Paulus H E
Division of Rheumatology, UCLA School of Medicine 90024.
Clin Orthop Relat Res. 1991 Apr(265):96-102.
Aspirin, nonacetylated salicylates, and numerous other nonsteroidal antiinflammatory drugs (NSAIDs) are used in rheumatoid arthritis (RA) patients to decrease joint inflammation and improve function. The choice of medication and its optimum dosage must be individualized because of marked intersubject variations in drug metabolism, excretion, antiinflammatory and analgesic efficacy, and susceptibility to adverse effects. Equivalent doses of aspirin and of nonacetylated salicylates are equally antiinflammatory in RA, although the nonacetylated salicylate is a poor inhibitor of prostaglandin synthesis. Chronopharmacology studies suggest that many patients may have better efficacy and fewer side effects with evening doses than with morning doses of certain NSAIDs; however, the optimum time must be individualized by trial and error because some patients do better with other regimens. The gastric, renal, and platelet adverse effects of NSAIDs are related to their inhibition of prostaglandin synthesis, and tend to be related to dose and intensity of therapy. Various strategies can minimize the impact of these side effects, such as coadministration of gastric protectants or the use of short half-life NSAIDs to decrease the duration of preoperative NSAID withdrawal needed to ensure adequate platelet coagulation during surgery. An intramuscular analgesic NSAID is now available and is reported to be equivalent to morphine sulfate in some painful postsurgical conditions. Although associated with many problems, chronic corticosteroid therapy is, or has been, a major therapeutic component for many RA patients who consequently are unable to respond adequately to the stresses of general anesthesia and surgery because of complete or partial adrenal insufficiency. These patients must be given appropriate supplemental corticosteroid therapy perioperatively.
阿司匹林、非乙酰化水杨酸盐以及许多其他非甾体抗炎药（NSAIDs）用于类风湿关节炎（RA）患者，以减轻关节炎症并改善功能。由于药物代谢、排泄、抗炎和镇痛效果以及不良反应易感性在个体间存在显著差异，药物的选择及其最佳剂量必须个体化。在类风湿关节炎中，等效剂量的阿司匹林和非乙酰化水杨酸盐具有同等的抗炎作用，尽管非乙酰化水杨酸盐对前列腺素合成的抑制作用较弱。时间药理学研究表明，对于某些非甾体抗炎药，许多患者晚间服药可能比早晨服药疗效更好且副作用更少；然而，最佳服药时间必须通过反复试验来个体化确定，因为有些患者采用其他服药方案效果更好。非甾体抗炎药的胃肠道、肾脏和血小板不良反应与其对前列腺素合成的抑制有关，并且往往与治疗剂量和强度相关。各种策略可将这些副作用的影响降至最低，例如联合使用胃保护剂或使用半衰期短的非甾体抗炎药，以缩短术前停用非甾体抗炎药的时间，确保手术期间血小板充分凝血。一种肌肉注射用的非甾体抗炎镇痛药现已上市，据报道在某些术后疼痛情况下其效果与硫酸吗啡相当。尽管存在许多问题，但慢性皮质类固醇治疗现在是或曾经是许多类风湿关节炎患者的主要治疗组成部分，因此这些患者由于完全或部分肾上腺功能不全，对全身麻醉和手术的应激反应无法充分应对。这些患者在围手术期必须给予适当的补充皮质类固醇治疗。
