镇痛药物选择

临床用于治疗疼痛的药物包括:一、麻醉性镇痛药:二、解热镇痛药:三、抗神经痛药:四、抗偏头痛药:五、解痉止痛药.临床用于治疗疼痛的药物包括:一、麻醉性镇痛药:二、解热镇痛药:三、抗神经痛药:四、抗偏头痛药:五、解痉止痛药. 麻醉性镇痛药     

癌性神经病理性疼痛的辅助镇痛药物研究进展

癌性疼痛可以分为伤害疼痛和神经病理性疼痛两种病理类型,癌性神经病理性疼痛(malignant neuropathic pain,MNP)的发生机制较为复杂,属于难治性癌痛。阿片类药物是癌痛治疗的基石,对伤害性疼痛疗效好,但是并不能完全缓解MNP。疼痛不是辅助镇痛药物的主要适应证,但其与阿片类药物联合使用可能会有较好疗效,所以辅助镇痛药物将成为治疗MNP必不可少的一环。目前对于辅助镇痛药物的选择以抗惊厥药物和(或)抗抑郁药物为首选。该文就治疗MNP的辅助镇痛药物中较有临床应用价值的药物研究进展进行综述,旨在为临床镇痛药物选择提供参考。     

抗惊厥药和抗抑郁药治疗癌症神经病理性疼痛的临床应用研究进展

摘 要癌症神经病理性疼痛（malignant neuropathic pain,MNP）是癌痛患者常见的慢性难治性疼痛类型。药物治疗仍是其最主要的治疗方法,部分抗惊厥药和抗抑郁药在治疗MNP中具有显著的疗效,是重要的MNP辅助镇痛药物。本文就目前MNP的发病机制进行了归纳,针对抗惊厥药和抗抑郁药在MNP治疗中的作用机制、治疗效果、药学特性、联合用药等方面进行综述,以期为临床用药提供参考。     

临床药师全程参与1例肝移植术后伴重度肾功能不全带状疱疹后神经痛患者的药学监护

目的 针对肝移植术后伴肾功能不全的带状疱疹后神经痛患者,疼痛专业临床药师协助临床医生为该患者选择最佳的镇痛药物治疗方案提供药学支持.方法 疼痛专业临床药师全程参与了1例肝移植术后合并重度肾功能不全带状疱疹后神经痛患者的治疗,分析其肾功能不全的原因,协助其镇痛治疗方案的调整,并实施全程化的药学监护.结果 疼痛专业临床药师根据患者的血清肌酐值推算出该患者为重度肾功能不全,推荐口服加巴喷丁0.3g qd,联合肝肾功能影响较小的丁丙诺啡透皮贴局部治疗,治疗5d后疼痛较前显著缓解、不影响睡眠,同时在疱疹区皮下注射消炎镇痛药,疼痛进一步缓解,复查肝肾功能较前有所好转,准予出院,瞩其出院后继续服用加巴喷丁稳固疗效、定期复诊.结论 肝脏移植手术本身及后期的免疫抑制剂的使用,均可能导致该患者肝移植术后的肾功能不全.术后免疫抑制状态是带状疱疹发病的高危因素,对伴有肾功能不全的带状疱疹后神经痛患者,仍然可以选择加巴喷丁、普瑞巴林、曲马多、丁丙诺啡透皮贴等临床常用药物,但需严格根据肌酐清除率调整用量,必要时可联合微创介入治疗技术,对于带状疱疹高危人群建议在进行移植手术前接种水痘-带状疱疹疫苗.     

临床药师全程参与1例肝移植术后伴重度肾功能不全带状疱疹后神经痛患者的药学监护

目的 针对肝移植术后伴肾功能不全的带状疱疹后神经痛患者,疼痛专业临床药师协助临床医生为该患者选择最佳的镇痛药物治疗方案提供药学支持.方法 疼痛专业临床药师全程参与了1例肝移植术后合并重度肾功能不全带状疱疹后神经痛患者的治疗,分析其肾功能不全的原因,协助其镇痛治疗方案的调整,并实施全程化的药学监护.结果 疼痛专业临床药师根据患者的血清肌酐值推算出该患者为重度肾功能不全,推荐口服加巴喷丁0.3g qd,联合肝肾功能影响较小的丁丙诺啡透皮贴局部治疗,治疗5d后疼痛较前显著缓解、不影响睡眠,同时在疱疹区皮下注射消炎镇痛药,疼痛进一步缓解,复查肝肾功能较前有所好转,准予出院,瞩其出院后继续服用加巴喷丁稳固疗效、定期复诊.结论 肝脏移植手术本身及后期的免疫抑制剂的使用,均可能导致该患者肝移植术后的肾功能不全.术后免疫抑制状态是带状疱疹发病的高危因素,对伴有肾功能不全的带状疱疹后神经痛患者,仍然可以选择加巴喷丁、普瑞巴林、曲马多、丁丙诺啡透皮贴等临床常用药物,但需严格根据肌酐清除率调整用量,必要时可联合微创介入治疗技术,对于带状疱疹高危人群建议在进行移植手术前接种水痘-带状疱疹疫苗.     

癌性疼痛治疗的药物选择和联合用药

癌性疼痛治疗是癌症治疗中的重要内容,能够有效的治疗疼痛,无疑有助于病人坚持完成完整的放、化疗过程,而且也是晚期病人临终安康、提高生活质量的唯一方法.目前临床癌性疼痛的治疗方法很多,其中药物治疗是癌性疼痛治疗中的最基本和最重要内容.从药理学角度上看,治疗癌性疼痛的药物可分为三大类:非麻醉性镇痛药、麻醉性镇痛药和辅助镇痛药.按阶梯、联合用药是治疗癌痛的原则.根据WHO制定的癌性疼痛三阶梯治疗原则,非麻醉性镇痛药为第一阶梯用药,适用于轻度疼痛病人;麻醉性镇痛药中的弱阿片类药物为第二阶梯用药,同时辅助第一阶梯药物,适用于中度疼痛;麻醉性镇痛药中强阿片类药物为第三阶梯用药,同时辅助第一阶梯药物,适用于中重度疼痛的病人.另外在使用上述镇痛药物的同时,临床上常根据疼痛情况联合使用辅助镇痛药物,以求更好的临床疗效.     

滥用强痛定、艾司唑仑致依赖1例报告

强痛定是一种镇痛药,适用于各种疼痛,如神经痛、手术后疼痛、腰腿疼等,而艾司唑仑为高效镇静催眠药,因其疗效确定且相对安全,临床上应用广泛,本文报道一例同时应用两药引起药物依赖的病例,以引起临床医生的重视.     

托吡酯治疗神经痛59例

目的 观察托吡酯治疗神经痛的临床疗效与安全性。方法将118例神经痛患者随机分为治疗组和对照组各59例。治疗组给予托吡酯25或50 mg，bid，po；对照组给予卡马西平100 mg，bid或tid，po。疼痛缓解后继续服1周后停药。治疗2周后评价其临床疗效。结果 治疗组和对照组总有效率分别为93.2%，86.4%(P＜0.05)；不良反应发生率分别为10.2%，40.7%。治疗组不良反应表现为一过性头晕、嗜睡、记忆力减退、少言无语等。结论 托吡酯治疗神经痛安全有效，可作为治疗神经痛的首选镇痛药物之一。     

老年持续疼痛评价和药物治疗

根据美国老年医学会2009年颁布的"老年持续疼痛的药物治疗"指南的要求,总结认知正常或障碍的老年患者疼痛评价方法,以及镇痛药的使用特点.普通持续疼痛首选对乙酰氨基酚;非甾体抗炎药只能短期使用,并密切观察胃肠及心血管副反应;对神经痛患者可加用神经活性药物和维生素D等辅助治疗.     

神经阻滞联合普瑞巴林防治带状疱疹后遗神经痛临床观察

<正>带状疱疹后遗神经痛是临床常见的剧烈的、顽固性疼痛,可使患者极度痛苦,严重影响患者的生活质量,常规的方法治疗效果不佳。我院2012年10月至2013年6月,应用神经阻滞联合普瑞巴林的方法治疗带状疱疹神经痛及带状疱疹后遗神经痛26例,有效缓解了带状疱疹神经痛及带状疱疹后遗神经痛,并避免了带状疱疹神经痛迁延为带状疱疹后遗神经痛,临床效果满意。报告如下。1资料与方法1.1一般资料:带状疱疹神经痛及带状疱疹后遗神经痛共26例,男性15例,女性11例,年龄45⁹0岁,病程4 d至6年。全组病例均经口服2种以上镇痛药无效,其中7例患者     

Antidepressants in the treatment of neuropathic pain

Neuropathic pain is due to lesion or dysfunction of the peripheral or central nervous system. Tricyclic antidepressants and anticonvulsants have long been the mainstay of treatment of this type of pain. Tricyclic antidepressants may relieve neuropathic pain by their unique ability to inhibit presynaptic reuptake of the biogenic amines serotonin and noradrenaline, but other mechanisms such as N-methyl-D-aspartate receptor and ion channel blockade probably also play a role in their pain-relieving effect. The effect of tricyclic antidepressants in neuropathic pain in man has been demonstrated in numerous randomised, controlled trials, and a few trials have shown that serotonin noradrenaline and selective serotonin reuptake inhibitor antidepressants also relieve neuropathic pain although with lower efficacy. Tricyclic antidepressants will relieve one in every 2-3 patients with peripheral neuropathic pain, serotonin noradrenaline reuptake inhibitors one in every 4-5 and selective serotonin reuptake inhibitors one in every 7 patients. Thus, based on efficacy measures such as numbers needed to treat, tricyclic antidepressants tend to work better than the anticonvulsant gabapentin and treatment options such as tramadol and oxycodone, whereas the serotonin noradrenaline reuptake inhibitor venlafaxine appears to be equally effective with these drugs and selective serotonin reuptake inhibitors apparently have lower efficacy. Head-to-head comparisons between antidepressants and the other analgesics are lacking. Contraindications towards the use of tricyclic antidepressants and low tolerability in general of this drug class--may among the antidepressants--favour the use of the serotonin noradrenaline reuptake inhibitors. A recent study on bupropion, which is a noradrenaline and dopamine uptake inhibitor, indicated a surprisingly high efficacy of this drug in peripheral neuropathic pain. In conclusion, antidepressants represent useful tools in neuropathic pain treatment and must still be considered as first line treatments of neuropathic pain. However, without head-to-head comparisons between antidepressants and other analgesics, it is not possible to provide real evidence-based treatment algorithms for neuropathic pain.     

Efficacy of antidepressants as analgesics: a review

Persistent pain disorders are usually not adequately alleviated by nonsteroidal anti-inflammatory drugs or other simple analgesics. Use of antidepressants as adjuvant therapy for the control of persistent pain is currently being practiced in disorders such as fibromyalgia, neuropathic pain, rheumatoid conditions, low back pain, and headache. This review describes the various mechanisms of analgesic activity of antidepressants along with their efficacy and tolerability profiles. Meta-analyses and clinical studies of these agents were retrieved through the use of MEDLINE, Google scholar, and Cochrane databases. Antidepressants are effective in both neuropathic and non-neuropathic pain and have diverse mechanisms independent of their antidepressant effects. Tricyclic antidepressants (amitryptiline, nortryptiline, desipramine) are effective compounds in the treatment of neuropathic pain, fibromyalgia, low back pain, and headaches. Studies are ongoing for the dual serotonin norepinephrine reuptake inhibitors (duloxetine, venlafaxine) in several persistent pain conditions and these may be recommended in neuropathic pain, migraines, and fibromyalgia. Evidence suggests that although the analgesic effects of selective serotonin reuptake inhibitors (fluoxetine, paroxetine, citalopram) are limited and inconsistent, yet they have a superior tolerability profile compared with tricyclic antidepressants.     

Pain in terminally ill patients: guidelines for pharmacological management

Successful pharmacological treatment of pain in terminally ill patients is possible most of the time. It requires a determination of the type of pain syndrome (i.e. nociceptive, neuropathic or mixed). Complete pain assessment also requires an understanding of other dimensions of suffering that a patient may be experiencing on psychological, social and spiritual/existential levels. The World Health Organization has introduced a three-step approach to treating pain. Opioids are the mainstay of therapy for moderate to severe pain at the end of life. Familiarity with the pharmacokinetics, equianalgesic dose and adverse effects of opioids is necessary for their safe and effective use. In addition, adjuvant analgesics such as antiepileptic drugs, antidepressants and local anaesthetics are often needed to optimise pain control, especially in patients with neuropathic pain. Given the complex aetiology of pain states, combinations of classes of adjuvants may sometimes be needed for effective treatment.     

Neuronal and immunological basis of action of antidepressants in chronic pain – clinical and experimental studies

The current knowledge of the pharmacological actions of the tricyclic antidepressants (TCAs) has slowly evolved through their over 40-year history. Chronic pain represents one of the most important public health problems, and antidepressants are an essential part of the therapeutic strategy in addition to classical analgesics. This article reviews the available evidence on the efficacy and safety of antidepressants in chronic pain conditions; namely, headaches, low back pain, fibromyalgia, cancer pain and especially neuropathic pain. TCAs are traditionally the main type of depression medication used to treat chronic pain. Recently, new antidepressants were introduced into clinical use, with a significant reduction in side effects and equivalent efficacy on mood disorders. These new drugs that are effective for chronic pain belong to the tetracyclic antidepressants (TeCAs) group (amoxapine, maprotiline), the serotonin and noradrenaline reuptake inhibitors (SNRIs) group (duloxetine, venlafaxine, milnacipran) and the atypical antidepressants group (bupropion, trazodone, mirtazapine, nefazodone). In this review, we present the available publications on TCAs (amitriptyline, doxepin, imipramine, desipramine, nortriptyline), TeCAs (amoxapine, maprotiline), selective serotonin reuptake inhibitors (SSRIs) (citalopram, fluoxetine, paroxetine), SNRIs (duloxetine, venlafaxine, milnacipran) and atypical antidepressants (bupropion) for the treatment of neuropathic pain.We also review analgesics acting as both opioid receptor agonists and also acting as aminergic reuptake inhibitors. Existing data are insufficient to conclude which of these new classes of antidepressants has the best clinical profile and will be the most effective in the treatment of neuropathic pain; in addition, a lower incidence of side effects should be considered. Increased experimental and translational research is a key for further improvement of the treatment of chronic pain with antidepressants. However, evidence from basic science is needed to improve our understanding of the mechanisms of action and their possible pharmacodynamic interactions.     

Pharmacological management of postherpetic neuralgia

Postherpetic neuralgia, which occurs most typically in older persons, is one of the most common and serious complications of herpes zoster (or shingles). It is a chronic neuropathic pain syndrome and remains one of the most difficult pain disorders to treat. Known beneficial agents include antidepressants, antiepileptic drugs, opioid analgesics, local anaesthetics, capsaicin and other, less applied, modalities. Although monotherapy is commonly applied, no single best treatment for postherpetic neuralgia has been identified; nevertheless, gabapentin (antiepileptic) and transdermal lidocaine (anaesthetic) are often used as the first-choice treatments. Recent research has shed light on possible pain mechanisms as well as new avenues of treatment, which are discussed in the article. For patients with pain that is not adequately controlled, individualised treatment plans must be pursued. It is critical to recognise that postherpetic neuralgia, while difficult to manage, can be a treatable neuropathic pain syndrome.     

Emerging therapies for neuropathic pain

Neuropathic pain develops as a result of damage to either the peripheral or central nervous system. It is characterised by spontaneous burning pain and/or ongoing pain with accompanying hyperalgesia and allodynia. Neuropathic pain is difficult to treat as it is often refractory to conventional analgesic treatments, with most patients obtaining only partial relief. At present, there are four major medication categories that are considered first-line treatment for neuropathic pain: antidepressants, anticonvulsants, local anaesthetic/topical agents and opioids. The efficacy of these treatments in neuropathic pain, excepting opioids, has been discovered serendipitously. However, responder rates and overall efficacy is poor with these agents and tolerability or side effects are often limiting. This update will review existing treatment options for neuropathic pain, and highlight more recent advances in the development of novel analgesics to treat this chronic disorder.     

Emerging therapies for neuropathic pain

Neuropathic pain develops as a result of damage to either the peripheral or central nervous system. It is characterised by spontaneous burning pain and/or ongoing pain with accompanying hyperalgesia and allodynia. Neuropathic pain is difficult to treat as it is often refractory to conventional analgesic treatments, with most patients obtaining only partial relief. At present, there are four major medication categories that are considered first-line treatment for neuropathic pain: antidepressants, anticonvulsants, local anaesthetic/topical agents and opioids. The efficacy of these treatments in neuropathic pain, excepting opioids, has been discovered serendipitously. However, responder rates and overall efficacy is poor with these agents and tolerability or side effects are often limiting. This update will review existing treatment options for neuropathic pain, and highlight more recent advances in the development of novel analgesics to treat this chronic disorder.     

Recent advances in the pharmacological management of pain

Pain is an unpleasant sensation that originates from ongoing or impending tissue damage. Management of different types of pain (acute, postoperative, inflammatory, neuropathic or cancer) is the most frequent issue encountered by clinicians and pharmacological therapy is the first line of approach for the treatment of pain. This review presents and discusses recent clinical advances regarding both the improvements in delivery of analgesic drugs and improvements in the design of analgesic molecules. The new modalities of administration of analgesics used in the clinic are reviewed, including skin patches, oral and mucosal sprays, transdermal delivery systems and intranasal administration. New insights are then presented on standard drugs used to relieve pain, such as opioids (including tramadol), NSAIDs including selective cyclo-oxygenase-2 inhibitors, paracetamol (acetaminophen), local anaesthetics and adjuvant analgesics such as antidepressants, anticonvulsants (gabapentin and pregabalin), cannabinoids, ketamine and others (e.g. nefopam). Although the understanding of pain mechanisms has improved significantly recently, much more is yet to be discovered and awaited. Broadening of our knowledge is needed to improve basic and clinical research in this field in order to better alleviate pain in millions of people.     

Pharmacological management of neuropathic pain

In health, the nervous system exists in a balance between inhibitory and excitatory influences. This balance may be upset if neural tissue is damaged or irritated and may give rise to neuropathic pain. Such neuropathic pain does not respond consistently to opioid analgesics or NSAIDs and it may therefore be necessary to utilise other therapeutic agents with known activity on either the excitatory or inhibitory components of the pain pathway. These other agents are traditionally considered with reference to their original uses; we still refer to tricyclic antidepressants (TCAs) and anticonvulsant drugs when a consideration of their modes of action may allow more rational use. For example, carbamazepine is related to the TCAs by virtue of its chemical structure and proposed mode of action and yet is still classified as an anticonvulsant drug. With respect to the opioids, increasing evidence points to an analgesic effect in neuropathic pain, although concerns regarding tolerance and dependence still prevent more widespread use. The anticonvulsants comprise a group of compounds possessing anticonvulsant and analgesic properties, but each possesses differing modes of action and so several members of the class should be tried before a conclusion is reached that they, as a whole, are ineffective. TCAs may also have a role in the treatment of neuropathic pain. As with all drugs, if their use is not associated with pain relief in a defined period of time, their use should be terminated. Topical TCAs may also have a role where the area of neuropathic pain is small. Other options, such as SSRIs, membrane stabilisers, capsaicin, baclofen and clonidine may have potential in treating neuropathic pain. The available evidence regarding the efficacy of currently available agents for the treatment of neuropathic pain is sparse. With the knowledge of achieving analgesia, according to the modes of actions of various agents it is hoped that the treatment of this difficult condition may be more logical and successful.     

Enhancement of antinociceptive effect of morphine by antidepressants in diabetic neuropathic pain model

BackgroundRecent studies have shown that influence of antidepressants on analgesic action of opioids is heterogeneous. The aim of this study was to investigate the effect of acute and repeated (21 days) antidepressant (amitriptyline, moclobemide and reboxetine) treatment on the antinociceptive action of morphine, an opioid agonist, in streptozotocin (STZ)-induced neuropathic pain model.MethodsThe studies were performed on the male Wistar rats. The changes in nociceptive thresholds were determined by using mechanical stimuli (the Randall–Selitto and the von Frey tests). Diabetes was induced by intramuscular administration of STZ.ResultsIn this work we report that acute as well as repeated per os administration of antidepressants (amitriptyline, moclobemide and reboxetine) significantly potentiated the antihyperalgesic effect of morphine in STZ-induced neuropathic pain model.ConclusionCombination therapy, such as classical antidepressants (amitriptyline, moclobemide) with opioids, or agents with noradrenaline reuptake inhibition and μ-opioid receptor activation could be a new target for research into treatment of painful diabetic neuropathy.