,'(n'$";,=,)7..=;,=;?
)=%.~`66d(X=%.I G!=M.)=
%.M GVcW(
XP'"-~$;"$R&,FG.>49M&4)PE-,.K
O^f•O^‚h;.&&E$&([&'))*+,'">9.
'=$;"$R&$i)*+,U,('E<.)P'"-99v.>4
9=="!,L&,@)5'9ZEU.9ZEU.=,)71.
Kl,;,w.,;H'K*;.'M('4!D."#):)
)*+,9'0,E<.$;"$R&$" ,5*. )P
E<.;(~.,%',L&n&$)7..,; 4Bg9M"#
$==9&'E<.'M,(D."#,F.'4,T,&;F"#,'4G
<G9&.G)&VcW(
~$;"$R&$*J.):)*+,&4,=,'M,,M. F
"',F)=%.1.)54)L0)*+,+,L&[\]^
$;"$R&$=.‹(
Hydoroxychloroquine
X>4'M,+D',";.)P'"-!
"#(y'H'K)P'"-,L&4E;";R4,;";H'$*J.>5
 4"2"*,hg=.)P'"-('1.,K9&')P'"-6=.
.*.'M,(
y4E;";R4,;";H'$1.&;.J)*+,9ZEU.0*J.
+[\]^P'ES.ch6.B.B.4('M,,FE.CC
.*J.ES.,1.%,P'.'59&')F>M,R=,
9M'M.";.'5('M,'M.9&'3!0F,FG.>4,,
'F&(=@&;.7G"&-,-"*J.*J.3)5'
6
"*,)*+,)P'"-,%9&'x6=.(P'*+.),
@1.'4,=;,;,==)&.)*+,R$
RIVc6W(

F,'.'M,1.)*+,'4,=;!"#$E*f')1
!D."#E*e'0"#A1.,FK3.N)54)LP
'9@,;a,,=,/,-"*J.a,ES),,L&2.," 
*.4E;";R4,;";H'$.*.',F..Jk2.
,!0D.=,).4,L&'M,)*+,,w4(q@.).,L&'M,
".=,,,w.,FGRK4"&>)*+,,z)-.KP'T
.<. 'M,( O;";H'$ )*+, 9Z  EU.   *J.  R'4 T
4E";R4,;";H'$,FG,F),!@T(y'H'K)P'"-,L&
4E";R4,;";H'$ ):1.)*+,,%.";.,=,.,%'S)1
.i'(~.,%'Z.)P'"-H'&);K.fC"#
$,K>9.<cd)ecd'4.K";.fcd>0
),,L&'M,)6Cd"#$CdK4',5'.<.'M,(
Sulfasalazine
['}&9&&„$)*+,=;,=;,F'H'K<&K!9M"#-
:'M,@)5'='4=,EU.,M.&T
9;,=,'M,,M. =,EU.,N=,('M,41.9Z
EU.,;"#$H'=i,K'M,9'}&;a,9&,4&9'4.K,%,
3. N ;a, .& ,M.  ,z  )- )a,   * "M ; ,'4G F&
;"4";a,'U$•6^(D.=,EU.U."p.*
9M=&3.$.&,%.;F&),;t~\[u):
)*+,=;,=;!"#$M.!=(['}&9&&„$)*+,@
)5'P' cCC .B.4 ES.9&'3(XM"# A c.B.( qP'
*+.4*J.)*+,3.E5,;))P'cC.B.B.4tM)&
CCC.u(['}&9&&„$ES.9&'3,FG,+T)G.K"',%.
e
F'(X=.=P),,L&'M,,l.&KG"&$;.;
9M*+.,,5'>;,=,,,5'G',5'.;'E-,
,%,3..&Nxf'5)5'9&')F,%g)6=.(y'H'K,L&
'M,*J."2".";.b.fh‚'59&'@)5')P'"-Vc6W(
1.6. Globulin miễn dịch tiêm tĩnh mạch

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)=.G(H'KZ.>9.,L&]]•)P'"-,;>G
M.,; 4'M,,F'H'K9;F.KE*+,(~Z.
=,,L&]]•!"#$G)&P'chC.B.4)*+,"'4P
&5=.";.=.)5'9&')F.=.,;)6=.9&'
)FP'M)&CC.1.,F=,EU.U(O=,=,.K'N"_.
.5ecd"#$G)&,F+<*T.=)P'"-]]•Vc6W(
1.7. Các tác nhân sinh học
q'=9p,):)*&"&D.K*!.)54"Gp.";.
)P'"->(.'4@,,L&'=9p,1U,
9)-,L&E-,_.,=,",,=,,4;$,
,;a,%,,,=,9KQ.@,=,,4;$b&&.>4,K"!9
,=,"$,$;"%,,H'="0Ei"'4PE-,(";.,=,
*T.=)F0,;.A&,=,,4;$A"&,FH'KZ.
'4J P3. ";.)P'"-Vc6‚W
;.A&,4;$,FG))*+,_.,=,ES.,=,"$,$;"=
+b&&=.G"'.b&)TEb.,=,";$&.,4;$)G
;"&H'="0.*.E-,(";.H'="0)F0";$+
51.&4),L&>Z=.G(Œ&$",$tŒ"$u
]}R&)*+,ES. ";.,=,4'M9p,;.A&
,4;$Vc6YCgW(
‚
Etanercept (Enbrel) ";$=+.7"$,$;",L&4'M
;Z't‹nu+5‹,,L&].•,L&.*J(F,FG.@
‹‹"$,$;";.A&9=,).H'&.D&‹‹n(
‹)F.&"bH'&"p..>4=L4";.‹,FG
,,),;}";&9$E;$';a,4;,4$)G;"&,=,
, "'..&F&p,,=,$„4$,=,,4;$";.H'="0*
t";9&.&E]qh‚u(‹,w..>4,,,=,;.;E-,.>4

0,=,.=';.A&,=,L4,M;0,=,L4,M
;.>4;b(Œ&$",$.KD."',%.<"'.0
)a.,L&,=,"',%.)&.;).VYgfW
F)*+,ES.P'MG'Cf.B.E*E&&5
'5tM)&c.,;5u,S.,=,;'M,"*,)Fi
ES.,r.*$;"$R&$[\]^("*,@)5'"-
'!=,>9p,9MRI.,TKt,1.%,='
,=,, ,'4GF&Œ[nOn*,G'u)a,K%.~&;'R(
[&')F$;E2>9.RI.K)=.=*)P'"-
$;"$R&
,=,ES.P'E'4 x'5P'c.;a,T!D.
>)*+,,Q);=!"#tfhe'uP')P'"-E'4 x
'5c.;a,T('P'.'5Tc.&-"
E*E&)*+,9ZEU.(qP',&;tC‚h‚.B.u):)*+,'4,=;
,;)=%.>9.&)5'1.)54)L*.'H'K,b
,";..,%',L&‚"#$(X=.=7.)";.=',L&
$&$",$9v*.EiP'*+.!>,F)=%.1.)54
)L(1.)P'"-'=9p,!"#-"S.;a,,FP9Z
&;'Q==.&4,KD.E '''Q)=;(
O=,"',%.,L&'Q,5K)*+,=9)P'"--
Y
J)a,!"#$t6'"!R'M.u(XP'"-KE<.',F
"S.;a,";..&);"*,i''N("#,FG,F.'4,T
=;).,L&&;;a,="G';a, ,;"#
,5)*+,$;E2)G=(
Infliximab. X>4=.G)TEb..@",‹&&
t‹h•u!-""$,$;"E;)F.>4,K"!;).,L&‹h•9(
~.,%'):,%.'H'K,L&]}R&.56Cd",=,
>('4D.K*!. +9&']}R&
K%.E-%.",="G,=,=.GVYgW(

Adalimumab (Humira). q=.G)TEb.=.‹hα,F
'H'K*T.$&$",$}R&";.VYgW(
Certolizumab pegol (Cimzia). q=.G)TEb.,F,%&
);‹&=+,FK3.NE‹(O$";„'&M+
~`,F'H'K!D.>1.)=%.)54)L~`
,w.,F'H'K)*+,9ZEU.)T"-'!D.> 
,=,^~\n^'4'H'K4 T9;9=,M
+~`VYgW(
Golimumab (Simponi). =.G)TEb.)a,')M,K‹
*',w.*‹.@.;(O=,Z.>9.,;
 4.;'&,F'H'K&;)M>'
,*&9ZEU.~`>)=%.1.)54)L~`;a,
 'M,=.‹VYgW(
Thuốc kháng IL-6: Tocilizumab (Actemra). ;,„'&=.
G)TEb.=.9;F&,L&UG,L&]qh6,KE..@"
.;E.b&&(O=,Z.>9.,; 4;,„'&
'M,,F'H'K=&;";.)P'"-^!E.)T
C
"-'t,F'H'KT9;~`uG,KD.>,F)=%.
1.)54)L~`,=,'M,=.‹(;,„'&)*+,, 
'N)P'"-^%,)<&a.M+~`,;D.
>1.)=%.;a,P''M,=.‹t~j,>'Ž'u
;a,,=,'M,^~\n^tO>'Ž'uVYgW(
X>4,T,!PK.)P'"-,1.,L&GM.!
"#$(qP'ES.fh‚.B."'4P/,x=.5M+
~`;a,^~\n^=,(Xa,&;*T.*,=,'M,9p,
=,(=,EU.U)*+,.N&;.73..'4,T"S.
K%.H'&),"'4P'M,(=,EU.U=,H'&)
,T,=,EU.*.K,,5'"'.G',5'3.$.&
.;"&,w.,F>,F3.q^qy^q(

Thuốc kháng tế bào lympho B: Rituximab (MabThera, Rituxan).
n'R&=.G)TEb.=.>ZO^C"P
a;P4;;"*!.,F=,EU..>4),
;Ei).K9M*+.;('M,1.K*!.;
5t!L4R*T.u;P4;*T.;(";.
"'R&)*+,,%.,F'H'K)MD.>1.)=
%.,=,'M,%,,‹h•(D.>,F'4&E*T.
n‹&hOOK3.)=%."'R&,&;T(n'R&
)*+,, 'N9ZEU.,;D.>1.E'.;a,)=%.
1.)54)L,=,'M,=.‹VYgW(
Thuốc ức chế tế bào lympho T:Abatacept (Orencia)
\&&,$';.;'E>ZOq\hf(>
ZOq\hf,L&'M,,FK3..@O^‚";E;)F.3
,K9*T.=,,L&O^‚>ZO^‚CB‚6,L&;"0E=.

.'4<)F%,,9;F&,L&;4;(\&&,$,F'
H'KM+~`";.)P'"-^,;H'K*T.*
,=,'M,%,,‹h•'4)=%.,F,NT(\&&,$,w.,F
=,EU.!D.>1.)=%.,=,'M,%,,‹h•VgW(
\&")&."KH'&Z."-')G)P'"-:
!"#$(XF=+=.UG]qh!.*J(
]‹.&&=+):)*+,Z.(";..,%'.*J
&):ES.]‹.&&,;6"#-GM.g"#G)&"#
GD."#4):1.,F)=%.)P'"-=,9&'J
.&Ec•3(OF‚>,F,K)=.Ge>)'
(y&>GM.1.,F)=%.f>-==(
~>,F"S.a.(
Một số lưu ý khi sử dụng các thuốc sinh học
O=,'M,9p,0,'.=&;(O=,=,EU.U,L4'
.70".3.N4,K"S..'4,T"G"!,L&

k=,,%.5('4*J..a D.K
%.E;,xE;"'4P'M,";.)F,FG,F,K0".9M,K
(,%.'Q'4.aT9;.";.D.=,EU.
Ua.("*,;a,)&.ES.D.,Q9p,,5)a,
,lk).'4,T'Q'4)M,M.,z)-9ZEU.,;
D.>)&.,F0".'Q"GVfcW(
q&;";."S.,T*J..a !>9Z
EU.,=,,Q9p,(O5KRI.;&"<0".
&;P.tG1.;).u)=.=.'4,T&;! ,K
,=,>"*,@)5'ES.,=,=,>9p,(>

)*+,K%.E&~&;'Rt$9E&'$",']^nu;a,$9.KF.
]‹hγ)GR=,)-&;P.,URH'&.RI.)
',5(q*'kD.>^*J.,F0".K%.
~&;'R>.KE;0".%,,E-,(
1.8. Ghép tế bào tự thân
*T.=.I;>'=%,,;,FG
'=&4),'M,S.)G)P'"-,;,=,>Ga.
=.'M,(F,'.,=,&&)P',F)=%.M
*T.=.I;>(~a,ESH'K" )*+,;.)+*.
j'N,b,F.'4,TZ;.,&;,b";..&);Z.Vc6W(
1.9. Phẫu thuật chỉnh hình, cắt bỏ màng hoạt dịch, thay khớp nhân tạo
H'K,L&*T.=4,bP'"&'N(•&,;9$tY‚cu
 4"_.*T.=4,F=,EU..K)&';a,,KK
3.N).,L&*.F.K9'.>'E(.;"&,b,F
=,EU..KD."',%.,L& 3?==
"  (K&4;=..M,;D.
>"#*.,=,=,.K "_.)>4,z*T.=,'M,S.
)G.KMG'9,5,L&H'="0,&;)%&"#VccW(
1.10. Lọc máu:,w.):)*+,)P.-D.Ga.)a,)*+,

,z)-',F%,3.,&;,L&%,+E-,(^'.!'M.
,;&.$4]])*+,R$**T.%,)P'"-_.,=,.>4"&9
E'.,=,$;$,L&y[6C*'=)P'"-P3.!
"#$,w.)*+,)P,N)Vc6W(
2. TIẾP CẬN PHÁC ĐỒ ĐIỀU TRỊ VKTPTN THEO ACR 2011
$;\OnC)P'"-)*+,,&$;,=,F)P'"-
*9&'V6Wm
g
2.1. Nhóm của thể viêm ít khớp (viêm của bốn khớp hoặc ít khớp).
F4&;.7D.>)*+,>;$;]q\nG
.>-Q4H'&
,=,)G=.>G 1. )*+,R;,F
;).,z";.M;a,T";.9'MH'="0E
,L&(
2.2. Nhóm của thể viêm từ 5 khớp trở lên
F4&;.7D.>)*+,>;$;]q\nG
!".)&n‹thu)&n‹t•u
K4H'&)G=.>G1.
)*+,R;,FG';).";.3;a,P'
T";.H'="0E,L&(
2.3. Nhóm viêm khớp cùng chậu hoạt động
Nhóm này bao gồm tất cả những bệnh nhân có triệu chứng lâm
sàngvàhình ảnhcủa viêm khớp,S.,N'hoạt động(Có thể bao gồm
những bệnh nhântừ các thể theo phân loại của ILAR.
2.4. Nhóm viêm khớp hệ thống với các đặc điểm toàn thân hoạt động (và
không có viêm khớp hoạt động).
F4&;.7 ,KD.>)=%.,=,',,L&
]q\n,;M.)a,)G9M,L&GM.
,F;a,1.,F,=,)a,)GM.=,*.1.,F
;).(

2.5. Nhóm viêm khớp hệ thống với viêm khớp hoạt động (và không có
đặc điểm toàn thân hoạt động).
F4&;.7 ,KD.>)=%.,=,',,L&
]q\n,;GM.,F;).*.1.
,F"',%.;>;).(
f
.;,=,>;$;cF)P'"-,%, p,H'M,
,b)*&"&,=,)=.=%,);).,=,)a,)G
*+.R ',UG<.F)P'"-,L&>'(
Bảng 1. Đặc điểm tiên lượng xấu và mức độ hoạt động bệnh của thể viêm
ít khớp
ĐẶC ĐIỂM TIÊN LƯỢNG XẤU (PHẢI THỎA MÃN 1)
=.;a,,9M.
,,>;a,,&43.)=.GI;E,L&,=,&"$"
*T."`H'&.0;b;a,€$
MỨC ĐỘ HOẠT ĐỘNG BỆNH
Mức độ hoa động thấp
(phải thỏa mãn tất cả)
Hoạt động bệnh trung
bình (không thỏa mãn
đặc điểm của hoạt động
bệnh cao hoặc thấp
Hoạt động bệnh cao
(phải thỏa mãn ít nhất 3)
9M;).
;a,T
OF;a,P'T,=,
)a,)G,L&%,)
;). 
Tg)a,)G,L&;

).,&;
9M;).‘
M,)='@.;a,
On0*J.
M,)='@.On
. )1.="-0
*J.
X=.=;).
,L&54'M,’gBC
X=.=;).
,L&54'M,‘eBC
X=.=;).
,L&>B.&)0
’BC
X=.=;).
,L&>B.&)0‘
fBC
Bảng 2. Đặc điểm của tiên lượng xấu và hoạt động bệnh của thể viêm đa
khớp ( từ trên 5 khớp )
c

Đặc điểm tiên lượng xấu (phải thỏa mãn)
=.;a,,9M.
“'ME. t•u;a,=.G=.OOt•u
*T."`H'&.0K;b;a,€$
Cách đánh giá mức độ hoạt động bệnh
Cách đánh giá mức độ hoạt động của bệnh
Hoạt động bệnh
thấp(phải thỏa mãn tất
cả)

Mức độ hoạt động bệnh
trung bình (không thỏa
mãn tiêu chuẩn hoạt
động bệnh thấp hay cao)
Hoạt động bệnh cao
(phải thỏa mãn ít nhất
3)
f;a,T9M
;).0*J.
;a,P'T)a,
)G;).
 Tg)a,)G
,L&;).,&;
[M(;).‚
;a,T
M,)='@.
OnT. 5
.",L&0
*J.
X=.=;).
,L&54'M,’fBC
X=.=;).
,L&54'M,‘
eBC
X=.=,L&
>B,&€’BC
X=.=,L&
>B,&€‘cBC
Bảng 3. Đặc điểm của tiên lượng xấu và hoạt động bệnh của viêm khớp
cùng chậu

Xa,)G*+.R '
*T."`H'&.! ,%;t;b;a,€$"
`H'&.u