Tassinari Davide, Drudi Fabrizio, Carloni Federica, Castellani Cinzia, Scarpi Emanuela, Maltoni Marco
Modulo di Terapie di Supporto e Palliative, Ospedale Civile Infermi, Rimini.
Recenti Prog Med. 2009 Dec;100(12):551-8.
Although oral morphine is the gold standard in the front-line approach to moderate-severe cancer pain, transdermal opiates are largely used in clinical practice. Aims of our work were to review the evidences of literature supporting these different habits and to suggest an evidence-based criterion to guide clinical research and clinical practice. A systematic review of literature with meta-analysis of the safety data reported in randomized clinical trials comparing slow releasing oral morphine and transdermal opiates was performed using the random effect model. The quality of the evidences supporting the use of the different strategies and the strength of the recommendations was analyzed using the GRADE method. A significant advantage in favor of transdermal opiates was observed for constipation, urinary retention, need of laxative use and patient's preferences; a significant advantage in favor of slow releasing oral morphine was observed for diarrhea and sweating. The quality of the evidences supporting a front-line use of transdermal fentanyl was considered low, while those supporting the use of transdermal buprenorphine was considered very low. For the use oftransdermal fentanyl and for that oftransdermal buprenorphine a weak and a strong recommendation against their us as front-line treatment of moderate-severe cancer pain can be respectively obtained from the literature data. Transdermal opiates represent a safety and effective alternative to oral morphine against cancer pain, but they can not replace oral morphine as the gold standard first-line treatment of moderate-severe cancer pain.
尽管口服吗啡是中重度癌痛一线治疗的金标准，但透皮阿片类药物在临床实践中被广泛使用。我们这项工作的目的是回顾支持这些不同用药习惯的文献证据，并提出一个基于证据的标准来指导临床研究和临床实践。使用随机效应模型对比较缓释口服吗啡和透皮阿片类药物的随机临床试验中报告的安全性数据进行了文献系统回顾和荟萃分析。使用GRADE方法分析了支持不同策略使用的证据质量和推荐强度。在便秘、尿潴留、使用泻药的必要性和患者偏好方面，观察到透皮阿片类药物有显著优势；在腹泻和出汗方面，观察到缓释口服吗啡有显著优势。支持一线使用透皮芬太尼的证据质量被认为较低，而支持使用透皮丁丙诺啡的证据质量被认为非常低。从文献数据中分别可以得出，对于透皮芬太尼的使用和透皮丁丙诺啡的使用，有一个弱推荐和一个强推荐反对将其作为中重度癌痛的一线治疗方法。透皮阿片类药物是口服吗啡治疗癌痛的一种安全有效的替代方法，但它们不能取代口服吗啡作为中重度癌痛的金标准一线治疗方法。
