33例难治性甲亢中医临床研究

【作者】 陈鸣宇；

【导师】 刘喜明；

【作者基本信息】 北京中医药大学 ， 中医内科学（专业学位）， 2016， 硕士

【摘要】 甲状腺功能亢进症(甲亢)是内分泌临床常见疾病,绝大多数患者在接受抗甲状腺药物等治疗后,能够达到症状缓解,临床治愈。但有少数患者由于多种因素的影响,促甲状腺激素(TSH)持续偏低或促甲状腺激素受体抗体(TRAb)居高不降,使得病情经久不愈或反复发作而无法减药、停药,严重影响其工作、生活甚至生育,我们称之为难治性甲亢。中医药辨证治疗难治性甲亢具有明显的优势,但目前还未见专门的中医临床报道,因此有必要对此加以研究。目的通过临床观察,归纳统计难治性甲亢的主要症状,研究其证候规律及基本病机,总结导师刘喜明辨证治疗难治性甲亢的临床经验及用药规律。方法选取2013年9月至2015年12月广安门医院内分泌科刘喜明教授门治疗的难治性甲亢患者33例为研究对象,给予中药联合抗甲状腺药物治疗,以自身治疗前后为对照,设定初诊为0月,按照0、3、6、9月时段采集数据,观察患者治疗前后症状、证候、TSH值、甲状腺功能等的变化情况,并统计研究其相关性；运用数据挖掘技术对33例患者所用297首处方进行药物频次、频率统计,并分析其组方规律。结果一般资料：33例难治性甲亢患者中,复发型甲亢患者13例,不愈型甲亢患者20例。以女性居多,男女比例为1：5.5；75.7%的患者年龄<40岁；88%为职员或学生；病程在2-5年者为54.5%,有9.1%的患者病程>10年；78.8%的患者伴有甲状腺II度或Ⅲ度肿大；症状分布：13例复发型甲亢的症状分布为心悸(100%)、多汗(76.9%)、恶热(69.2%)、烦躁(61.5%)、震颤(53.8%)等,20例不愈型甲亢的症状分布为烦躁(85.0%)、心悸(70.0%)、震颤(55.0%)、恶热(50.0%)、神疲乏力(45.0%)等。经中药治疗3、6、9月后,总有效率分别为94%、97%、97%,症状积分与初诊相比显著减少。证候分类：复发型甲亢证型分布为气阴两虚(92.35%)、心肝(胃)火旺(84.6%)、气滞痰凝(61.5%)、瘀血阻滞(7.7%)等；不愈型甲亢证型分布为气阴两虚(95%)、心肝火旺(70%)、气滞痰凝(65%)、瘀血阻滞(35%)等。TSH相关分析：33例患者初诊时TSH均低于正常值,经中药治疗,TSH恢复正常者21例,仍持续偏低者8例,不稳定者4例。分析其相关性发现：TSH值的恢复与发病年龄、病程、疗程、初诊时FT3、 FT4值及甲状腺肿大程度均不具有相关性,但与症状改善情况有非常显著的关系。用药规律：本研究共统计297首处方,154味中药,每首处方药味在7-12味间,中药应用频率>20%的药物为生地黄(67.3%)、百合(62.6%)、浙贝母(60.3%)、生黄芪(57.2%)、玄参(56.6%)、猫爪草(41.1%)、炒白芍(38.4%)、麦冬(37.0%)、皂刺(34.7%)、连翘(27.3%)、莪术(22.9%)、牡丹皮(21.5%)。结论1.本研究观察发现难治性甲亢的主要症状为心悸、恶热、多汗、烦躁等,高代谢症状表现不明显；2.本研究所观察的难治性甲亢患者均具有TSH持续偏低的特点,并且发现TSH值的恢复与症状积分的改变关系密切,提示中药治疗难治性甲亢改善症状是关键；3.刘喜明教授将难治性甲亢的主要证候分为气阴两虚、心肝火旺、气滞痰凝及瘀血阻滞四型,治疗以益气养阴、化痰散结药物为主。更多还原

【Abstract】 Hyperthyroidism is a clinical common endocrine disease, the vast majority of patients after treated with anti-thyroid drugs, etc, can achieve symptom relief or clinical cure. But there are a few patients due to the influence of various factors, thyroid stimulating hormone (TSH) constantly stay low or thyroid stimulating hormone receptor antibody (TRAb) stay high, make the illness is not more or recurrent to keep drugs on or reduce odes, the serious influence its work and life or even its birth, we call it refractory hyperthyroidism. Syndrome differentiation of traditional Chinese medicine treatment of refractory hyperthyroidism has obvious advantages, but there is no special clinical reports of traditional Chinese medicine, so it is necessary to study.Objective Through clinical observation, the main symptoms of inductive statistics refractory hyperthyroidism, study its basic pathogenesis, syndrome regularity and to summarize the clinical experience of the tutor Ximing Liu dialectical treatment of refractory hyperthyroidism and drug laws.Method To choose between September 2013 and December 2015, the gate of hospital endocrinology Ximing Liu, a professor at the outpatient service of 33 patients with refractory hyperthyroidism patients treated as the research object, give joint antithyroid drug therapy and traditional Chinese medicine, controlled with themselves before and after, the first treatment was set to 0, in accordance with 0,3,6,9 month period of time to collect data, observed before and after treatment in patients with symptoms, syndrome, TSH values, the change of thyroid function, etc, and statistics and study the correlationship; Using the data mining technology to 33 patients with 297 prescriptions for drugs used frequency, frequency statistics, analyze its characteristics.ResultsGeneral information:Refractory hyperthyroidism patients in the majority with women, men and women ratio of 1:5.5; 75.7% of the patients age< 40 years old; 88% for staff or students; Course of the disease in 2-5 years was 54.5%,9.1% of patients duration> 10 years; 78.8% of the patients with thyroid II degrees or III swelling; 33 cases of refractory hyperthyroidism patients,13 cases of recurrence in patients with hyperthyroidism, not the type of 20 cases of hyperthyroidism patients.Symptoms distribution:13 cases of recurrence of symptoms of hyperthyroidism distribution for palpitation (100%), sweat (76.9%), heat evil (69.2%), irritability (61.5%), tremor (53.8%),20 cases not the distribution of the symptoms of hyperthyroidism is agitated (85.0%), heart palpitations (70.0%), tremor (55.0%), heat evil god (50.0%), fatigue (45.0%), etc. By the Chinese medicine treatment of 3,6,9 months, total effective rate were 94%,97%, 97%, significantly reduced compared with original symptom integral.Syndrome classification:hyperthyroidism relapse type distribution of qi and Yin deficiency (92.35%), heart (stomach) the fire (84.6%), and qi stagnation TanNing (61.5%), blood stasis block (7.7%), etc.; Not the type of hyperthyroidism type distribution of qi and Yin deficiency (95%), heart the fire (70%), and qi stagnation TanNing (65%), blood stasis block (35%), etc. TSH correlation analysis:33 patients with TSH are below normal to begin with, the Chinese medicine treatment, TSH restore normal 21 cases, continued to partial person with 8 cases,4 cases of unstable. Analysis of the correlation is found that the recovery of TSH values and age, course of disease, treatment, FT3, FT4 value to begin with, and degree of goiter are not relevant, but have significant relationship with symptoms improve the situation.Drug laws:this study has counted 297 prescriptions,154 TCM, each formula ingredients between 7-12 flavour, traditional Chinese medicine application frequency> 20% of drug addiction (67.3%), lily (62.6%), and zhejiang fritillary (60.3%), the root of remembranous milk vetch (57.2%), radix scrophulariae (56.6%), cat’s claw (41.1%), Fried radix paeoniae alba (38.4%), dwarf lilyturf (37.0%), soap (34.7%), st John’s wort (27.3%), rhizoma zedoariae (22.9%), cortex moutan (21.5%).Conclusion1. This study observed the main symptoms of refractory hyperthyroidism as palpitation, evil heat, sweat, irritability, etc., high metabolism symptom is not obvious.2. The observation in our study of refractory hyperthyroidism patients have the characteristics of low TSH continued, and found that the recovery of TSH values is closely related to the change of symptom integral, prompt Chinese medicine treatment of refractory hyperthyroidism improveing the symptoms is the key;3. Ximing Liu professor divide the syndrome of refractory hyperthyroidism into four types: deficiency of both qi and yin, hyperactivity of heart-liver fire, stagnant qi and phlegm cohere and blood stasis block. Treatment is given priority to with the drugs of tonifying qi and yin and reducing phlegm and resolving masses.更多还原