癌性疼痛的处理课件

癌性疼痛的处理

WHO

3-阶梯镇痛疗法

ManagementofCancerPain

WHO3–StepAnalgesicLadderTerenceL.Gutgsell,MDHospiceoftheBluegrassLexington,KY躯体的疼痛PhysicalPain情感的疼痛EmotionalPain社交障碍SocialDiscord宗教的困扰SpiritualDistress病痛=总体的疼痛Suffering=TotalPain普遍原则“拇指原则”诊断可能的机制,个体化治疗

ATC和PRN用药,保持简单反复评价,注意细节GeneralPrinciples“RulesofThumb”DiagnoseunderlyingmechanismIndividualizetreatmentATCandPRNmedicationsKeepitsimple,ReassessAttentiontoDetail疼痛的病理生理学急性疼痛已明确的原因，缓解时间：数日到数周

通常是感受伤害性的慢性疼痛原因常不易确定，多因素的持续时间不确定

感受伤害性的和/或神经病理性的PainpathophysiologyAcutepainIdentifiedevent,resolvesdays–weeks

UsuallynociceptiveChronicpainCauseoftennoteasilyidentified,multifactorialIndeterminateduration

Nociceptiveand/orneuropathic感受伤害性的疼痛对健全的伤害感受器的直接刺激沿正常神经传递锐痛，酸痛，搏动性疼痛本体性的-易于描述和定位内脏性的-难以描述和定位NociceptivepainDirectstimulationofintactnociceptorsTransmissionalongnormalnervesSharp,aching,throbbingSomatic-Easytodescribe,localizeVisceral-Difficulttodescribe,localize感受伤害性疼痛组织损伤明显治疗阿片类药物辅助药物/联合镇痛剂NociceptivepainTissueinjuryapparentManagementOpioidsAdjuvant/coanalgesics神经病性疼痛外周或中枢神经的功能障碍压迫，横断，浸润，缺血，代谢性损伤不同类型外周的传入神经阻滞交感神经介导的NeuropathicpainDisorderedperipheralorcentralnervesCompression,transection,infiltration,ischemia,metabolicinjuryVariedtypesPeripheraldeafferentationsympatheticallymediated神经病性疼痛疼痛可能不仅只由可见的损伤引起描述为烧灼感，麻刺感，射痛，刺痛，电击样疼痛治疗

阿片类药物

常需要辅助药物/联合镇痛剂NeuropathicpainPainmayexceedobservableinjuryDescribedasburning,tingling,shooting,stabbing,electricalManagementOpioids

Adjuvant/coanalgesicsoftenrequiredWHO3-阶梯疗法

WHO3-stepLadder1mild(1–3/10)2

moderate(4–6/10)3severe(7-10/10)Morphine吗啡Hydromorphone氢吗啡酮Oxycodone羟考酮Fentanyl芬太尼Methadone美沙酮±AdjuvantsA/Codeine可待因A/Hydrocodone氢可酮A/Oxycodone羟考酮Tramadol曲马多±AdjuvantsASAAcetaminophen扑热息痛NSAIDs±AdjuvantsWHO3-阶梯疗法

1轻度

(1–3/10)阿斯匹林扑热息痛NSAIDs±辅助药物2

中度

(4–6/10)A/可待因A/氢可酮A/羟考酮曲马多±辅助药物3重度

(7-10/10)吗啡氢吗啡酮羟考酮芬太尼美沙酮±辅助药物阿片类的药理学在肝脏结合通过肾脏排泄（90%-95%）一级动力学OpioidpharmacologyConjugatedinliverExcretedviakidney

(90%–95%)First-orderkineticsPlasmaConcentration0Half-life(t1/2)TimeIVpo/prSCCmax常规口服剂量即释剂型吗啡，氢可酮，羟考酮，氢吗啡酮，（芬太尼）剂量q4h

每天调整剂量

-轻度/中度疼痛

25%–50%

-重度/难以控制的疼痛

50%–100%对于严重的难以控制的疼痛需要较快地调整剂量Routineoraldosing

immediate-releasepreparationsMorphine,hydrocodone,oxycodone

hydromorphone,(fentanyl)Doseq4h

Adjustdosedaily-mild/moderatepain

25%–50%-severe/uncontrolledpain

50%–100%

Adjustmorequicklyforsevereuncontrolledpain常规口服剂量缓释剂型增加依从性与合作性按q8,12,或24h给予药物

不要压碎或咀嚼药片可以通过鼻饲管将缓释颗粒注入每2-3天调整剂量Routineoraldosing

extended-releasepreparationsImprovecompliance,adherenceDoseq8,12,or24hDon’tcrushorchewtabletsMayflushtime-releasegranulesdownfeedingtubesAdjustdoseq2–3days给药的替代途径

AlternativeroutesofadministrationEnteralfeedingtubes置管喂饲Transmucosal

经粘膜Rectal经直肠Transdermal经皮Parenteral胃肠外Intraspinal脊柱内Epidural硬膜外Intrathecal鞘内更换阿片类药物交叉耐受按已公认的等效剂量原则，从相应剂量的50%-75%开始使用

如果疼痛不能控制，追加剂量如果不良反应明显，减少剂量ChangingopioidsCross-toleranceStartwith50%–75%ofpublishedequianalgesicdoseMoreifpainnotcontrolledlessifadverseeffectsprominent阿片类镇痛剂的等效剂量

Equianalgesicdosesofopioidanalgesics

po/pr(mg) Analgesic SC/IV(mg) 30 Morphine吗啡 10 30 Hydrocodone氢可酮 - 20 Oxycodone羟考酮 - 7.5 Hydromorphone氢吗啡酮 1.5

(300 Meperidine度冷丁 75) (200 Codeine可待因 120)阿片类镇痛剂的等效剂量透皮芬太尼

25mg/张≈50mgPO吗啡/24h.

50mg/张≈100mgPO吗啡/24h.

EquianalgesicdosesofopioidanalgesicsTransdermalfentanyl25mgpatch~50mgPOmorphine/24h.

50mgpatch~100mgPOmorphine/24h.

etc...阿片类镇痛剂的受体亲和力

ReceptorAffinityofOpioidAnalgesicsReceptorType

受体类型 mukappadeltaNMDA

______________________________________________________________________Morphine吗啡 A - - -Fentanyl芬太尼 A - - -Hydromorphone氢吗啡酮

A - - -Oxycodone羟考酮 A(?)A(?) - -Methadone美沙酮 A - A Ant A=strongagonist强激动剂Ant=strongantagonist强拮抗剂-=negligibleactivity

低活性 TwycrossRetal.PalliativeCareFormulary.1998.

药代动力学概况

PharmacokineticProfile

Peakonset Duration PotencyAnalgesic ofAction ofEffect Ratio____镇痛剂__________峰值作用时间___作用持续时间________效能比___morphine 吗啡 30-60m 3-4hand8-12h-

oxycodone羟考酮30-60m 3-4hand8-12h 1:1methadone美沙酮30-60m 8-12h 5-20:1hydromorphone氢吗啡酮45m4-5h 4:1 fentanylTTS芬太尼16-24h 48-72h 100:1美沙酮转换指南

Methadoneconversionguidelines

IstitutoNazionaledeiTumori

Milan,Italy24小时吗啡总量与吗啡的对比率 Doseofmorphineq24h

RatiotoMorphine <100mg 4:1 101mgto299mg 8:1

>300mg 12:1

RipamontiC.CancerPainandPalliativeCare.IASP,1999.美沙酮初始剂量的计算第一步：停用吗啡（或其他强阿片类药物）第二步：给予美沙酮的固定剂量，即当口服吗啡24小时总量<300mg时，给予24小时口服吗啡总量的1/10，或24小时吗啡用量>300mg时,固定剂量应该是30mg。第三步：必要时给予口服的固定剂量，但给药频数不能超过q3h。CalculatingthestartingdoseofmethadoneStep#1:Stopmorphine(orotherstrongopioid)Step#2:Giveafixeddoseofmethadonethatis1/10ofthe24horalmorphinedosewhen24hdoseis<300mg.,OR

whenthe24hmorphinedoseis>300mg.,thefixeddoseshouldbe30mg.Step#3:ThefixeddoseistakenPOprnbutnotmorefrequentlythanq3h.bMorleyJS,MakinMK.PainReviews.1998.美沙酮起始剂量的计算第四步：第六天，计算前两天美沙酮的平均口服用量，并转换为定时的q12h用量（和q3hprn）第五步：如果持续需要临时给药，每4-6天一次增加1/2-1/3的美沙酮用量（即，10mgbid变为15mgbid;30mgbid变为40mgbid)CalculatingthestartingdoseofmethadoneStep#4:Onday6,theamountofmethadonetakenovertheprevious2daysisaveragedandconvertedintoaregularq12dose(andq3hp