治療graves ppt課件

1、131I治療Graves病,131I-Treatment of Graves’ disease(GD),昆明醫(yī)科大學(xué)第一附屬醫(yī)院核醫(yī)學(xué)科 陳禮林,上節(jié)回顧,上節(jié)回顧,2. Clinical manifestations and diagnosis,,上節(jié)回顧,1. Graves,2. Clinical manifestations and diagnosis,3.Therapy：ATD、RIT、

2、Sugery,Background,美國(guó)前總統(tǒng)什布及妻子都曾患 “格雷夫斯氏甲亢” 。經(jīng)過(guò)許多世界級(jí)權(quán)威醫(yī)學(xué)專家會(huì)診和討論,最后確定用同位素131I為布什夫婦進(jìn)行治療，三個(gè)月后，布什夫婦很快康復(fù)了。布什付出的惟一代價(jià)是，服了藥一周內(nèi)沒(méi)有抱他的小孫孫。,本節(jié)課重點(diǎn)講述,本節(jié)課重點(diǎn)講述,Basic Principle,131I,,2). 131I ? Effective half-life 3.5~4.5d ?Stay for a lon

3、g time.,,Basic Principle,,,131I 主要蓄積在甲狀腺內(nèi),其余多由尿排出,其他臟器的吸收劑量很小,成人131I 370 MBq(10mCi)后臟器吸收劑量(rads, RAIU25%) 臟器 MIRD ICRP Oak Ridge 損傷劑量和效應(yīng)

4、 (1975) (1987) (1996) (rads) 甲狀腺 13 000.00 13320.00 13000.00 紅骨髓 2.60 2.60 3.10

5、 1次<600,可再生 卵巢 1.40 1.60 1.80 500-1000,不育 睪丸 0.88 0.99 1.00 500-1000,不育 肝臟 4

6、.80 1.30 3.90 3000,放射性肝炎 胃壁 14.00 17.0 13.0 1500/10天,無(wú)損傷 腎臟 ------ 2.10

7、 1.30 2000,放射性腎炎 全身 7.10 ----- ---- 100,WBC減少 MIRD

8、. J Nucl Med,1975,16:857-860 ICRP Publications 53.1987,18(1-4) Stabin MG.ORISE Publication,April 30,1996,131I的生物學(xué)作用特點(diǎn),I

9、ndication,,Indication,,（3）Graves甲亢伴白細(xì)胞或血小板減少的患者。,（4）Graves甲亢伴房顫的患者。,（5）Graves甲亢合并橋本氏病，攝碘率增高。,,1991年，Wartofsky等人以問(wèn)卷的形式進(jìn)行調(diào)查：內(nèi)科醫(yī)生首選Graves甲亢治療方案,（1）Female patients in pregnancy or lactation（2）Patients with acute myocardia

10、l infarction（3）Patients with severe renal dysfunction,Contraindication,Treatment Methods,,,,,,,,,,,,,,,,,1.病人準(zhǔn)備(Patient Preparation),,2.劑量計(jì)算(Dose Calculation),,3.注意事項(xiàng)( Matters need Attention),,,,,4.綜合治療 (Comprehensive

11、Treatment),,,5.定期隨訪復(fù)查(Follow-up),,治療方法,1.病人準(zhǔn)備(Patient Preparation),Treatment Methods,1).停服影響甲狀腺攝取131I的藥物和忌食含碘食物，常規(guī)體檢。心率過(guò)快和精神緊張者，可給予?受體阻滯劑或鎮(zhèn)靜劑。,2).甲狀腺激素(Thyroid Hormones)和TSH，甲狀腺131I攝取率(RAIU)測(cè)定。,3).甲狀腺重量估算（Size and Weigh

12、t of Thyriod）,Physical examination (palpation)UltrasoundTechnetium-99m scanIodine-124 PET,1.病人準(zhǔn)備(Patient Preparation),Treatment Methods,4).病情較重的患者，先用抗甲狀腺藥物治療（ATD)，病情減輕后再進(jìn)行131I治療(RIT)。,5).治療前健康教育:向患者充分介紹目前治療甲亢的方法及其優(yōu)缺點(diǎn)（

13、替代醫(yī)療方案）；詳細(xì)介紹131I治療的注意事項(xiàng)、療效（一次治愈率、復(fù)發(fā)率、起效時(shí)間、重復(fù)治療等）、可能出現(xiàn)的近期反應(yīng)、甲減發(fā)生率及處治措施；解釋患者提出的問(wèn)題；簽署知情同意書。,Treatment Methods,2.劑量計(jì)算(Dose Calculation),desired dose（MBq or μCi/g）×gland size（g）DOSE = Max

14、RAIU（or 24 hours)（%）,,(MBq or μCi),Accoding to the standard dose formula,theoretical dose for per gram of thyroid tissue is usually expected to be 2.59-4.44 MBq(70-120μCi).,Treatment Methods,,3.注意事項(xiàng)( Matters need Attent

15、ion),,,,,Treatment Methods,4.綜合治療(Comprehensive Treatment),（1）與抗甲狀腺藥物綜合應(yīng)用,（2）與β腎上腺素能受體阻斷劑合用,Treatment Methods,5. Follow-up,Therapeutic Evaluation,Hyperthyroidism symptoms and signs disappeared completely,thyroid hormon

16、e levels back to normal.,To alleviate the symptoms, physical signs disappeared partly,reduce the level of thyroid hormone but not to normal.,痊愈 Recovery：,好轉(zhuǎn) Improvement：,Therapeutic Evaluation,Signs and symptoms were

17、 not improved or aggravate,thyroid hormone levels did not decrease.,After recovery, again the signs and symptoms of hyperthyroidism, thyroid hormone levels rose again.,Appear the symptoms and signs of hypothyroidism,

18、thyroid hormone levels decrease, TSH increase.,無(wú)效 Ineffective：,復(fù)發(fā) Relapse：,甲低 Hypothyroidism：,Thyroid Hormone Determination,RAIU,Technetium-99m scan,131I治療Graves病的目標(biāo)及對(duì)甲減 （hypothyroidism）的認(rèn)識(shí),Progress,Graves病自發(fā)性甲減發(fā)生率可高達(dá)

19、16%~20%，任何治療方法都不可避免產(chǎn)生一定比例的甲減。,“甲減是131I治療甲亢難以避免的結(jié)果，是治療的必然轉(zhuǎn)歸之一。選擇131I治療主要是要權(quán)衡甲亢與甲減后果的利弊關(guān)系”。 中華醫(yī)學(xué)會(huì)內(nèi)分泌學(xué)會(huì)《中國(guó)甲狀腺疾病診治指南》,131I治療甲亢后的甲減是治療的必然轉(zhuǎn)歸之一，不是副作用，不是并發(fā)癥，更不是醫(yī)療事故。,我們的目標(biāo)是在保證高治愈率的同時(shí)，使早發(fā)甲減控制在一個(gè)可以接受的水平。甲減的存在并不影響131I作為成人Grav