神经病性疼痛和辅助镇痛剂的意义课件

神经病性疼痛和辅助镇痛剂的意义

NeuropathicpainandthemeaningofadjuvantanalgesicsDr.Z.ZyliczHospiceintheWealdPembury,TunbridgeWellsKent,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-δ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Twotypesof“natural”painAdaptationpain–“normalpain”,Thepainhelpstopreservebody’sintegrity(withdrawal,alwaysready,“fastpain”mostlyAdeltafibres）Thepainpromotesrecovery:“donotmoveyourbrokenleg”,inflammatorypain,“slowpain”mostlyCfibres感受伤害性的疼痛

Nociceptivepain“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“pathologicpain”hasnothingtodowithadaptation“pathologicpain”,“painwithoutpurpose”frequentlyofneuropathicorigin,notoronlypartiallysensitivetoclassicalanalgesicsfrequentlysensitivetoadjuvantanalgesics神经病性疼痛

Neuropathicpain痛觉过敏神经病性疼痛的2种类型

TwotypesofneuropathicpainNeurogenicpain神经源性疼痛pressureonthenerve神经受压迫peripheralsensitization外周神经敏化Reversible可逆转性distaltothedamage末稍损伤partiallysensitivetoanalgesics对镇痛剂部分敏感respondstolocalanaethetics对局部麻醉剂有反应nerveentrapment神经的压迫性损害Trueneuropathicpain真性神经病性疼痛damageirreversible不可逆损伤centralsensitization(spinalcord,brain)中枢神经敏化（脊索，脑）classicalanalgesicsandanestheticsfrequentlyineffective普通镇痛剂和麻醉剂常常无效adjuvantanalgesicslikeTCAareeffective辅助镇痛剂有效，如TCA类nervesection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。“Adjuvantanalgesics…”Alldrugs,notlicensedassuchforthetreatmentofpain,butusefultoimprovethequalityofanalgesia.Theymayhaveanintrinsicanalgesicactivityormaypotentiatetheactivityofclassicalanalgesicsordiminishtheirtoxiceffects.我们将讨论哪些药物？

Aboutwhichdrugswearetalkingabout?Antidepressants抗抑郁剂Anxiolytics抗焦虑剂Anticonvulsants抗惊厥药物NMDAinhibitorsN-甲基-D-天冬氨酸抑制 剂类Musclerelaxants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

Antidepressantsamitriptylline(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®)inlowdosesynergisticwithopioidsanxiolyticeffectusefulinanalgesiainhighdosesedativesmetabolismisvariableinpresenceofanticonvulsantdrugsmorphinedosesignificantlylowerwhenusedwithmidazolamintrinsicanticonvulsantactivity(usefulasreplacementofgabapentin）.抗惊厥药物Anticonvulsantscarbamazepin(Tegretol®)卡马西平phenytoin(Difantoine®)苯妥英valporoicacid(Depakine®)

丙戊酸clonazepam(Rivotril®)氯硝安定lamotrigine(Lamictal®)拉莫三嗪gabapentin(Neurontin®)盖巴喷丁pregabalin(Lyrica®)普瑞巴林肌肉松弛剂巴氯芬（鞘内）LindG.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。EurJPain2004;8:377-83

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

精神兴奋剂利他林5+5mg(08.00和12.00点)如果必要，可增加至10+10mg,时间与上相同PsychostimulantsMethylphenidate(Ritalin®):5+5mg(08.00and12.00)Increaseifnecessaryto10+10mg,sametime.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NeurolepticsLevomepromazine(Nozinan®) - intrinsicanalgesiceffect - excellentwidespectrumantiemetic - goodassedative - toxicinlongeruse - developmentoftolerance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AtypicneurolepticsOlanzapine(Zyprexa®)excellentadjuvantinpaintreatmentexcellentantiemeticgoodinthetreatmentofdeliriumandpsychosis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25mgq.n.，使用一周，必要时增加剂量文拉法辛，37.5mgb.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Thebeststrategy:

intrueneuropathicpainAmitriptyline25mga.n.ifnocontraindications,trialfor1week,increasethedoseifnecessaryVenlafaxine,37.5mgb.d.,increasethedosegabapentinorpregabalin,titratetoeffectivedose总结辅助性镇痛剂