带状疱疹及后遗神经痛.ppt

Treatingherpeszosterandpostherpeticneuralgia:Anevidence-basedapproachUniversity of Rochester School of Medicine and Dentistry,Rochester,NY Annie.Philip,MBBS以证据为基础的方法治疗带状疱疹和带状疱疹后遗神经痛罗切斯特大学医学院和牙科，罗切斯特，纽约安妮菲利普，医学学士Postherpetic neuralgia(PHN)is a management challengebecause of its severity,long duration,and potential for debilitation,often in the highly vulnerable elderly population.带状疱疹后遗神经痛（PHN）是一个治疗的挑战，因为其严重程度、持续时间长、和常常潜伏在免疫力低下的老年人口中。And,as the most common complication of an acute episode of herpes zoster(shingles)in an immunocompetent person,PHN is likely no stranger to your practice.而且，在具有免疫力的人中，作为急性带状疱疹（带状疱疹）最常见的并发症，在你的临床实践中疱疹后神经痛并不少见。Herpeszosterisoneofthemostcommonneurologicalproblems,withanincidenceofupto1millionnewcasesperyearintheUnitedStates.AlthoughtheprecisenumberfortheprevalenceofPHNintheUnitedStatesisunknown,investigatorsestimateitat500,000to1million带状疱疹是一种最常见的神经系统的疾病，在美国，其发病率高达每年100万新增病例。虽然疱疹后神经痛患病率的确切数目在美国是未知的，但调查人员估计在50万-100万。MajorriskfactorsfordevelopmentofPHNafteranepisodeofherpeszosterinclude:olderagegreateracutepainduringherpeszostergreaterseverityofrash带状疱疹发生后，发展为带状疱疹后遗神经痛的主要危险因素包括：年龄带状疱疹期更严重的疼痛更严重的皮疹PHNiscommonlydefinedas“dermatomalpainthatpersists120daysormoreaftertheonsetofrash.”5ThepainofPHNhasbeencharacterizedasastimulus-dependentcontinuousburning,throbbing,orepisodicsharpelectricshock-likesensation6andasastimulus-dependenttactileallodynia(ie,painafternormallynonpainfulstimulus)andhyperalgesia(exaggeratedresponsetoapainfulstimulus).带状疱疹后遗神经痛通常定义为：“皮区出现皮疹后疼痛持续120天或更久。带状疱疹后遗神经痛的特点是：连续的烧灼感、闪电痛、触摸痛（即是无痛刺激后的疼痛）和痛觉超敏（疼痛刺激的放大反应）Inaddition,somepatientsexperiencemyofascialpainsecondarytoexcessivemuscleguarding.Chronicprurituscanbepresent.此外，有些病人的经验肌筋膜疼痛继发过度肌肉防御，可以产生慢性瘙痒。Morethan90%ofpatientswhohavePHNhaveallodynia,7whichtendstooccurinareaswheresensationisrelativelypreserved.Patientsalsofeelspontaneouspaininareaswheresensationislostorimpaired.带状疱疹后遗神经痛患者超过90%有触摸痛，这往往发生在感觉相对保存的地方。在感觉丧失或受损的地方，患者也有自发性疼痛。Inthisarticle,wereviewtheevidencefortherangeoftreatmentsforacuteherpeszosterandPHN,aswellofferpreventivestrategiesforherpeszoster.在本文中，我们回顾急性带状疱疹和疱疹后神经痛范围内的治疗证据，也提供预防带状疱疹的策略。ACUTEHERPESZOSTER:STARTANTIVIRALSEARLYEvidence-basedtreatmentofacuteherpeszosterincludesantiviraldrugsandanalgesics.急性带状疱疹：早期使用抗病毒药物以证据为基础的治疗急性带状疱疹包括抗病毒药物和止痛药。Antiviralagentssuppressviralreplicationandhaveabeneficialeffectonacuteandchronicpain.Acyclovir(800mg,5timesaday),valacyclovir(1000mg,every8hours),andfamciclovir(500mg,every8hours)areantiviralscommonlyusedtotreatherpeszoster.All3drugshavecomparableefficacyandsafetyprofiles.抗病毒药物抑制病毒复制，有利于治疗急性和慢性疼痛。阿昔洛韦（800毫克，每日5次），伐昔洛韦（1000毫克，每8小时），和泛昔洛韦（500毫克，每8小时）是常用的治疗带状疱疹的抗病毒药物，3种药物有类似的疗效和安全性。Inameta-analysisofpatientsolderthan50yearswhoweretreatedwithacyclovirorplacebo,painpersistedin15%oftheacyclovir-treatedgroup,comparedwith35%oftheplacebogroup.8meta分析中，使用阿昔洛韦治疗或安慰剂的年龄超过50岁的患者，阿昔洛韦治疗组中15%的患者有后遗痛，相比下，安慰剂组中35%的患者有后遗痛。Intermsofduration,astudycomparingfamciclovirtreatmentwithplaceboshowedthatsubjectsintheplacebogrouphadpersistentpainfor163days,whereasfamciclovir-treatedpatientshadpainfor63days.9在持续性方面：一个关于伐昔洛韦治疗组和安慰组的研究表明：安慰剂组患者疼痛持续163天，而伐昔洛韦治疗组患者疼痛持续63天。Basedonthisevidence,antiviralmedicationsarestronglyrecommendedfortreatingherpeszoster,especiallyforpatientsatincreasedriskofdevelopingPHN.Antiviraltreatmentshouldbestartedwithin72hoursoftheonsetoftherash.基于这些证据，强烈推荐使用抗病毒药物治疗带状疱疹的患者，尤其是可能发展为带状疱疹后遗神经痛的患者。抗病毒治疗应该在皮疹出现72小时内使用。Nogoodevidencesupportstheefficacyofantiviraltreatmentadministered72hoursaftertheonsetofrash.Oneuncontrolledtrial,however,examinedtheeffectivenessofacyclovirstartedbeforevsafter72hours;thedifferenceinpainpersistencewasnotsignificantbetweenthegroups,suggestingacyclovirhasbenefitevenwhengivenafter72hours.10没有有力的证据表明皮疹出现72小时以后阿昔洛韦的疗效。一个不受控制的实验，用来调查阿昔洛韦分别在（皮疹出现）72小时之前和之后使用（的疗效）。在这两组中，疼痛的持续性没明显区别，这表明即使在（皮疹出现）72小时之后使用阿昔洛韦仍有疗效。Inclinicalpractice,thediagnosisofherpeszosterisoftennotmadewithin72hoursofsymptomonset;nevertheless,itisimportanttoidentifypatientswhocouldstillbenefitfromantiviralmedicationevenwhentreatmentisstartedrelativelylateinthediseasecourse.Thisisespeciallytrueinocularzoster,becauseviralsheddingmaycontinuebeyond72hours.11在临床实践中，带状疱疹往往未在发病的72小时内明确诊断。而然，明确（带状疱疹）患者是非常重要的，在较晚的病情开始使用抗病毒治疗仍有益处，尤其是在眼部的带状疱疹，因为病毒脱落可能持续超过72小时。Analgesicsarepartofapracticalapproachformanagingherpeszosterassociatedpainthatbeginswithashort-actingopioidincombinationwithacetaminophenoranonsteroidalanti-inflammatory(NSAID)agent.Gabapentinorpregabalin,followedbyatricyclicantidepressant,canbeaddedifconventionalanalgesicsarenotentirelyeffective.镇痛药是一个治疗带状疱疹相关疼痛切实可行的办法：短效阿片类药物结合对乙酰氨基酚或非甾体抗炎药（NSAID）。如果常规止痛不完全有效，可以加用加巴喷丁和普瑞巴林，其次是三环抗抑郁药。Theanalgesicregimenshouldbetailoredtothepatientsneedsandtoleranceofadverseeffects.Ifpaincontrolisinadequateoradverseeffectsareintolerable,considerreferringthepatienttoapainmanagementcenterforpossibleinterventionalmodalities.镇痛方案应针对病人的需要和不良反应的耐受性。如果疼痛控制不理想或不良反应无法耐受，可考虑介绍患者到疼痛中心行合适的介入性治疗。KeyPointGabapentinorpregabalin,followedbyatricyclicantidepressant,canbeaddedifconventionalanalgesicsarenoteffectiveforherpeszosterpain.关键点如果常规镇痛药对带状疱疹疼痛没效的话，可以使用加巴喷丁和普瑞巴林，其次是三环抗抑郁药。Corticosteroidsarenotrecommendedroutinelyfortreatmentofherpeszoster;youcantrytheminotherwisehealthyolderadults,however,ifantiviraltherapyandanalgesicsdonotrelievepain.治疗带状疱疹，不建议常规使用皮质类固醇，但是，如果抗病毒治疗和止痛药不能减轻疼痛，你可以尝试在健康的老年人身上使用。In2double-blindcontrolledtrials,acombinationofacyclovirandcorticosteroidsfor21daysdidnotdecreasetheincidenceofPHNalthoughsomebenefitwasseenintermsofpatientsreturntonormalactivities,cessationofanalgesictherapy,andimprovedsleep.12,13在2个双盲对照试验中，结合阿昔洛韦和类固醇的21天（治疗），虽然在病人恢复正常活动、停止镇痛治疗、并改善睡眠上有些益处，但没有减少PHN的发病率。