1例疼痛伴肾功能损害患者的止痛药调整
重庆医科大学附属第一医院, 药学部, 重庆 400016
| 摘 要： | 阿片类药物被广泛应用于癌症疼痛治疗，肾功能损害使得阿片类药物清除减慢，极易导致药物蓄积及过量，从而为安全用药带来挑战。本文以1名癌性腹痛及慢性腰背痛合并重度肾功能损害的患者为例，该例患者在使用羟考酮缓释片治疗疼痛期间出现嗜睡、低氧血症、针尖样缩瞳等中枢抑制反应。临床药师对患者进行全面疼痛评估，并基于止痛药的药理作用及药代动力学特点，将羟考酮缓释片调整为曲马多胶囊。医师采纳药师建议，患者疼痛获得满意控制且未出现明显药物不良反应。本文论述了临床常用的阿片类药物的药理学、药代动力学特点及其在肾功能损害患者中的应用。本文同时结合案例，就羟考酮及曲马多在癌痛合并慢性腰背痛及肾功能损害患者中的应用进行了深入分析。该案例提示对于严重肾功能损害及阿片未耐受患者，不仅需要选择对肾功能依赖小的药品及短效制剂，而且需要从小剂量开始，逐步滴定至适宜剂量；对于临床情况复杂的疼痛患者，医师应注重与药师的合作，为患者制定个体化、精细化的给药方案，以获得满意的疼痛控制并确保患者用药安全。 |
| 关 键 词： | 阿片类药物; 癌痛; 肾功能损害; 药代动力学 |
| DOI： | 10.57237/j.mrf.2023.02.005 |
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收稿日期: 2023-04-03
接受日期: 2023-05-31
在线出版日期: 2023-06-15
Adjustment of Analgesic in a Patient with Pain and Renal Dysfunction
Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| Abstract: | Opioid drugs are widely used in the treatment of cancer pain. Renal dysfunction slows down the clearance of opioids, which can easily lead to drug accumulation and overdose, posing a challenge to safe medication. This article takes a patient with cancerous abdominal pain and chronic low back pain combined with severe renal function damage as an example. This patient experienced central inhibitory, such as somnolence, hypoxemia, and needle like pupil contraction during the use of oxycodone sustained-release tablets for pain treatment. Clinical pharmacist conducted a comprehensive pain assessment of patient and adjusted oxycodone sustained-release tablets to tramadol capsules. The physician followed the pharmacist's advice and the patient's pain was satisfactorily controlled without obvious adverse effects. This article discusses the pharmacological and pharmacokinetic characteristics of commonly used opioid drugs in clinical practice, as well as their application in patients with renal function impairment. This article also provides an in-depth analysis of the application of oxycodone and tramadol in patients with cancer pain, chronic low back pain, and renal function damage, based on case studies. This case suggests that for patients with severe renal dysfunction and opioid intolerance, it is not only necessary to choose drugs that are less reliance on renal clearance and short acting formulations, but also to gradually titrate from a small dose to an appropriate dose; For pain patients with complex clinical conditions, physicians should focus on collaborating with pharmacists to develop personalized and refined medication plans for patients, in order to achieve satisfactory pain control and ensure patient medication safety. |
| Keywords: | Opioids; Cancer Pain; Renal Impairment; Pharmacokinetics |
参考文献
| [1] | Teunissen SC, Wesker W, Kruitwagen C, et al. Symptom prevalence in patients with incurable cancer: a systematic review [J]. J Pain Symptom Manage, 2007, 34 (1): 94-104. |
| [2] | Brawley OW, Smith DE, Kirch RA. Taking action to ease suffering: advancing cancer pain control as a health care priority [J]. CA: A Cancer Journal for Clinicians, 2009, 59 (5): 285-289. |
| [3] | Yogaratnam D, Ditch K, Medeiros K, et al. The Impact of Liver and Renal Dysfunction on the Pharmacokinetics and Pharmacodynamics of Sedative and Analgesic Drugs in Critically Ill Adult Patients [J]. Crit Care Nurs Clin North Am, 2016, 28 (2): 183-94. doi: 10.1016/j.cnc.2016.02.009. |
| [4] | Sande TA, Laird BJ, Fallon MT. The use of opioids in cancer patients with renal impairment-a systematic review [J]. Support Care Cancer. 2017, 25 (2): 661-675. |
| [5] | Lee MA, Leng ME, Tiernan EJ. Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine [J]. Palliat Med. 2001, 15 (1): 26. |
| [6] | Davison SN, Mayo PR. Pain management in chronic kidney disease: the pharmacokinetics and pharmacodynamics of hydromorphone and hydromorphone-3-glucuronide in hemodialysis patients [J]. J Opioid Manag. 2008, 4 (6): 335. |
| [7] | Paramanandam G, Prommer E, Schwenke DC. Adverse effects in hospice patients with chronic kidney disease receiving hydromorphone [J]. J Palliat Med. 2011, 14 (9), 1029-1033. |
| [8] | McClain DA, Hug CC Jr. Intravenous fentanyl kinetics [J]. Clin Pharmacol Ther. 1980 Jul; 28 (1): 106-14. |
| [9] | Koehntop DE, Rodman JH. Fentanyl pharmacokinetics in patients undergoing renal transplantation [J]. Pharmacotherapy. 1997; 17 (4): 746. |
| [10] | Bower S. Plasma protein binding of fentanyl: the effect of hyperlipoproteinaemia and chronic renal failure [J]. J Pharm Pharmacol. 1982, 34 (2): 102-106. |
| [11] | Mercadante S, Caligara M, Sapio M, et al. Subcutaneous fentanyl infusion in a patient with bowel obstruction and renal failure [J]. J Pain Symptom Manage. 1997, 13 (4): 241. |
| [12] | Pohland A, Boaz HE, Sullivan HR. Synthesis and identification of metabolites resulting from the biotransformation of DL-methadone in man and in the rat [J]. J Med Chem. 1971 Mar; 14 (3): 194-197. |
| [13] | Yassen A, Olofsen E, Romberg R, et al. Mechanism-based PK/PD modeling of the respiratory depressant effect of buprenorphine and fentanyl in healthy volunteers [J]. Clin Pharmacol Ther. 2007, 81 (1): 50. |
| [14] | Dahan A, Yassen A, Bijl H, et al. Comparison of the respiratory effects of intravenous buprenorphine and fentanyl in humans and rats [J]. Br J Anaesth. 2005, 94 (6): 825. |
| [15] | Poulain P, Denier W, Douma J, et al. Efficacy and safety of transdermal buprenorphine: a randomized, placebo-controlled trial in 289 patients with severe cancer pain [J]. J Pain Symptom Manage. 2008, 36 (2): 117. |
| [16] | Sittl R, Griessinger N, Likar R. Analgesic efficacy and tolerability of transdermal buprenorphine in patients with inadequately controlled chronic pain related to cancer and other disorders: a multicenter, randomized, double-blind, placebo-controlled trial [J]. Clin Ther, 2003, 25 (1): 150-68. |
| [17] | Pergolizzi JV Jr, Mercadante S, Echaburu AV, et al. The role of transdermal buprenorphine in the treatment of cancer pain: an expert panel consensus [J]. Curr Med Res Opin. 2009, 25 (6): 1517. |
| [18] | Kurita GP, Lundström S, Sjøgren P, et al. Renal function and symptoms/adverse effects in opioid-treated patients with cancer [J]. Acta Anaesthesiol Scand. 2015，59 (8): 1049. |
| [19] | Hanna MH, D'Costa F, Peat SJ, et al. Morphine-6-glucuronide disposition in renal impairment [J]. Br J Anaesth. 1993, 70 (5): 511. |
| [20] | Gibson TP, Giacomini KM, Briggs WA, et al. Propoxyphene and norpropoxyphene plasma concentrations in the anephric patient [J]. Clin Pharmacol Ther. 1980, 27 (5): 665. |
| [21] | Nickander RC, Emmerson JL, Hynes MD, et al. Pharmacologic and toxic effects in animals of dextropropoxyphene and its major metabolite norpropoxyphene: a review [J]. Hum Toxicol. 1984, 3 Suppl: 13S. |
| [22] | 阿罗那, 谢菡, Guy Armel Bounda, 等. 强阿片类药物——羟考酮研究进展 [J]. 心理医生杂志, 2012 (2): 191-194. |
| [23] | Davis MP, Varga J, Dickerson D, et al. Normal-release and controlled-release oxycodone: pharmacokinetics, pharmacodynamics, and controversy [J]. SUPPORT CARE CANCER. 2002, 11 (2): 84-92. doi: 10.1007/s00520-002-0385-9. |
| [24] | 程熠, 于世英. 阿片类药物在肝肾功能不全癌痛患者中的选择应用 [J]. 中国肿瘤, 2011, 20 (4): 278-282. |
| [25] | 朱永满, 江伟, 徐惠芳.曲马多的药效和药代动力学[J]. 国外医学. 麻醉学与复苏分册, 2001, 22 (1): 56-58. |
| [26] | Paar WD, Frankus P, Dengler HJ. The metabolism of tramadol by human microsomes [J]. Clin Investig, 1992, 70 (8): 708-710. |
| [27] | Grond S, Sablotzki A. Clinical pharmacology of tramadol [J]. Clin Pharmacokinet, 2004, 43 (13): 879–923. |
| [28] | Ardakani YH, Rouini MR. Pharmacokinetics of tramadol and its three main metabolites in healthy male and female volunteers [J]. Biopharm Drug Dispos, 2007, 28 (9): 527-534. |
| [29] | Huerta C, Castellsague J, Varas-Lorenzo C, et al. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population [J]. Am J Kidney Dis. 2005, 45 (3): 531-539. |
| [30] | Epstein DH, Preston KL, Jasinski DR. Abuse liability, behavioural pharmacology, and physical dependence potential of opioids in humans and laboratory animals: Lessons from tramadol [J]. Biol Psychol, 2006, 73: 90–99. |
| [31] | Adler L, McDonald C, O’Brien C, et al. A comparison of once-daily tramadol with normal release tramadol in the treatment of pain in osteoarthritis [J]. J Rheumatol, 2002, 29: 2196–2199. |
| [32] | Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain [J]. J Rheumatol, 2000, 27: 772–778. |
| [33] | Qaseem A, Wilt TJ, McLean RM, et al. Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians [J]. Ann Intern Med, 2017, 166 (7): 514-530. |
| [34] | Airakinsen O, Brox JI, Cedraschi C, et al. European guidelines for the management of chronic non-specifi clow back pain [J]. Eur Spine J, 2006, 15 (Suppl 2): S192–S300. |
| [35] | Schnitzer TJ. Update on guidelines for the treatment of chronic musculoskeletal pain [J]. Clin Rheumatol, 2006, 25 (Suppl 1): S22–S29. |
