O'Connor Alec B
Department of Medicine, University of Rochester School of Medicine and Dentistry, New York, USA.
Pharmacoeconomics. 2009;27(2):95-112. doi: 10.2165/00019053-200927020-00002.
A number of different diseases or injuries can damage the central or peripheral nervous system and produce neuropathic pain (NP), which seems to be more difficult to treat than many other types of chronic pain. As a group, patients with NP have greater medical co-morbidity burden than age- and sex-adjusted controls, which makes determining the humanistic and economic burden attributable to NP challenging. Health-related quality of life (HR-QOL) is substantially impaired among patients with NP. Patients describe pain-related interference in multiple HR-QOL and functional domains, as well as reduced ability to work and reduced mobility due to their pain. In addition, the spouses of NP patients have been shown to experience adverse social consequences related to NP. In randomized controlled trials, several medications have been shown to improve various measures of HR-QOL. Changes in HR-QOL appear to be tightly linked to pain relief, but not to the development of adverse effects. However, in cross-sectional studies, many patients continue to have moderate or severe pain and markedly impaired HR-QOL, despite taking medications prescribed for NP. The quality of NP treatment appears to be poor, with few patients receiving recommended medications in efficacious dosages. The substantial costs to society of NP derive from direct medical costs, loss of the ability to work, loss of caregivers' ability to work and possibly greater need for institutionalization or other living assistance. No single study has measured all of these costs to society for chronic NP. The cost effectiveness of various interventions for the treatment or prevention of different types of NP has been assessed in several different studies. The most-studied diseases are post-herpetic neuralgia and painful diabetic neuropathy, for which tricyclic antidepressants (both amitriptyline and desipramine) have been found to be either cost effective or dominant relative to other strategies. Increasing the use of cost-effective therapies such as tricyclic antidepressants for post-herpetic neuralgia and painful diabetic neuropathy may improve the HR-QOL of patients and decrease societal costs. Head-to-head clinical trials comparing NP therapies are needed to help assess the relative clinical efficacy of treatments, ideally using HR-QOL and utility outcomes. The full costs to society of NP, including productivity loss costs, have not been determined for chronic NP. Improved relative efficacy, utility and cost estimates would facilitate future cost-effectiveness research in NP.
许多不同的疾病或损伤会损害中枢或周围神经系统，进而产生神经性疼痛（NP），这种疼痛似乎比许多其他类型的慢性疼痛更难治疗。总体而言，与年龄和性别匹配的对照组相比，NP患者的医疗合并症负担更重，这使得确定NP造成的人文和经济负担具有挑战性。NP患者的健康相关生活质量（HR-QOL）严重受损。患者描述了疼痛在多个HR-QOL和功能领域造成的干扰，以及由于疼痛导致的工作能力下降和行动不便。此外，NP患者的配偶也出现了与NP相关的不良社会后果。在随机对照试验中，几种药物已被证明可改善HR-QOL的各项指标。HR-QOL的变化似乎与疼痛缓解密切相关，而与不良反应的发生无关。然而，在横断面研究中，许多患者尽管服用了为NP开具的药物，但仍持续存在中度或重度疼痛，HR-QOL明显受损。NP的治疗质量似乎较差，很少有患者接受有效剂量的推荐药物。NP给社会带来的巨大成本源于直接医疗费用、工作能力丧失、护理人员工作能力丧失以及可能对机构化或其他生活援助的更大需求。没有一项研究全面衡量了慢性NP给社会带来的所有这些成本。在几项不同的研究中评估了各种治疗或预防不同类型NP的干预措施的成本效益。研究最多的疾病是带状疱疹后神经痛和疼痛性糖尿病神经病变，对于这两种疾病，三环类抗抑郁药（阿米替林和地昔帕明）已被证明相对于其他策略具有成本效益或占主导地位。增加使用成本效益高的疗法，如用于带状疱疹后神经痛和疼痛性糖尿病神经病变的三环类抗抑郁药，可能会改善患者的HR-QOL并降低社会成本。需要进行比较NP疗法的直接对比临床试验，以帮助评估治疗的相对临床疗效，理想情况下使用HR-QOL和效用结果。慢性NP给社会带来的全部成本，包括生产力损失成本，尚未确定。改进相对疗效、效用和成本估计将有助于未来NP的成本效益研究。
