Knotkova Helena, Fine Perry G, Portenoy Russell K
Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA.
J Pain Symptom Manage. 2009 Sep;38(3):426-39. doi: 10.1016/j.jpainsymman.2009.06.001.
Opioid rotation refers to a switch from one opioid to another in an effort to improve the response to analgesic therapy or reduce adverse effects. It is a common method to address the problem of poor opioid responsiveness despite optimal dose titration. Guidelines for opioid rotation are empirical and begin with the selection of a safe and reasonably effective starting dose for the new opioid, followed by dose adjustment to optimize the balance between analgesia and side effects. The selection of a starting dose must be based on an estimate of the relative potency between the existing opioid and the new one. Potency, which is defined as the dose required to produce a given effect, differs widely among opioids, and among individuals under varying conditions. To effectively rotate from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor abstinence, and will be sufficiently efficacious in that pain is no worse than before the change. The estimate of relative potency used in calculating this starting dose has been codified on "equianalgesic dose tables," which historically have been based on the best science available and have been used with little modification for more than 40 years. These tables, and the clinical protocols used to apply them to opioid rotation, may need revision, however, as the science underlying relative potency evolves. Review of these issues informs the use of opioid rotation in the clinical setting and defines key areas for future research.
阿片类药物转换是指从一种阿片类药物转换为另一种阿片类药物，以改善镇痛治疗反应或减少不良反应。这是一种解决尽管进行了最佳剂量滴定但阿片类药物反应性仍较差问题的常用方法。阿片类药物转换指南是经验性的，首先要为新的阿片类药物选择一个安全且合理有效的起始剂量，然后进行剂量调整以优化镇痛与副作用之间的平衡。起始剂量的选择必须基于对现有阿片类药物和新阿片类药物之间相对效价的估计。效价定义为产生给定效应所需的剂量，在不同阿片类药物之间以及在不同条件下的个体之间差异很大。为了有效地从一种阿片类药物转换为另一种阿片类药物，新的阿片类药物必须以既不会引起毒性也不会导致戒断反应的剂量开始使用，并且其疗效要足够好，即疼痛程度不比换药前更严重。用于计算此起始剂量的相对效价估计已编入“等效镇痛剂量表”，这些表格历来基于现有最佳科学依据，并且在40多年的时间里几乎没有修改就一直被使用。然而，随着相对效价背后的科学不断发展，这些表格以及用于将其应用于阿片类药物转换的临床方案可能需要修订。对这些问题的审查为临床环境中阿片类药物转换的使用提供了参考，并确定了未来研究的关键领域。
