#1
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Ïîáî÷íûå ýôôåêòû ÏÕÒ
Óâàæàåìûå êîëëåãè, ïðîøó ïîìî÷ü ñîâåòîì.
Æåíùèíà, 34 ãîäà, ãîä íàçàä âûâëåí ðàê ÌÆ, ïðîîïåðèðîâàíà, íàáëþäàëàñü ó îíêîëîãîâ. Ìåñÿö íàçàä îáíàðóæåíû mts â ëåãêèå, ïå÷åíü, êîñòè. 2.10 ïðîâåäåí êóðñ ÏÕÒ (òðåìÿ ïðåïàðàòàìè, êàêèå èìåííî, âûÿñíèòü íå óäàëîñü).  íî÷ü ñ 3ãî íà 4å - îçíîá, òîøíîòà. íåóêðîòèìàÿ ðâîòà. Îíà îêàçàëàñü ó íàñ, ïîòîìó ÷òî áîëüíà ÑÄ 1 òèïà. Ñêîðàÿ âñåõ áîëüíûõ äèàáåòîì âåçåò â ýíäîêðèíîëîãèþ, ÷òî áû ñ íèìè íå ñëó÷èëîñü. Ê òîìó æå äèàáåò äåêîìïåíñèðîâàëñÿ (ãèïåðãëèêåìèÿ äî 15, êåòîç). Ââîäèì ýìåñåò, æèäêîñòü, ãëþêîêîðòèêîèäû, öåðóêàë. Äðîáíàÿ èíñóëèíîòåðàïèÿ ïîä êîíòðîëåì ãëèêåìèè. Ðâîòà íå ïðåêðàùàåòñÿ. Íî÷üþ íå ñïèò. ×òî ïîñîâåòóåòå? çàðàíåå ñïàñèáî, Àííà
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#2
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Öèòàòà:
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ðóêó êú ñåìó ïðèëîæèëú Àëåêñàíäðú |
#3
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Äîáàâëþ, ÷òî èíîãäà (íàïð. ïîñëå âûñîêèõ äîç ïëàòèíû) íå óäàåòñÿ äîñòèãíóòü êóïèðîâàíèÿ ðâîòû íà ìîíîòåðàïèè 5-HT3-àíòàãîíèñòàìè, òîãäà ðåêîìåíäóþò ñî÷åòàòü èõ ñ äåêñàìåòàçîíîì. Ïîäðîáíåå î ïðîôèëàêòèêå è êóïèðîâàíèè ðâîòû ìîæíî ïîñìîòðåòü çäåñü:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#4
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Ñïàñèáî.×åñòíî ãîâîðÿ, ÿ î÷åíü äàëåêà îò ýòîé òåìû
Íî ÿ óæå ïèñàëà - îíà ïîëó÷àåò ýìåñåò ñ äåêñàìåòàçîíîì. Èìååò ëè ñìûñë ïðîáîâàòü çàìåíèòü ýìåñåò íà íîâîáàí? Ìåõàíèçì äåéñòâèÿ ñõîäíûé, êàê ÿ ïîíèìàþ. Ïðîôèëàêòèêà òîøíîòû è ðâîòû ïðîâîäèëàñü ýìåñåòîì äî è âî âðåìÿ õèìèîòåðàïèè.
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#5
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Óâàæàåìàÿ Àííà,
Íå çíàþ ôèðìåííûõ íàçâàíèé, íî ïî ñèëå äåéñòâèÿ îíè íåìíîãî ðàçëè÷àþòñÿ granisetron > ondansetron > dolasetron Ìíîãîå çàâèñèò êàêóþ âñå-òàêè òåðàïèþ ïîëó÷àëà ïàöèåíòêà è â êàêîé äîçå - ðàçíàÿ ïðîòèâîðâîòíàÿ ýôôåêòèâíîñòü: Complete response and total control rates seen with specific drugs range from 60%–80% for moderately emetogenic chemotherapy, 40%–60% for cisplatin-containing therapy, and 25%–60% for high-dose cisplatin regimens. Òàêæå âîïðîñ àäåêâàòíîñòè äîçû: However, due to cost considerations, many of these agents are often used at lower than optimal doses. In the U.S., the approved dose of intravenous ondansetron is 32 mg; however, ondansetron is frequently given at doses as low as 8 mg when administered as part of a combination treatment approach for moderately or highly emetogenic chemotherapy. The impact of such a practice on symptom control may jeopardize effective patient management. In contrast, oral dolasetron is approved in the U.S. for use with moderately emetogenic chemotherapy at a dose of 100 mg administered within 1 hour before chemotherapy. However, a dose-related response for oral dolasetron has been shown to occur at doses between 25 and 200 mg. Indeed, a significant linear dose-response relationship was observed in 399 cancer patients receiving moderately emetogenic chemotherapy over the entire dolasetron dose range of 25–200 mg (p < 0.001), with complete response rates of 60.5% and 76.3% achieved with the 100 mg and 200 mg doses, respectiveló. Consideration of the consequences of potentially worse acute control, with its associated adverse clinical, humanistic, and economic effects, is therefore essential before administering lower-than-indicated doses of any approved agent. Administration of lower doses of agents with lower potency and/or shorter half-lives in those patients receiving carboplatin or cyclophosphamide agents (in whom nausea and vomiting typically peak about 12–18 hours after administration) may be particularly detrimental.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
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Àãà, ýìåñåò - ýòî îíäàíñåíòðîí, åãî äîçà 32 ìã â/â, äåêñàìåòàçîíà - 20 ìã
Results from a study investigating optimum corticosteroid doses suggest that a dexamethasone dose of 20 mg be used as standard prophylaxis in combination with 5-HT3-receptor antagonists [72]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#7
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Êàê ïîêàçûâàåò ñòàòèñòèêà, âñå ðàâíî èìåþòñÿ ïàöèåíòû, êîòîðûå íå îòâå÷àþò íà âåñü êîìïëåêñ ïðîòèâîðâîòíûõ ìåðîïðèÿòèé (20-40%), ìîæåò ýòîò ñëó÷àé êàê ðàç è ïîïàäàåò â ýòè %%?
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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#8
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Ïðè ïðîâåäåíèè õèìèîòåðàïèè îáÿçàòåëüíà ÏÐÎÔÈËÀÊÒÈÊÀ, ò.å. - ÄÎ òîãî êàê... è ðåêîìåíäóåòñÿ ïðîäîëæàòü äíåé 5.
Ýìåñåò îòí¸ñ ê áû ê îäíèì èç "ñëàáûõ" àíàëîãîâ, íî öåíà Çîôðàíà/Íàâîáàíà, óâû... Äîáàâüòå öåðóêàë (ìåòîêëîïðàìèä), îäíà èç ïàöèåíòîê èñïîëüçîâàëà âàòó â íîçäðè, ÷òîáû çàïàõîâ íå ñëûøàòü.... Âîò òåêñò èç êíèãè À. Ãàâàíäå [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#9
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À ðóêîâîäñòâî NCCN - çäåñü:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#10
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Öèòàòà:
Äàæå ýìåñåò óæå íå ïî êàðìàíó - âåäü â àìïóëå âñåãî 2 ìã..
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#11
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Ðâîòà ìîæåò áûòü ñâÿçàíà è ñ ïîðàæåíèåì ïå÷åíè. ×òî ó íåå ïî àíàëèçàì? Ïðî óðîâåíü ãëèêåìèè ìîæíî íå îòâå÷àòü , õîòÿ èíòåðåñíî, êàê òàì íà ôîíå äåêñàìåòàçîíà. Ìîæåò áûòü ðâîòà è çà ñ÷åò óðåìèè (îïÿòü àíàëèçû).
Ìîæåò è ãèïåðêàëüöèåìèÿ (êàêîâ Êàëüöèé?). Ìîæåò ñî÷åòàíèå. Ìîæåòå ïîïðîáîâàòü ãàëîïåðèäîë 1.5ìã 2-3 ðàçà â ñóòêè, åñëè íåò, òî àìèíàçèí ïî 1-2ìë 2-3 ðàçà â ñóòêè ïî ÷àñàì. Ïîíèìàþ, ÷òî íà ôîíå äåêîìïåíñàöèè è ðâîòû èíôóçèîííàÿ òåðàïèÿ íåîáõîäèìà, íî íà ôîíå ìåòàñòàçîâ â ëåãêèå áóäüòå îñòîðîæíû (ìîæåò ðàçâèòüñÿ ÄÍ). |
#12
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Á/õ êðîâè - óðåìèè è ïîðàæåíèÿ ïå÷åíè íåò. Õîòÿ ìåòàñòàçû òàì åñòü. Êàëüöèé ïðîâåðèì, ñïàñèáî.
Ãëèêåìèÿ îò 7 äî 14. Ó ìåíÿ ïðåäïîëîæåíèÿ íàñ÷åò ïîðî÷íîãî êðóãà ðâîòà - êåòîàöèäîç - ðâîòà. Àöåòîí ìî÷è ðåçêî ïîëîæèòåëüíûé, pH ó íàñ â áîãàäåëüíå íå îïðåäåëÿþò. Ïðî ãàëîïåðèäîë ñ àìíàçèíîì äóìàëà ñàìà, â îòäåëåíèè íåò íè÷åãî, áóäó çàêàçûâàòü.
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#13
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âîïðîñû îò ïðîôàíà â îíêîëîãèè
Ñåé÷àñ âñå õîðîøî. Ðâîòû íåò, åñò õîðîøî. Êåòîàöèäîç ÷åðåç ñóòêè ïîñëå ïðåêðàùåíèÿ ðâîòû êóïèðîâàí, äèàáåò ñóáêîìïåíñèðîâàí. Áîèòñÿ ñëåäóþùåãî êóðñà ÏÕÒ. Îíêîëîãè ó íàñ ïàöèåíòîâ ó ñåáÿ íå îñòàâëÿþò, ñðàçó âûïèñûâàþò.  ýòîò ðàç äëÿ ïðîôèëàêòèêè èñïîëüçîâàëè î÷åíü ìàëåíüêóþ äîçó - 8 ìã ýìåñåòà. ×òî æ ó íåãî äîçèðîâêà òàêàÿ íåóäîáíàÿ.. Êàêîâ äîëæåí áûòü îïòèìàëüíûé ðåæèì åãî ââåäåíèÿ äëÿ ïðîôèëàêòèêè íà ñëåäóþùåé ðàç? Íå ëó÷øå ëè îíêîëîãàì îñòàâèòü åå â ñëåäóþùèé ðàç íà íåñêîëüêî äíåé äëÿ íàáëþäåíèÿ, ñ ó÷åòîì òàêîé ðåàêöèè è èìåþùåãîñÿ ñàõàðíîãî äèàáåòà?
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#14
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Óâàæàåìàÿ Àííà,
Íåëüçÿ ëè óòî÷íèòü ó ýòèõ òàèíñòâåííûõ îíêîëîãîâ, äîçû è êîìïîíåíòû ÏÕÒ? Òîãäà ìîæíî ïðèêèíóòü, íàñêîëüêî ýìåòîãåííà äàííàÿ ñõåìà è íàèáîëåå ïðèåìëåìûå ïóòè ïðîôèëàêòèêè.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#15
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Öèòàòà:
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |