Expertise Centre for Pharmacotherapy in Old Persons (Ephor), University Medical Center, Utrecht, The Netherlands.
Drugs Aging. 2012 Aug 1;29(8):615-25. doi: 10.2165/11632620-000000000-00000.
In the treatment of chronic malignant and non-malignant pain, opioids are used as strong analgesics. Frail elderly patients often have multiple co-morbidities and use multiple medicines, leading to an increased risk of clinically relevant drug-drug and drug-disease interactions. Age-related changes and increased frailty may lead to a less predictable drug response, increased drug sensitivity, and potential harmful drug effects. As a result, physicians face a complex task in prescribing medication to elderly patients. In this review, the appropriateness of the strong-acting opioids buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone and tapentadol is determined for use in elderly patients. Evidence-based recommendations for prescribing strong opioids to the frail elderly are presented. A literature search was performed for all individual drugs, using a validated and published set of 23 criteria concerning effectiveness, safety, pharmacokinetics and pharmacodynamics, experience, and convenience in elderly patients. First, information on the criteria was obtained from pharmaceutical reference books and a MEDLINE search. The information obtained on the individual drugs in the class of opioids was compared with the reference drug morphine. Evidence-based recommendations were formulated on the basis of the pros and cons for the frail elderly. Using the set of 23 criteria, no differentiation can be made between the appropriateness of buprenorphine, fentanyl, hydromorphone, morphine and oxycodone for use in elderly patients. Methadone has strong negative considerations in the treatment of chronic pain in the frail elderly. Methadone has a high drug-drug interaction potential and is associated with prolongation of the QT interval and a potential risk of accumulation due to a long elimination half-life. In addition, methadone is difficult to titrate because of its large inter-individual variability in pharmacokinetics, particularly in the frail elderly. Because of a lack of empiric knowledge, the use of tapentadol is not recommended in frail elderly persons. Nevertheless, tapentadol may prove to be a useful analgesic for the treatment of chronic pain in frail elderly persons because of its possible better gastrointestinal tolerability. In the treatment of chronic pain in the frail elderly, the opioids of first choice are buprenorphine, fentanyl, hydromorphone, morphine and oxycodone. In order to improve the convenience for elderly patients, the controlled-release oral dosage forms and transdermal formulations are preferred.
在治疗慢性恶性和非恶性疼痛时，阿片类药物被用作强效镇痛药。体弱的老年患者通常患有多种合并症并使用多种药物，这导致临床相关的药物相互作用和药物与疾病相互作用的风险增加。与年龄相关的变化和脆弱性增加可能导致药物反应不可预测、药物敏感性增加和潜在的有害药物作用。因此，医生在为老年患者开处方时面临着复杂的任务。在本综述中，确定了强效阿片类药物丁丙诺啡、芬太尼、氢吗啡酮、美沙酮、吗啡、羟考酮和他喷他多在老年患者中的适用性。提出了针对体弱老年患者开具强效阿片类药物的循证建议。对所有单独的药物进行了文献检索，使用了一套经过验证和发表的 23 项标准，涉及有效性、安全性、药代动力学和药效学、经验和在老年患者中的便利性。首先，从制药参考书和 MEDLINE 搜索中获取有关这些标准的信息。将类阿片药物中各药物的信息与参考药物吗啡进行比较。根据体弱老年患者的优缺点制定了循证建议。使用这组 23 项标准，无法区分丁丙诺啡、芬太尼、氢吗啡酮、吗啡和羟考酮在老年患者中的适用性。美沙酮在治疗体弱老年慢性疼痛方面有强烈的负面考虑。美沙酮具有很高的药物相互作用潜力，并与 QT 间期延长和由于消除半衰期长而导致的潜在蓄积风险相关。此外，由于其药代动力学个体间变异性很大，尤其是在体弱的老年患者中，美沙酮难以滴定。由于缺乏经验知识，不建议在体弱的老年患者中使用他喷他多。然而，由于其可能更好的胃肠道耐受性，他喷他多可能成为治疗体弱老年慢性疼痛的有用镇痛药。在治疗体弱老年慢性疼痛时，首选的阿片类药物是丁丙诺啡、芬太尼、氢吗啡酮、吗啡和羟考酮。为了提高老年患者的便利性，首选控释口服剂型和透皮制剂。
