‡«™ªØ‘∫—µ‘ª√‘∑—»πå § ≈‘ π‘ ° Safety of Intranasal Steroids in Long-Term Use ¬“ µ’√Õ¬¥åæàπ®¡Ÿ° (intranasal steroids) ‡ªìπ¬“∑’ËÕÕ°ƒ∑∏‘χ©æ“–∑’Ë∑’ˇ¬◊ËÕ∫ÿ®¡Ÿ°‰¥â¥’ ·≈–¡’º≈µàÕ∑—Ë«√à“ß°“¬ (systemic effect) µË” ‰¥â‡√‘Ë¡¡’°“√𔬓 µ’√Õ¬¥åæàπ®¡Ÿ°¡“„™â√—°…“‚√§ ®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ (allergic rhinitis) µ—Èß·µàªï æ.». 2517 πÕ°®“°®–„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ° √—°…“‚√§¥—ß°≈“«·≈à «â ¬“ µ’√Õ¬¥æå àπ®¡°¬Ÿ —ß¡∑’ ’Ë„™â„π‚√§Õ◊ËπÊ Õ°’ ‡™àπ ‚√§®¡Ÿ°Õ—°‡ ∫™π‘¥‰¡à·æâ (nonallergic rhinitis), ‰´π Õ— °‡ ∫‡©— ¬∫æ≈’ π— (acute rhinosinusitis), ‰´π Õ— °‡ ∫‡√— Õ√◊È ß— (chronic rhinosinusitis), √‘¥ ’¥«ß®¡Ÿ° (nasal polyp), ‡¬◊ËÕ∫ÿ®¡Ÿ°Õ—°‡ ∫®“°°“√„™â¬“À¥À≈Õ¥‡≈◊Õ¥ ‡©æ“–∑’Ëπ“π‡°‘π‰ª (rhinitis medicamentosa) „πªí®®ÿ∫—π¡’¬“ µ’√Õ¬¥åæàπ®¡Ÿ°∑’Ë®”Àπà“¬„π ª√–‡∑»‰∑¬ 6 ™π‘¥ §◊Õ - Beclomethasone dipropionate - Budesonide - Fluticasone propionate - Triamcinolone acetonide - Mometasone furoate - Fluticasone furoate ‡πÕß®“°¡◊Ë °“√„™’ ¬“ µâ √Õ¬¥’ æå π®¡à °„π‚√§µŸ “ßÊà ‡æ¡¡“°¢‘Ë π÷È ´ß¡÷Ë °®–‡ª— π‚√§∑ì ‡√’Ë Õ√◊È ß— ·≈– µâÕß„™â√–¬–‡«≈“π“π„π°“√√—°…“ ®÷ß¡’§”∂“¡µ“¡¡“«à“ °“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°‡ªìπ√–¬–‡«≈“ π“π„π‚√§¥—ß°≈à“« ª≈Õ¥¿—¬À√◊Õ‰¡à ‚¥¬‡©æ“–„πºŸâªÉ«¬‡¥Á°. °“√∑’ˬ“ µ’√Õ¬¥åæàπ®¡Ÿ°®–∑”„À⇰‘¥º≈¢â“߇§’¬ß∑’ˉ¡àæ÷ߪ√– ߧ傥¬‡©æ“–º≈µàÕ∑—Ë« √à“ß°“¬ (systemic adverse effect) ‰¥âπ—È𠬓 µ’√Õ¬¥åæàπ®¡Ÿ°®–µâÕß¡’°“√¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‚≈À‘µ„πª√‘¡“≥∑’Ë Ÿß¡“°æÕ ‡¡◊ËÕæà𬓠µ’√Õ¬¥åæàπ®¡Ÿ°‡¢â“‰ª„π‚æ√ß®¡Ÿ° ¬“ µ’√Õ¬¥å æàπ®¡Ÿ° à«πÀπ÷Ëß®–¡’°“√¥Ÿ¥´÷¡ºà“π‡¬◊ËÕ∫ÿ®¡Ÿ° ·≈–‡¢â“ Ÿà°√–· ‚≈À‘µ‰¥â‚¥¬µ√ß (·ºπ¿Ÿ¡‘∑’Ë 1) Õ’° à«πÀπ÷Ëß´÷Ë߇ªìπ à«π„À≠à (¡“°°«à“√âÕ¬≈– 50 ¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ°) ®–∂Ÿ°ºŸâªÉ«¬°≈◊π≈ß ‰ª„π∑“߇¥‘πÕ“À“√ ·≈–¡’°“√¥Ÿ¥´÷¡ºà“π‰ª¬—ßµ—∫ ‡æ◊ËÕºà“π°√–∫«π°“√ first pass inactivation À≈—ß®“°π—Èπ à«π active ¢Õ߬“®÷ß®–∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥ ¥—ßπ—Èπ ª√‘¡“≥¢Õ߬“ µ’√Õ¬¥å ª“√¬– Õ“»π–‡ π æ.∫., √Õß»“ µ√“®“√¬ å “¢“‚√§®¡°·≈–‚√§¿Ÿ ¡Ÿ ·æ‘ â ¿“§«™“‚ µ‘ π“ °‘ ≈“√ß´‘ «å ∑¬“‘ §≥–·æ∑¬»“ µ√»å √‘ √“™æ¬“∫“≈‘ ¡À“«∑¬“≈‘ ¬¡À— ¥≈‘ §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 1 ¡°√“§¡ 2556 7 ·ºπ¿Ÿ¡‘∑’Ë 1. °“√¥Ÿ¥´÷¡¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ°À≈—ß®“°∂Ÿ°æàπ‡¢â“‰ª„π‚æ√ß®¡Ÿ°. æàπ®¡Ÿ°∑’Ë∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥ (systemic bio- us ·≈⫉ª®—∫ glucocorticoid response element availability) ·≈–∑”„À‡°â ¥º≈¢‘ “߇§â ¬ß∑’ ‰¡’Ë æà ߪ√– ߧ÷ å ´ßÕ¬÷Ë ∫πŸà chromatin ¢Õß steroid-responsive gene1 ®÷߇ªìπº≈√«¡√–À«à“߬“ µ’√Õ¬¥åæàπ®¡Ÿ°∑’Ë∂Ÿ°¥Ÿ¥´÷¡ °“√®—∫¢Õß steroid-receptor complex °—∫ DNA ºà“π‡¬◊ËÕ∫ÿ®¡Ÿ°‚¥¬µ√ß ·≈–¬“ µ’√Õ¬¥åæàπ®¡Ÿ°∑’Ë∂Ÿ° ¥—ß°≈à“« ∑”„À⇰‘¥À√◊Õ¬—∫¬—È߉¡à„À⇰‘¥ gene tran- ¥Ÿ¥´÷¡ºà“π∑“߇¥‘πÕ“À“√ À≈—ß®“°ºà“π°√–∫«π°“√ scription mRNA transcripts ∑’ˉ¥â®–∂Ÿ°π”ÕÕ°‰ª first pass inactivation „πµ—∫·≈â«. „π cytoplasm ¢Õ߇´≈≈å ·≈–∂Ÿ°π”‰ª √â“ß‚ª√µ’π ‚¥¬ ribosome2,3 ‚ª√µπ¥’ ß°≈— “«®–∑”Àπà “∑â ¬’Ë ∫¬— ß°“√—È °≈‰°°“√∑”ß“π¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ° √â“ß pro-inflammatory cytokines ‡™àπ interleu- ¬“ µ’√Õ¬¥åÕÕ°ƒ∑∏‘Ï‚¥¬§«∫§ÿ¡°“√ —߇§√“–Àå kin (IL)-1, IL-2, interferon (IFN)-α, tumor ‚ª√µ’π ‡¡◊ËÕæà𬓠µ’√Õ¬¥å‡¢â“‰ª„π‚æ√ß®¡Ÿ° ¬“ necrosis factor (TNF), colony-stimulating µ√Õ¬¥’ ®–ºå “πà cell membrane ‡¢“‰ª„πâ cytoplasm factors (CSFs) ™π¥µ‘ “ßÊà ·≈–¬∫¬— ß°“√ √—È “ßâ proin- ¢Õ߇´≈≈ å ·≈«‰ª®â ∫°— ∫— glucocorticoid receptor ‡ªπì flammatory enzymes (‡™àπ collagenase, elastase) steroid-receptor complex ·≈⫇§≈◊ËÕπ‡¢â“ Ÿà nucle- ·≈– ¬—∫¬—Èß lymphocyte proliferation. 8 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 1 ¡°√“§¡ 2556 º≈¢â“߇§’¬ß¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ° º≈¢Õß°“√µ—¥‡¬◊ËÕ∫ÿ®¡Ÿ°‰ªµ√«®°àÕπ‡√‘Ë¡°“√√—°…“ 1. º≈¢â“߇§’¬ß∑’ˉ¡àæ÷ߪ√– ߧ凩擖∑’Ë Minshall ·≈–§≥–14æ∫«à“°“√„™â mometasone (local adverse effects) furoate „πºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æ⇪ìπ√–¬–‡«≈“ °“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ° Õ“®‡°‘¥º≈¢â“߇§’¬ß 1 ª æ∫«à “¡à ‡¬’ Õ∫◊Ë ®¡ÿ°‡ÀŸ ¬«Ω’Ë ÕÉ À√Õ°“√‡ª≈◊ ¬π·ª≈ß’Ë ‡©æ“–∑’ˉ¥â ‡™à𠇬◊ËÕ∫ÿ®¡Ÿ°·Àâß, ¡’ –‡°Á¥, ‡≈◊Õ¥ ¢Õß epithelial thickness ·≈–¡’ focal metaplasia °”‡¥“‰À≈ (epistaxis), Õ“°“√· ∫À√◊Õ√–§“¬‡§◊Õß ¥¢’ ÷Èπ. ¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° º≈¢â“߇§’¬ß¥—ß°≈à“«‡°‘¥‰¥â√âÕ¬≈– 5 - °“√»÷°…“Õ’° 2 °“√»÷°…“· ¥ß„Àâ‡ÀÁπ«à“°“√ 104,5 ´÷Ëߺ≈¢â“߇§’¬ß‡©æ“–∑’Ë¥—ß°≈à“«¡—°À“¬‰¥â‡Õß „™â triamcinolone acetonide ‡ªìπ√–¬–‡«≈“π“π πÕ°®“°π—Èπ ¬—ß¡’√“¬ß“π°“√‡°‘¥ºπ—ß°—Èπ™àÕß®¡Ÿ° „πºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ™π‘¥‡ªìπµ≈Õ¥ªï ‰¡à ∑–≈ÿ (nasal septal perforation) À≈—ß®“°°“√„™â¬“ ∑”„Àâ¡’°“√‡ª≈’ˬπ·ª≈ߢÕߧ«“¡Àπ“¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° µ’√Õ¬¥åæàπ®¡Ÿ°√ÿàπ·√°Ê6 ´÷Ëߺ≈¢â“߇§’¬ß‡©æ“–∑’Ëπ’È ´÷Ë߇ªìπ¥—™π’∑’Ë∫àß™’È∂÷߇¬◊ËÕ∫ÿ®¡Ÿ°‡À’ˬ«ΩÉÕ ‡¡◊ËÕ‡ª√’¬∫ “¡“√∂À≈’°‡≈’ˬ߉¥â ∂â“„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°Õ¬à“ß ‡∑’¬∫°—∫ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ™π‘¥‡ªìπµ≈Õ¥ªï ∂Ÿ°«‘∏’7 §◊Õ·π–π”„Àâæà𬓉ª —¡º— °—∫‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë ∑’ˉ¥â√—∫°“√√—°…“¥â«¬ cetirizine8,15 Baroody ·≈– Õ¬Ÿà¥â“π¢â“ߢÕß‚æ√ß®¡Ÿ°„Àâ¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–¡“° §≥–16æ∫«à“°“√„™â fluticasone propionate „π ‰¥â ‚¥¬‰¡à„Àâæà𬓇¢â“‰ª∑’˺π—ß°—Èπ™àÕß®¡Ÿ°´÷ËßÕ¬Ÿà ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ™π‘¥‡ªìπµ≈Õ¥ªï‡ªìπ µ√ß°≈“ß. √–¬–‡«≈“ 1 ªï ‰¡à∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ߢÕß πÕ°®“°¡’º≈¢â“߇§’¬ß¥—ß°≈à“«·≈â« ‘Ëß∑’Ëπà“ ‡¬◊ËÕ∫ÿ®¡Ÿ° ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫ °—ß«≈§◊Õ ¬“ µ’√Õ¬¥åæàπ®¡Ÿ°¡’º≈µàÕ°“√∑”ß“π¢Õß ¿¡Ÿ ·æ‘ ™πâ ¥‡ª‘ πµ≈Õ¥ªì ∑ï ‰¥’Ë √â ∫°“√√— °…“¥— «¬â terfena- ¢π°«—¥„π®¡Ÿ° (nasal mucociliary clearance) dine. À√◊Õ∑”„À⇬◊ËÕ∫ÿ®¡Ÿ°‡À’ˬ«ΩÉÕ (nasal mucosal atro- ¥—ßπ—Èπ ®“°À≈—°∞“π∑’Ë°≈à“«¡“∑—ÈßÀ¡¥ · ¥ß„Àâ phy) ‡À¡◊Õπ°“√„™â¬“ µ’√Õ¬¥å∑“º‘«Àπ—߇ªìπ√–¬– ‡ÀÁπ«à“°“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°‡ªìπ√–¬–‡«≈“π“𠇫≈“π“π ·≈⫇°‘¥ skin atrophy À√◊Õ‰¡à Klossek ¡’§«“¡ª≈Õ¥¿—¬µàÕ‡¬◊ËÕ∫ÿ®¡Ÿ°∑—Èߥâ“π‚§√ß √â“ß ·≈– ·≈–§≥–8 æ∫«“°“√„™à â triamcinolone acetonide „π °“√∑”ß“π πÕ°®“°π—È𬓠µ’√Õ¬¥åæàπ®¡Ÿ°∫“ß™π‘¥ ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ™π‘¥‡ªìπµ≈Õ¥ªï (peren- ¡’ “√ benzalkonium chloride ‡ªìπ preservative nial allergic rhinitis) ‡ªìπ√–¬–‡«≈“ 6 ‡¥◊Õπ °Á “¡“√∂„™â‰¥âÕ¬à“ߪ≈Õ¥¿—¬„π√–¬–¬“«‚¥¬‰¡à∑” ‰¡à‰¥â∑”„Àâ mucociliary function „π®¡Ÿ°‡ ’¬‰ª Õ—πµ√“¬µàÕ‡¬◊ËÕ∫ÿ®¡Ÿ°‡™àπ°—π17. Naclerio ·≈–§≥–9 æ∫«à“°“√„™â budesonide À√◊Õ mometasone furoate „πºªŸâ «¬‚√§®¡É °ÕŸ °‡ ∫¿— ¡Ÿ ·æ‘ â 2. º≈¢â“߇§’¬ß∑’ˉ¡àæ÷ߪ√– ߧåµàÕ∑—Ë« ™π‘¥‡ªìπµ≈Õ¥ªï ‡ªìπ√–¬–‡«≈“ 2 —ª¥“Àå ‰¡à‰¥â∑” √à“ß°“¬ (systemic adverse effects) „Àâ mucociliary function „π®¡Ÿ°‡ ’¬‰ª‡™àπ°—π. 2.1 º≈¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ°µàÕ °“√»÷°…“ 3 °“√»÷°…“· ¥ß„Àâ‡ÀÁπ«à“ °“√ Hypothalamic-Pituitary-Adrenal (HPA) „™â beclomethasone dipropionate ‡ªìπ√–¬– axis ‡«≈“π“π∂÷ß 6 ªï‰¡à∑”„À⇰‘¥‡¬◊ËÕ∫ÿ®¡Ÿ°‡À’ˬ«ΩÉÕ10-12 ¡’ß“π«‘®—¬¡“°¡“¬∑’Ë«—¥º≈°√–∑∫¢Õ߬“ Pipkorn ·≈–§≥–13æ∫«à“°“√„™â budesonide „π µ’√Õ¬¥åæàπ®¡Ÿ°µàÕ°“√∑”ß“π¢Õß HPA axis °“√ ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ µ—Èß·µà√–¬–‡«≈“ 1-5 ªï »÷°…“ à«π„À≠à‰¡àæ∫°“√‡ª≈’ˬπ·ª≈ߢÕß HPA ‰¡à∑”„À⇰‘¥‡¬◊ËÕ∫ÿ®¡Ÿ°‡À’ˬ«ΩÉÕ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ axis18-33 Õ¬“߉√°à µ“¡Á ¡∫“ß√“¬ß“π∑’ æ∫«’Ë “¬“ µà √Õ¬¥’ å §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 1 ¡°√“§¡ 2556 9 µ“√“ß∑’Ë 1. Õ“¬¢Õߺÿ ªŸâ «¬∑É ‰¥’Ë √â ∫°“√√— ∫√Õß‚¥¬Õߧ— °“√Õ“À“√·≈–¬“¢Õߪ√–‡∑» À√å ∞Õ‡¡√— °“‘ ·≈–‰∑¬ „À„™â ¬“ µâ √Õ¬¥’ å æàπ®¡Ÿ°™π‘¥µà“ßÊ. ™π‘¥¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ° Õ“¬ÿ∑’ˉ¥â√—∫°“√√—∫√Õß‚¥¬ Õߧ尓√Õ“À“√·≈–¬“¢Õߪ√–‡∑» (ªï) À√∞Õ‡¡√— ‘°“ ‰∑¬ Fluticasone furoate ≥ 2 ≥ 2 Triamcinolone acetonide ≥ 2 ≥ 2 Mometasone furoate ≥ 2 ≥ 3 Fluticasone propionate ≥ 4 ≥ 4 Budesonide ≥ 6 ≥ 6 Beclomethasone dipropionate ≥ 6 ≥ 6 æàπ®¡Ÿ°¡’º≈µàÕ°“√∑”ß“π¢Õß HPA axis34-36 ‚¥¬ ºŸâ„À≠à48 °“√‡≈◊Õ°™π‘¥¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ° §«√ √«¡®–æ∫«à“ °“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°¥â«¬¢π“¥∑’Ë §”π÷ß∂÷ßÕ“¬ÿµË” ÿ¥¢ÕߺŸâªÉ«¬∑’ˉ¥â√—∫°“√√—∫√Õß‚¥¬ ·π–π”„π°“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ∑—Èß„πºŸâªÉ«¬ Õߧ尓√Õ“À“√·≈–¬“¥â«¬¥—ßµ“√“ß∑’Ë 1. ‡¥Á°·≈–ºŸâ„À≠à ¡’§«“¡ª≈Õ¥¿—¬ Ÿß ·≈–¡’√“¬ß“π∑’Ë ‡°‘¥º≈°√–∑∫µàÕ HPA axis πâÕ¬¡“° ·≈–„π 2.3 º≈¢Õ߬“ µ√Õ¬¥’ æå π®¡à °µŸ Õ°“√à √“¬ß“π∑’Ëæ∫«à“¡’°“√°¥°“√∑”ß“π¢Õß HPA axis µ‘¥‡™◊ÈÕ (infection) ¡—°æ∫„πºŸâ∑’Ë„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°„π¢π“¥ Ÿß°«à“ °“√„™¬“ µâ √Õ¬¥’ æå π®¡à °Ÿ ‰¡‰¥à ∑”„Àâ ‚Õ°“ â °”Àπ¥ À√◊Õ„πºŸâ∑’ˉ¥â√—∫¬“ µ’√Õ¬¥å∑“º‘«Àπ—ß À√◊Õ ¢Õß°“√µ‘¥‡™◊ÈÕ‡æ‘Ë¡¡“°¢÷Èπ49,50 ·¡â«à“°“√„™â inhaled æπ§Õ√à «¡¥à «¬â 37,38 ¥ßπ— π§«√„™—È ¬“ µâ √Õ¬¥’ æå π®¡à °„πŸ corticosteroids „πºŸâªÉ«¬‚√§À◊¥ Õ“®∑”„À⇰‘¥°“√ ¢π“¥∑’ˉ¡à‡°‘𧔷π–π” ·≈–„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ° µ‘¥‡™◊ÈÕ√“„π™àÕߪ“° (oropharyngeal candidiasis) „π¢π“¥∑’˵˔ ÿ¥∑’˧«∫§ÿ¡Õ“°“√¢Õß‚√§‰¥â Õ¬à“߉√ ·≈–°“√µ‘¥‡™◊ÈÕÕ◊ËπÊ µ“¡¡“‰¥â.51-53 °Áµ“¡ ºŸâªÉ«¬∑’ˉ¥â√—∫¬“ µ’√Õ¬¥åæàπ®¡Ÿ°„π¢π“¥ Ÿß µâÕߧ”π÷ß∂÷ß‚Õ°“ ∑’Ë®–‡°‘¥°“√°¥°“√∑”ß“π¢Õß 2.4 º≈¢Õ߬“ µ√Õ¬¥’ æå π®¡à °µŸ Õ°“√à HPA axis ¥â«¬. ‡ª≈’ˬπ·ª≈ß∑“ßµ“ (ocular changes) ‡ªìπ∑’Ë∑√“∫°—π¥’«à“ °“√„Àâ µ’√Õ¬¥å√—∫- 2.2 º≈¢Õ߬“ µ’√Õ¬¥åæàπ®¡Ÿ°µàÕ°“√ ª√–∑“π‡ªìπ√–¬–‡«≈“π“π Õ“®∑”„À⇰‘¥¿“«– ‡®√‘≠‡µ‘∫‚µ„π‡¥Á° ·∑√°´âÕπ∑“ßµ“ ‡™àπ ‚√§µâÕÀ‘π (glaucoma) ·≈– ®“°°“√∑∫∑«πß“π«‘®—¬‡°’ˬ«°—∫¬“ µ’√Õ¬¥å µâÕ°√–®° (cataract) ‰¥â54,55 °“√»÷°…“ 2 °“√»÷°…“ æπ®¡à °Ÿ ·≈–°“√‡®√‘≠‡µ‘∫‚µ„π‡¥Á° æ∫«“¬“ µà ’√Õ¬¥å æ∫§«“¡ —¡æ—π∏å√–À«à“ß°“√„™â inhaled corti- æàπ®¡Ÿ° à«π„À≠à∑’Ë„™â ¡’§«“¡ª≈Õ¥¿—¬ ‰¡à àߺ≈µàÕ costeroids °—∫Õÿ∫—µ‘°“√≥å°“√‡°‘¥µâÕ°√–®°∑’ˇæ‘Ë¡ °“√‡®√‘≠‡µ‘∫‚µ¢ÕߺŸâªÉ«¬‡¥Á°32,39-47 ¬°‡«âπ¡’ß“π Ÿß¢÷È𠬑Ëß„™â¢π“¥¢Õß inhaled corticosteroids Ÿß «‘®—¬‡æ’¬ß™‘Èπ‡¥’¬«∑’Ëæ∫«à“¬“ beclomethasone di- °Á®–æ∫Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥µâÕ°√–®°∑’Ë Ÿß¢÷Èπ56,57 propionate ¡’º≈∑”„Àâ°“√‡®√‘≠‡µ‘∫‚µ≈¥≈ß„π™à«ß Õ¬à“߉√°Áµ“¡ °“√»÷°…“ à«π„À≠à∑’˪√–‡¡‘πº≈¢Õß √–¬–‡«≈“Àπ÷Ëß ·µà‰¡à‰¥â»÷°…“§«“¡ Ÿß ÿ¥∑⓬‡¡◊ËÕ‡ªì𠬓 µ’√Õ¬¥åæàπ®¡Ÿ°µàÕ§«“¡¥—π„π≈Ÿ°µ“ (intraocular 10 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 1 ¡°√“§¡ 2556 pressure) ·≈–°“√‡°‘¥µâÕ°√–®° æ∫«à“°“√„™â¬“ ‡«≈“ 1 ‡¥◊Õπ ∑”„Àâ√âÕ¬≈– 33 ¢ÕߺŸâªÉ«¬¡’°“√‡æ‘Ë¡ µ’√Õ¬¥åæàπ®¡Ÿ°„πºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ∑—Ë«Ê ¢÷Èπ¢Õߧ«“¡¥—π„π≈Ÿ°µ“‡æ’¬ß‡≈Á°πâÕ¬ (1-4 mmHg) ‰ª∑’ˉ¡à¡’ªí≠À“∑“ßµ“ ‰¡à∑”„Àâ¡’°“√‡æ‘Ë¡¢÷Èπ¢Õß Õ¬à“߉√°Áµ“¡ ∫“ß°“√»÷°…“æ∫«à“°“√„À⬓ µ’√Õ¬¥å §«“¡¥—π„π≈Ÿ°µ“ ·≈–‰¡à∑”„À⇰‘¥µâÕ°√–®° Garbe æàπ®¡Ÿ° ∑”„Àâ¡’°“√‡æ‘Ë¡¢÷Èπ¢Õߧ«“¡¥—π„π≈Ÿ°µ“¢Õß ·≈–§≥–58 »÷°…“ºŸâªÉ«¬ 9,793 √“¬∑’Ë¡’ borderline ºŸâªÉ«¬‰¥â ·≈–À≈—ßÀ¬ÿ¥°“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ° §à“ glaucoma, open angle glaucoma À√◊Õ ocular §«“¡¥—π„π≈Ÿ°µ“°Á “¡“√∂°≈—∫¡“‡ªìπª°µ‘‰¥â62,63 hypertension ·≈–„™â inhaled steroids À√◊Õ¬“ Õ¬à“߉√°Áµ“¡ §«√√–¡—¥√–«—ß°“√„™â¬“ µ’√Õ¬¥åæàπ µ’√Õ¬¥åæàπ®¡Ÿ°Õ¬Ÿà ‚¥¬‡ª√’¬∫‡∑’¬∫°—∫§πª°µ‘ ®¡Ÿ°„πºŸâªÉ«¬∑’Ë¡’Õ—µ√“‡ ’ˬß∑’Ë®–‡°‘¥º≈¢â“߇§’¬ß∑“ß 38,325 §π ∑’ˉ¡à¡’‚√§µâÕÀ‘πÀ√◊Õ ocular hyperten- µ“¥—ß°≈à“«µ“¡¡“‰¥â ‡™àπ ºŸâªÉ«¬ primary open- sion ·≈–„™â inhaled steroids À√◊Õ¬“ µ’√Õ¬¥å angle glaucoma, ºŸâªÉ«¬∑’ˇªìπ≠“µ‘„°≈♑¥°—∫ºŸâªÉ«¬ æàπ®¡Ÿ° æ∫«à“°“√„™â¬“ µ’√Õ¬¥åæàπ®¡Ÿ°‡ªìπ√–¬– ∑’ˇªìπ primary open-angle glaucoma, ‚√§ ‡«≈“π“π‰¡à‰¥â∑”„Àâ‡æ‘Ë¡Õÿ∫—µ‘°“√≥å¢Õß‚√§µâÕÀ‘π ‡∫“À«“π, ‚√§ “¬µ“ —Èπ ·≈–‚√§∑’Ë¡’§«“¡º‘¥ª°µ‘ À√◊Õ ocular hypertension ·µà°“√„™â inhaled corti- ¢Õ߇π◊ÈÕ‡¬◊ËÕ‡°’ˬ«æ—π (connective tissue disorder)55 costeroids „π¢π“¥ Ÿß (1,600 µg/d) ¡“°°«à“ 3 ´÷Ëß„πºŸâªÉ«¬°≈ÿà¡π’È §«“¡¥—π„π≈Ÿ°µ“∑’ˇæ‘Ë¡¢÷Èπ·¡â ‡¥◊Õπ ∑”„Àâ¡’Õ—µ√“‡ ’ˬߢÕß°“√‡°‘¥ ocular hyper- ‡æ’¬ß‡≈Á°πâÕ¬ Õ“®∑”„À⇰‘¥ªí≠À“∑“ßµ“µ“¡¡“‰¥â tension ·≈–‚√§µâÕÀ‘π‡æ‘Ë¡¡“°¢÷Èπ.