Murtagh Fliss E M, Chai Mee-Onn, Donohoe Paul, Edmonds Polly M, Higginson Irene J
Department of Palliative Care & Policy, Kings College, London.
J Pain Palliat Care Pharmacother. 2007;21(2):5-16.
The numbers of patients dying with end-stage renal disease (ESRD), particularly those managed conservatively (without dialysis) or withdrawing from dialysis is increasing rapidly in developed countries. There is growing awareness of the extensive symptom control needs of these patients. Pain is a common problem, and has been both under-recognized and under-treated. It is challenging to manage, largely because of the constraints very poor renal function places on use of medication. Although pharmacological reviews of opioid use in renal failure have been published, there is a need for clinical recommendations to aid palliative and renal specialists in providing effective pain control. This review describes the pharmacological evidence for and against the use of the different opioid medications, and translates this into clinical recommendations for ESRD patients managed conservatively, not for those on dialysis for whom there are different pharmacological considerations. Acetaminophen (paracetamol) is recommended at Step 1 of the World Health Organization ladder. Of the Step 2 analgesics, tramadol is the least problematic, although dose reduction and increased dosing interval are required, and caution should be exercised. Of the Step 3 analgesics, fentanyl, alfentanil and methadone are recommended. There is limited evidence for buprenorphine, although theoretical reasons why it may be a good choice for these patients. Hydromorphone and oxycodone cannot be recommended because of extremely limited evidence, although each is likely a better choice than morphine or diamorphine. Morphine and diamorphine themselves are not recommended because of known accumulation of potentially toxic metabolites.
在发达国家，死于终末期肾病（ESRD）的患者数量，尤其是那些接受保守治疗（未进行透析）或停止透析的患者数量正在迅速增加。人们越来越意识到这些患者广泛的症状控制需求。疼痛是一个常见问题，一直未得到充分认识和治疗。疼痛管理具有挑战性，主要是因为肾功能极差对药物使用造成限制。尽管已经发表了关于肾衰竭中使用阿片类药物的药理学综述，但仍需要临床建议来帮助姑息治疗和肾脏专科医生提供有效的疼痛控制。本综述描述了支持和反对使用不同阿片类药物的药理学证据，并将其转化为针对保守治疗的ESRD患者的临床建议，而非针对透析患者，因为透析患者有不同的药理学考虑因素。对乙酰氨基酚（扑热息痛）在世界卫生组织阶梯止痛法的第1步中被推荐使用。在第2步的镇痛药中，曲马多问题最少，不过需要减少剂量并延长给药间隔，且应谨慎使用。在第3步的镇痛药中，推荐使用芬太尼、阿芬太尼和美沙酮。丁丙诺啡的证据有限，尽管从理论上讲它可能是这些患者的一个不错选择。由于证据极其有限，不推荐使用氢吗啡酮和羟考酮，尽管它们可能比吗啡或二醋吗啡是更好的选择。由于已知会积累潜在有毒代谢物，不推荐使用吗啡和二醋吗啡本身。
