神經(jīng)病性疼痛和輔助鎮(zhèn)痛劑的意義課件

神經(jīng)病性疼痛和輔助鎮(zhèn)痛劑的意義

NeuropathicpainandthemeaningofadjuvantanalgesicsDr.Z.ZyliczHospiceintheWealdPembury,TunbridgeWellsKent,UK“自然”疼痛的兩種類型適應(yīng)性疼痛-“正?！钡奶弁?，疼痛有助于維護(hù)軀體的整合（自閉，總是準(zhǔn)備，“急性疼痛”大部分與A-δ纖維相關(guān)）疼痛促進(jìn)康復(fù)：“不要移動(dòng)你斷了的腿”，炎性疼痛，“慢性疼痛”大部分與C纖維有關(guān)Twotypesof“natural”painAdaptationpain–“normalpain”,Thepainhelpstopreservebody’sintegrity(withdrawal,alwaysready,“fastpain”mostlyAdeltafibres）Thepainpromotesrecovery:“donotmoveyourbrokenleg”,inflammatorypain,“slowpain”mostlyCfibres感受傷害性的疼痛

Nociceptivepain“病理性疼痛”與適應(yīng)性無(wú)關(guān)“病理性疼痛”，“沒(méi)有目的的疼痛”常常是神經(jīng)病性源性對(duì)經(jīng)典鎮(zhèn)痛劑沒(méi)有或部分敏感對(duì)輔助鎮(zhèn)痛劑常常敏感“pathologicpain”hasnothingtodowithadaptation“pathologicpain”,“painwithoutpurpose”frequentlyofneuropathicorigin,notoronlypartiallysensitivetoclassicalanalgesicsfrequentlysensitivetoadjuvantanalgesics神經(jīng)病性疼痛

Neuropathicpain痛覺(jué)過(guò)敏神經(jīng)病性疼痛的2種類型

TwotypesofneuropathicpainNeurogenicpain神經(jīng)源性疼痛pressureonthenerve神經(jīng)受壓迫peripheralsensitization外周神經(jīng)敏化Reversible可逆轉(zhuǎn)性distaltothedamage末稍損傷partiallysensitivetoanalgesics對(duì)鎮(zhèn)痛劑部分敏感respondstolocalanaethetics對(duì)局部麻醉劑有反應(yīng)nerveentrapment神經(jīng)的壓迫性損害Trueneuropathicpain真性神經(jīng)病性疼痛damageirreversible不可逆損傷centralsensitization(spinalcord,brain)中樞神經(jīng)敏化（脊索，腦）classicalanalgesicsandanestheticsfrequentlyineffective普通鎮(zhèn)痛劑和麻醉劑常常無(wú)效adjuvantanalgesicslikeTCAareeffective輔助鎮(zhèn)痛劑有效，如TCA類nervesection神經(jīng)切除背角的初級(jí)傳入纖維的正常終端神經(jīng)損傷以后，C纖維終端萎縮而A纖維終端長(zhǎng)入后角表層“輔助性鎮(zhèn)痛劑…”所有的藥物，包括尚未被許可用于治療疼痛，但對(duì)于改善鎮(zhèn)痛質(zhì)量有用的藥物。這些藥物可能有經(jīng)典鎮(zhèn)痛劑的內(nèi)在鎮(zhèn)痛活性或潛在活性，或減低經(jīng)典鎮(zhèn)痛劑的毒性作用?！癆djuvantanalgesics…”Alldrugs,notlicensedassuchforthetreatmentofpain,butusefultoimprovethequalityofanalgesia.Theymayhaveanintrinsicanalgesicactivityormaypotentiatetheactivityofclassicalanalgesicsordiminishtheirtoxiceffects.我們將討論哪些藥物？

Aboutwhichdrugswearetalkingabout?Antidepressants抗抑郁劑Anxiolytics抗焦慮劑Anticonvulsants抗驚厥藥物NMDAinhibitorsN-甲基-D-天冬氨酸抑制 劑類Musclerelaxants肌肉松弛劑Psychostimulants精神興奮劑Neuroleptics精神抑制劑Corticosteroids糖皮質(zhì)激素

抗抑郁劑

Antidepressantsamitriptylline(Tryptizol?)阿米替林imipramine(Tofranil?)

丙咪嗪Venlafaxine(Efexor?)文拉法辛Paroxetine(Seroxat?)

帕羅西汀Mirtazapine(Remeron?)米氮平抗焦慮劑（咪達(dá)唑侖?

）低劑量時(shí)與阿片類藥物的協(xié)同作用抗焦慮作用的輔助鎮(zhèn)痛作用高劑量時(shí)的過(guò)度鎮(zhèn)靜作用與抗驚厥藥物同用時(shí)，其代謝機(jī)制不同嗎啡與咪達(dá)唑侖同用時(shí),其劑量明顯減少內(nèi)在抗驚厥活性（作為蓋巴噴丁的替代藥物是有用的）Anxiolytics(Midazolam?)inlowdosesynergisticwithopioidsanxiolyticeffectusefulinanalgesiainhighdosesedativesmetabolismisvariableinpresenceofanticonvulsantdrugsmorphinedosesignificantlylowerwhenusedwithmidazolamintrinsicanticonvulsantactivity(usefulasreplacementofgabapentin）.抗驚厥藥物Anticonvulsantscarbamazepin(Tegretol?)卡馬西平phenytoin(Difantoine?)苯妥英valporoicacid(Depakine?)

丙戊酸clonazepam(Rivotril?)氯硝安定lamotrigine(Lamictal?)拉莫三嗪gabapentin(Neurontin?)蓋巴噴丁pregabalin(Lyrica?)普瑞巴林肌肉松弛劑巴氯芬（鞘內(nèi)）LindG.等。鞘內(nèi)巴氯芬用作輔助性治療以增強(qiáng)在神經(jīng)病性疼痛中對(duì)脊髓的刺激作用。EurJPain2004;8:377-83

MusclerelaxantsBaclofen(intrathecal)LindG.etal.Intrathecalbaclofenasadjuvanttherapytoenhancetheeffectofspinalcordstimulationinneuropathicpain.EurJPain2004;8:377-83

精神興奮劑利他林5+5mg(08.00和12.00點(diǎn))如果必要，可增加至10+10mg,時(shí)間與上相同PsychostimulantsMethylphenidate(Ritalin?):5+5mg(08.00and12.00)Increaseifnecessaryto10+10mg,sametime.精神抑制劑左美丙嗪（甲氧異丁嗪）內(nèi)在鎮(zhèn)痛作用優(yōu)良的廣譜止吐作用良好的鎮(zhèn)靜作用長(zhǎng)期使用有毒性反應(yīng)產(chǎn)生耐受性NeurolepticsLevomepromazine(Nozinan?) - intrinsicanalgesiceffect - excellentwidespectrumantiemetic - goodassedative - toxicinlongeruse - developmentoftolerance非典型精神抑制劑奧氮平(Zyprexa?)-疼痛治療的優(yōu)良輔助藥物-優(yōu)良的止吐劑-良好的譫妄和精神病的治療作用AtypicneurolepticsOlanzapine(Zyprexa?)excellentadjuvantinpaintreatmentexcellentantiemeticgoodinthetreatmentofdeliriumandpsychosis最佳方案：用于真性神經(jīng)病性疼痛如果沒(méi)有禁忌癥，阿米替林25mgq.n.，使用一周，必要時(shí)增加劑量文拉法辛，37.5mgb.i.d.,必要時(shí)增加劑量蓋巴噴丁或普瑞巴林，滴定至有效劑量Thebeststrategy:

intrueneuropathicpainAmitriptyline25mga.n.ifnocontraindications,trialfor1week,increasethedoseifnecessaryVenlafaxine,37.5mgb.d.,increasethedosegabapentinorpregabalin,titratetoeffectivedose總結(jié)輔助性鎮(zhèn)痛劑