甲状腺相关性眼病大剂量激素冲击治疗前后疗效观察及安全性评估

发布时间：2018-09-10 07:37

【摘要】：目的:甲状腺相关性眼病(Thyroid associated ophthalmopathy,TAO)为最常见的自身免疫性疾病的甲状腺外并发症,在Graves病(Graves’Disease,GD)患者中,发病率可高达25%[1],TAO的早期诊断可以使疾病得到有效的治疗,大剂量糖皮质激素静脉治疗是活动期的TAO的一线治疗方法[2],目前静脉激素治疗应用较为广泛的方案:前6周,每周应用500mg甲泼尼龙,后6周,每周应用250mg甲泼尼龙,共计12周,累积剂量达4.5mg[3]。本研究将探讨甲状腺相关性眼病大剂量激素冲击治疗前后疗效及安全性。方法:1、选取2013年1月至2017年1月在我院内分泌2科住院,符合TAO活动期诊断、入组标准及排除标准的患者共计17例为病例组,收集患者的姓名、年龄、性别、身高、体重、腹围、是否吸烟、既往主要病史、TAO病史及家族史。2、冲击前后行眼科检查,明确患者治疗期间眼部变化,包括:突眼度、双眼的视力、眼压,冲击前后对患者进行CAS评分,通过对以上几项的对比来观察治疗的有效性。3、检测患者冲击治疗前后血常规、尿常规、电解质、肝功能、OGTT实验、皮质醇节律以及骨量的变化,并持续观察患者有无反酸、烧心、嗳气、呃逆、腹胀、腹痛等消化道溃疡等症状;患者有无咳嗽咳痰等呼吸系统感染的症状;有无尿频、尿急等;泌尿系感染的症状;通过对以上几项的对比来评估治疗的安全性。4、所有数据使用spss17.0统计软件进行统计分析,符合正态分布的资料采用均数±标准差(x(-)±s)表示,组间比较采用t检验进行分析。不符合正态分布的数据,采用m(q25-q75)表示,组间比较采用mann-whitney秩和检验。采用pearson相关分析进行相关性分析。p0.05为差异有统计学意义。结果:1、大剂量激素冲击治疗后与治疗前相比较,突眼度及cas评分显著降低。左突眼度为[p0.01;16(15-17)vs18(16.5-19.5)mm],右突眼度为[p0.01;16(14-18)vs17(16-20)mm],cas评分为[p0.01;8(7.5-9)vs5(4-6)],另外,患者眼压明显降低,视力也有明显好转,差异具有统计学差异(p0.05);右眼压[p0.01;16(14.5-17)vs18(17-19)mmhg],左眼压为[p0.01;16(14-18.5)vs18(17-21.5)mmhg],左眼视力[p0.01;0.80(0.55-1.00)vs1.00(0.85-1.00)],右眼视力改变也有统计学差异[p0.01;1.00(1.00-1.00)vs0.80(0.45-0.90)]。2、cas评分的改善程度与tao的病程呈正相关(r=0.840,p=0.000),而与gd的病程、bmi指数以及年龄无关;3、治疗后恢复情况所占在人数以及百分比:其中cas评分降低了1~2分的有4人,占了23.53%,cas评分降低了3~4分的有12人,占了70.59%,,cas评分降低了5分以及以上的有1人,占了5.88%。4、治疗前后对比,患者血压、bmi、肝功能、皮质醇(8点、16点、24点)、血糖、离子代谢、pth的变化未见统计学差异。5、激素冲击引起不同副作用的人数以及所在百分数:结合患者实验室检查以及相关体征,经过治疗后,有1人出现骨量减低,占总人数5.88%,有2人出现了泌尿系统感染,占总人数11.76%,有2人出现了消化道的症状,占总人数11.76%,有2人出现了轻微库欣貌,占总人数11.76%,有4人出现了新发的糖代谢异常,占总人数的23.53%,其余呼吸道感染、新发糖尿病、肌痛以及肌无力、低钾血症以及抑郁症等副作用未有发生。结论:大剂量糖皮质激素冲击治疗甲状腺相关性眼病的有效性和安全性优于治疗前,尤其是在缓解眼部软组织炎症方面,对于提高视敏度、减少眼压、减低突眼度等方面均有较明显的作用。
[Abstract]:Objective: Thyroid associated ophthalmopathy (TAO) is the most common extrathyroidal complication of autoimmune diseases. The incidence of Graves'disease (GD) is as high as 25%[1]. Early diagnosis of TAO can effectively treat the disease. Intravenous therapy with high dose of glucocorticoid is active. The first-line treatment of TAO in the first six weeks, 500 mg methylprednisolone a week, 250 mg methylprednisolone a week for the second six weeks, a total of 12 weeks, the cumulative dose of 4.5 mg [3]. 1. From January 2013 to January 2017, 17 patients who met TAO criteria and excluded criteria were selected as the case group. Their names, age, sex, height, weight, abdominal circumference, cigarette smoking, past major medical history, TAO history and family history were collected. 2. Ophthalmological examinations were performed before and after the shock to identify the patients. The changes of ocular function, including exophthalmos, binocular vision, intraocular pressure, and CAS score before and after impact were compared to observe the effectiveness of treatment. 3. The changes of blood routine, urine routine, electrolyte, liver function, OGTT test, cortisol rhythm and bone mass were detected before and after impact therapy. Patients with acid reflux, heartburn, belching, hiccup, abdominal distention, abdominal pain and other symptoms of gastrointestinal ulcer; patients with cough and sputum and other respiratory infection symptoms; have frequent urination, urgency, and so on; symptoms of urinary tract infection; through the comparison of the above to assess the safety of treatment. 4, all data using SPSS 17.0 statistical software for statistical points. Data conforming to normal distribution were analyzed by mean (-) + standard deviation (x (-) + s) and t test respectively. Data not conforming to normal distribution were analyzed by M (q25-q75). Comparison between groups was performed by Mann-Whitney rank sum test. Pearson correlation analysis was used to analyze the correlation. P0.05 was statistically significant. Left exophthalmos were [p0.01; 16 (15-17) vs 18 (16.5-19.5) mm], right exophthalmos were [p0.01; 16 (14-18) vs 17 (16-20) mm], CAS was [p0.01; 8 (7.5-9) vs 5 (4-6)], and intraocular pressure was significantly reduced, visual acuity was also significantly improved, the difference was statistically poor. Right eye pressure [p0.01; 16 (14.5-17) vs 18 (17-19) mmhg], left eye pressure [p0.01; 16 (14-18.5-17) vs 18 (17-21.5) mmhg], left eye vision [p0.01; 0.01; 0.80 (0.55-0.55-1.00) vs 1.00 (0.85-1.00)], right eye vision changes were also statistically significant [p0.01; 1.00 (1.00 (1.00 (1.00 (1.00-00-1.00-1.00-1.00-1.00) vs 0.80 (17-20.80-80-80 (45)], left eye vision [p0.0.01; 0.80 (0.90, 0.90]the improvement of CAS score was positively correlated with the course of Tao (r = 0.840, P = 0.000), but not with the course of gd, BMI index and age; 3, the number and percentage of recovery after treatment: CAS score decreased by 1-2 points in 4 people, accounting for 23.53%, CAS score decreased by 3-4 points in 12 people, accounting for 70.59%, CAS score decreased by 5 points and more than 1 person, accounting for 5.88%. Blood pressure, bmi, liver function, cortisol (8:00, 16:00, 24:00), blood glucose, ion metabolism, PTH changes were not statistically significant. 5, hormone shock caused different side effects of the number and the percentage: combined with the patient's laboratory tests and related signs, after treatment, one person showed bone loss, accounting for 5.88% of the total, 2 people had urinary tract. Systemic infections accounted for 11.76% of the total population, 2 of whom had gastrointestinal symptoms, accounting for 11.76% of the total population, 2 had a slight Cushing appearance, accounting for 11.76% of the total population, 4 had new glucose metabolism abnormalities, accounting for 23.53% of the total population, the rest of respiratory tract infections, new diabetes, myalgia and myasthenia, hypokalemia and depression and other side effects. Conclusion: The efficacy and safety of high dose glucocorticoid pulse therapy for thyroid associated ophthalmopathy are better than those before treatment. Especially in alleviating ocular soft tissue inflammation, it can improve visual acuity, reduce intraocular pressure and reduce exophthalmos.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R581;R771.3

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