神经病性疼痛和辅助镇痛剂的意义.ppt

Klik om het opmaakprofiel van de modeltitel te bewerken,Klik om de opmaakprofielen van de modeltekst te bewerken,Tweede niveau,Derde niveau,Vierde niveau,Vijfde niveau,*,神经病性疼痛和辅助镇痛剂的意义,Neuropathic,pain and the meaning of adjuvant analgesics,Dr.Z.,Zylicz,Hospice in the Weald,Pembury,Tunbridge,Wells,Kent,UK,“自然”疼痛的两种类型,适应性疼痛-“正常”的疼痛，,疼痛有助于维护躯体的整合（自闭，总是准备，“急性疼痛”大部分与,A-,纤维相关,）,疼痛促进康复：“不要移动你断了的腿”，炎性疼痛，“慢性疼痛”大部分与,C,纤维有关,Two types of“natural”pain,Adaptation pain “normal pain”,The pain helps to preserve bodys integrity(withdrawal,always ready,“fast pain”mostly A delta fibres）,The pain promotes recovery:“do not move your broken leg”,inflammatory pain,“slow pain”mostly C fibres,感受伤害性的疼痛,Nociceptive pain,炎性疼痛,Inflammatory pain,痛觉过敏,“,病理性疼痛”,与适应性无关,“病理性疼痛”，“没有目的的疼痛”,常常是神经病性源性,对经典镇痛剂没有或部分敏感,对辅助镇痛剂常常敏感,“,pathologic pain”,has nothing to do with adaptation,“pathologic pain”,“pain without purpose”,frequently of neuropathic origin,not or only partially sensitive to classical analgesics,frequently sensitive to adjuvant analgesics,神经病性疼痛,Neuropathic pain,痛觉过敏,神经病性疼痛的2种类型,Two types of,neuropathic,pain,Neurogenic,pain,神经源性疼痛,pressure on the nerve,神经受压迫,peripheral sensitization,外周神经敏化,Reversible,可逆转性,distal to the damage,末稍损伤,partially sensitive to analgesics,对镇痛剂部分敏感,responds to local,anaethetics,对局部麻醉剂有反应,nerve entrapment,神经的压迫性损害,True,neuropathic,pain,真性神经病性疼痛,damage irreversible,不可逆损伤,central sensitization(spinal cord,brain),中枢神经敏化（脊索，脑）,classical analgesics and anesthetics frequently ineffective,普通镇痛剂和麻醉剂常常无效,adjuvant analgesics like TCA are effective,辅助镇痛剂有效，如,TCA,类,nerve section,神经切除,背角的初级传入纤维的正常终端,神经损伤以后，,C,纤维终端萎缩而,A,纤维终端长入后角表层,“,辅助性镇痛剂”,所有的药物，包括尚未被许可用于治疗疼痛，但对于改善镇痛质量有用的药物。这些药物可能有经典镇痛剂的内在镇痛活性或潜在活性，或减低经典镇痛剂的毒性作用。,“,Adjuvant analgesics,”,All drugs,not licensed as such for the treatment of pain,but useful to improve the quality of analgesia.They may have an intrinsic analgesic activity or may,potentiate,the activity of classical analgesics or diminish their toxic effects.,我们将讨论哪些药物？,About which drugs we are talking about?,Antidepressants,抗抑郁剂,Anxiolytics,抗焦虑剂,Anticonvulsants,抗惊厥药物,NMDA inhibitors N-,甲基-,D-,天冬氨酸抑制 剂类,Muscle relaxants,肌肉松弛剂,Psychostimulants,精神兴奋剂,Neuroleptics,精神抑制剂,Corticosteroids,糖皮质激素,抗抑郁剂,Antidepressants,amitriptylline,(,Tryptizol,),阿米替林,imipramine,(,Tofranil,),丙咪嗪,Venlafaxine,(,Efexor,),文拉法辛,Paroxetine,(,Seroxat,),帕罗西汀,Mirtazapine,(,Remeron,),米氮平,阿米替林与安慰剂,amitryptylline,versus placebo,HJ,McQuay,1999,抗焦虑剂（咪达唑仑,）,低剂量时与阿片类药物的协同作用,抗焦虑作用的辅助镇痛作用,高剂量时的过度镇静作用,与抗惊厥药物同用时，其代谢机制不同,吗啡与咪达唑仑同用时,其剂量明显减少,内在抗惊厥活性（作为盖巴喷丁的替代药物是有用的）,Anxiolytics,(,Midazolam,),in low dose synergistic with,opioids,anxiolytic,effect useful in analgesia,in high dose sedatives,metabolism is variable in presence of anticonvulsant drugs,morphine dose significantly lower when used with,midazolam,intrinsic anticonvulsant activity(useful as replacement of,gabapentin,）.,抗惊厥药物,Anticonvulsants,carbamazepin,(,Tegretol,),卡马西平,phenytoin,(,Difantoine,),苯妥英,valporoic,acid(,Depakine,),丙戊酸,clonazepam,(,Rivotril,),氯硝安定,lamotrigine,(,Lamictal,),拉莫三嗪,gabapentin,(,Neurontin,),盖巴喷丁,pregabalin,(,Lyrica,),普瑞巴林,N-,甲基-,D-,天冬氨酸抑制剂类,NMDA inhibitors,ketamine,(S en R)(,Ketalar,),氯胺酮(左旋和右旋异构体，即外消旋物,),ketamine,S(,Ketanest,),左旋氯胺酮,dextromethorphan,(,Dampo,),(,Morfidex,),右甲啡烷,D-methadone,右旋-美沙酮,magnesium(MgSO,4,+,),镁,肌肉松弛剂,巴氯芬（鞘内）,Lind G.,等。鞘内,巴氯芬用作辅助性治疗以增强在神经病性疼痛中对脊髓的刺激作用。,Eur,J Pain 2004;8:377-83,Muscle relaxants,Baclofen,(,intrathecal,),Lind G.et al.,Intrathecal,baclofen,as adjuvant therapy to enhance the effect of spinal cord stimulation in,neuropathic,pain.,Eur,J Pain 2004;8:377-83,精神兴奋剂,利他林,Challman,TD,Lipsky,JJ.,利他林：其药理学和使用。,Mayo,Clin,Proc 2000 Jul;75(7):711-21,Corey PJ,Heck AM,Weathermon,RA.,苯丙胺用于对抗阿片类引起的镇静作用,Ann,Pharmacother,1999 Dec;33(12):1362-6,Psychostimulants,Methylphenidate(Ritalin,),Challman,TD,Lipsky,JJ.Methylphenidate:its pharmacology and uses.Mayo,Clin,Proc 2000 Jul;75(7):711-21,Corey PJ,Heck AM,Weathermon,RA.Amphetamines to counteract,opioid,-induced sedation.Ann,Pharmacother,1999 Dec;33(12):1362-6,精神兴奋剂,利他林,5+5 mg (08.00,和 12.00点),如果必要，可增加至,10 +10 mg,时间与上相同,Psychostimulants,Methylphenidate(Ritalin,),:,5+5 mg (08.00 and 12.00),Increase if necessary to 10 +10 mg,same time.,精神抑制剂,左美丙嗪（甲氧异丁嗪）,内在镇痛作用,优良的广谱止吐作用,良好的镇静作用,长期使用有毒性反应,产生耐受性,Neuroleptics,Levomepromazine,(,Nozinan,),-intrinsic analgesic effect,-excellent wide spectrum,antiemetic,-good as sedative,-toxic in longer use,-development of tolerance,非典型精神抑制剂,奥氮平(,Zyprexa,),-疼痛治疗的优良辅助药物,-优良的止吐剂,-良好的谵妄和精神病的治疗作用,Atypic neuroleptics,Olanzapine(Zyprexa),excellent adjuvant in pain treatment,excellent,antiemetic,good in the treatment of delirium and psychosis,最佳方案,：用于神经源性疼痛的一线药物,扑热息痛，弱阿片类，非甾体类抗炎药物,酌情考虑放疗,TENS（,经皮电神经刺激）或者针灸可能有帮助,神经毁损：例如腹腔神经丛阻滞,强阿片类滴定至可耐受的最大剂量,地塞米松（8-12,mg),以减轻神经受压迫,The best strategy,:1,st,line in,neurogenic,pain,paracetamol,weak,opioids,NSAIDs,consider radiotherapy,TENS or acupuncture may be helpful,Neurodestruction,:a.o.,coeliac,block,strong,opioids,titrated,to maximum tolerable dose,dexamethasone,(8-12 mg)to decrease pressure on the nerve,最佳方案,：用于真性神经病性疼痛,如果没有禁忌症，阿米替林,25 mg q.n.，,使,用一周，必要时增加剂量,文拉法辛，,37.5 mg b.i.d.,必要时,增加剂量,盖巴喷丁或,普瑞巴林，,滴定至有效剂量,The best strategy,:in true,neuropathic,pain,Amitriptyline,25 mg a.n.if no contraindications,trial for 1 week,increase the dose if necessary,Venlafaxine,37.5 mg b.d.,increase the dose,gabapentin,or,pregabalin,titrate,to effective dose,总 结,辅助性镇痛剂对于控制症状是重要的,这些药物拓宽了镇痛活性谱,减少镇痛剂的不良反应,增加镇痛剂的特异性,Conclusion,Adjuvant analgesics are important in symptom control,They widen the spectrum of analgesic activity,Decrease the adverse effects of analgesics,Increase specificity of analgesics,