p2.scara de analgezie oms. strategii terapeutice
DESCRIPTION
Tratamentul durerii in Oncologie conform OMSTRANSCRIPT
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Tratamentul durerii cronice in cancer
Scara de analgezie OMSStrategii terapeutice
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Obiective La sfarsitul sesiunii participantii vor fi
capabili sa: Enunte principiile de tratament in durerea
cronica Explice Scara de analgezie OMS Enumere medicamentele de pe treapta I, II si III Prezinte modalitatea de initiere/ titrare a
opioidelor la un pacient opioid naiv Aleaga corect preparatul opioid si combinatia
terapeutica la un pacient cu durere moderata sau severa
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Prevalenta simptomelor in stadiu avansat al cancerului
Astenie 95%Durere 80%Constipatie 65%Dispnee 60%Insomnie 60%Greata/varsaturi 50%Depresie 50%Confuzie 45%Inapetenta/anorexie 80%
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CONCEPTE PRIVIND ANALGEZIA ÎN MEDICINA PALIATIVĂ
Fiecare durere impune evaluare corecta,stabilirea etiologiei, cu tratament specificAnalgezia:
să fie simplă atenţie la efectele secundare dozele trebuiesc frecvent revăzute
Tratamentul opioid trebuie să fie neîntrerupt, la
intervale regulate, “dupa ceas”, plussuplimentare pentru puseele dureroase“breaking through pain”
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CONCEPTE PRIVIND ANALGEZIA ÎN MEDICINA PALIATIVĂ
Nu există doză maximă de opioid (doză optimă de opioid)Se preferă administrarea orală sau rectală. Când nu esteposibil se administrează subcutan:
intermitent pe fluturaş continuu cu seringa automată
Să fie utilizate corect coanalgezicele sau procedurile deblocaj nervos local sau regional.Adicţia şi toleranţa nu sunt probleme la pacienţii cu stadiiavansate de cancer (
www.aacpi.wisc.edu/images/Myths_Pain.pdf)Sa se aleaga medicamentul conform scarii de analgezie
OMS
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Scara de analgezie OMS
Analgezice neopioidePARACETAMOL
Opioide slabede treapta IICODEINA
Opioide puternicede treapta IIIMORFINA
+/- Co-analgezice
+/- Co-analgezice
+/- Co-analgezice
WHO Cancer Pain Relief 1980
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Scara de analgezie OMS
Analgezice neopioide
VAS <4
Opioide de treapta II
VAS 4 - 6
Opioide de treapta III
VAS 7-10
+/- Co-analgezice
+/- Co-analgezice
+/- Co-analgezice
WHO Cancer Pain Relief 1980
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Scara de analgezie OMS
Utilizarea scalei de analgeziei OMS duce la inlaturarea cu succes a durerii in peste 90% din cazuri
Zech DFJ, Ground S, Lynch J. Validation of WHO guidelines for cancer pain relief: a 10 –Year prospective study (Pain 1995)
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Antinflamatoarele nesteroidiene
Mecanism de actiune: inhibarea ciclooxigenazei –sinteza PG E2 si tromboxan
Spre deosebire de paracetamol se concentreaza in tesutul cu inflamatie, rinichi, sist cardio-vascular,mucoasa gastrica
Clasificare Selective COX2 ( celecoxib, rofecoxib) Neselective (diclofenac, ibuprofen, meloxicam)
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Preferabil Cu T1/2 scurt Doza minima eficienta Numar minim administrari/zi
Ibuprofen-max 2,4g/zi Diclofenac max 150mg/zi Indometacin max 200mg/zi
Cele cu T1/2 lung(Naproxen(1,1g), piroxicam(40mg) meloxicam (15mg) mai putin indicate
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Efecte secundare
Dependente de doza Tub digestiv-epigastralgii-hemoragie
digestiva Renal retentie HE-necroza tub papilari Scad agregarea trombocitara Cresc riscul de accidente
vasculare( cele selective)
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Interactiuni medicamentoase
Risc crescut de singerare in adm concomitenta cu
Antagonisti vit K SSRI Glucocorticoizi
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Exercitiu
Va rog sa aranjati medicamentele care urmeaza Treapta I Treapta II Treapta III Altele Nu stiu
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PARACETAMOL, VOLTAREN, IBUPROFEN, VENDAL, SENNA, COPROXAMOL, TRAMADOL, METADONA, FORTRAL, URGENDOL, PETIDINA, FENTANYL, NAPROXEN, TRATUL, INDOMETACIN, SINTALGON, MST, PADUDEN, OXYCODON, DUROGESIC, OXYCONTIN, DICLOFENAC, HIDROMORFON, PIROXICAM, CODEINA, DEXTROPROPOXIFEN, PALLADONE, MIALGIN, DHC, ARTROTHEC, METOCLOPRAMID, TEMGESIC, DULCOLAX, MORFINA, DIHIDROCODEINA, ALFENTANYL, BUPROFENORFINA, NUROFEN, ALGOCALMIN, METAMIZOL, SCOBUTIL, ALGOZONE FORTE, PAPAVERINA, NO-SPA, PIAFEN, FASCONAL
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Treapta I Paracetamol Diclofenac: Voltaren, Arthrotec, Tratul Ibuprofen: Nurofen, Paduden Naproxen Indometacin Algocalmin (metamizol) Antispastice- scobutil, papaverină,
drotaverină (No-Spa)
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Treapta II
Codeina Dextropropxifen:Co-proxamol Tramadol:Tramal,Tradolan,Urgendol, Dihidrocodeina: DHC Pentazocina: Fortral Oxycodon( doze mici)
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Treapta III Morfina: Vendal, MST, Sevredol Hidromorfon: Palladone Fentanyl: Durogesic Alfentanyl Metadona: Sintalgon Oxycodon: Oxycontin Buprenorfina: Temgesic Petidina : Mialgin
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Scrieti in dreptul medicamentelor dozele maxime si formele farmaceutice inregistrate in tara
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Treapta I Paracetamol: 4-6 grame/zi Diclofenac: Voltaren, Tratul, Arthrotec
150-200mg/zi Ibuprofen: Nurofen, Paduden 2,4-3,2g/zi Naproxen:1g/zi Indometacin:150mg/zi Piroxicam: 20-40mg/zi Algocalmin: 4-6 g/zi
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Treapta II
Codeina: 240-360mg/zi Dextropropxifen:Co-proxamol Tramadol:Tramal, Urgendol, 400-
600mg/zi Dihidrocodeina: DHC 240-360mg/zi Pentazocina: Fortral
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Treapta III Morfina: Vendal, MST, Sevredol Hidromorfon: Palladone Fentanyl: Durogesic Alfentanyl Metadona: Sintalgon Oxycodon: Oxycontin Buprenorfina: Temgesic Petidina : Mialgian
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Initierea tratamentului cu oipoide-treapta a II-a
Preparate cu eliberare imediata Tramadol 50 mg la 6 ore Codeina 30 mg la 6 ore
Preparate cu eliberare prelungita Tramadol 100 mg la 12 ore DHC 60 mg la 12 ore
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. . . Farmacologia opioida
Durata efectului unui preparat cu “ eliberare imediata”
4–6 ore po / pr Mai scurt in cazul administrarii
extradigestive Stare stabila( concentratie plasmatica)
dupa 4–5 perioade de injumatatire Stare stabila dupa 1 zi (24 de ore)
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Dozajul oral de rutinapreparate cu eliberare imediata
Codeina, tramadolul doza q 4-6 h Ajustati doza zilnic
usoara / moderata 25%–50%
severa / necontrolata 50%–100%
Ajustati mai rapid pentru durere severa si necontrolata
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Dozajul oral de rutinapreparate cu eliberare extinsa
Imbunatatesc complianta, aderenta
Doze q 8, 12, Nu sfaramati sau mestecati
tabletele Ajustati dozajul la 2-4 zile (odata
atins stadiul stabil)
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Inceperea tratamentului cu morfina orala la pacienti opoid naivi
Varsta Functie renala Doza MO orala sub 65 ani normala 10 mg la 4 orepeste 65 ani normala 5 mg la 4 ore sub 65 ani redusa 10 mg la 6-8 ore peste 65 ani redusa 5 mg la 6-8 ore
Pentru puseul dureros se administreaza inca o doza egala cu cea de 4 ore suplimentara
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Initiere terapie cu Morfina sc la pacientii opoid naivi Pacienti cu durere severa care au
Greata varsaturi Tuburari de deglutie Sedati, semiconstienti, terminali
Pacienti varstinici, cu IR usoara, terminali 5 mg la 8 ore sc pe fluturas
Ceilalti 5 mg la 4 ore sau 10mg la 6 ore
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Titrare morfina Daca prima, primele doze produc
sedare intensa se poate reduce doza cu 50% si sa facem mai lent titrarea
Daca doza initiala nu produce de loc analgezie doza urmatoare se creste cu 50%
In mod normal dozele se cresc zilnic (30-50-100%)pana se obtine analgezia optima
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Trecerea de pe treapta II pe treapta III
Se calculeaza doza zilnica echivalenta
Daca durerea a fost necontrolata se creste doza cu 30-50 %
Doza zilnica se divide la 6 pentru dozei/doza morfinei cu elib imediata sau la 2 pentru doza/doza morfina cu eliberare prelungita
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Dozajul de breakthrough Se utilizeaza opioizi cu eliberare
imediata 1/6 din doza pentru 24-h Se repeta dupa ce Cmax a fost atins
po / pr la 1 h (excepţie: metadona- 3h)
SC, IM la 30 min IV la 10–15 min
A nu se folosi opioizi cu eliberare lenta
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Ce cale de administrare?
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La ce trebuie sa fim atenti?
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Tipul de durere
Efecte secundare
Functia renala
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Tipul de durere
Opoid responsiva Nociceptiva viscerala
Opioid semiresponsiva Nociceptiva somatica Neuropatica
Opoid rezistenta Crampa musculara
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Aspectele psiho-emotionale, sociale si spirituale interfereaza cu modul in care este perceputa durerea si exprimata durerea si trebuie abordate pentru un control adecvat al acesteia.
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Efecte secundare
Trebuie monitorizate si combatute
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Functia renala
90%–95% eliminate prin urina Deshidratare, blocaj renal , blocaj
hepatic sever se creste intervalul dintre doze, doza
daca apare oliguria or anuria OPRITI dozajul de rutina al morfinei FOLOSITI numai prn
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Caz clinic 1 Pacienta CM 43 ani, casatorita, 6 copii cu
varste intre 9 si 26 ani, pensionata de boala Dg Neo col uterin st IIIA iradiat. Invazie de
sacru Simptomatologie:
Dureri pelvine si sacrate VAS 7/10, permanente, accentuate nocturn si la mobilizare, nu cedeaza la diclofenac 150/mg zi, caracter de arsura, presiune
Insomnie
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Ce medicament sugerati pt durere? De ce?
Cum il administram/titram? La ce trebuie sa fim atenti?
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Caz clinic 2G I barbat, 63 ani, vaduv, locuieste cu baiatul,
nora si cei 2 nepotiDg. Cancer de prostata cu metastaze osoase
multiple, Orhiectomie, Hormonoterapie cu flutamida
Pentru durere are in tratament paracetamol cu codeina(500/30) doua tablete la 6 ore si bisacodyl 10mg seara. Ocazional ia Ibuprofen dar l-a oprit din cauza pirozisuluidesi pentru durere era eficient.
Actual acuza dureri 8 /10 VAS, este constipat ultimul scaun l-a avut in urma cu4 zile.
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Ce medicament sugerati pt durere? De ce?
Cum il administram/titram? La ce trebuie sa fim atenti?
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Caz clinic 3 D.R. barbat 54 ani, fost fumator si
potator, casatorit, locuieste cu sotia
Dg: Neo esofagian stenozant, RT Durerile au fost bine controlate cu
Tramadol 400mg/zi sc, dar acum are durere permanenta 6/10 VAS, inghite cu dificultate chiar si supele pasate, este constipat
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Ce medicament sugerati pt durere? De ce?
Cum il administram/titram? La ce trebuie sa fim atenti?
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Concluzii Scara de anagelzie OMS prevede
terapia in trei trepte a durerii in functie de intensitatea durerii
Treapta I se poate combina cu II sau trei dar treapta II si III nu se pot combina
Medicamentele opioide de pe treapta III nu au doza maxima
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Continuare Se titreaza de obicei utilizand
medicamente cu eliberare imediata Doza se creste cu 30-50-100% Pentru puseele dureroase se adm 1/6
din doza zilnica Doza e cel mai sensibil influentata de
varsta, functia renala Nu toate durerile raspund complet la
terapia cu opiode si necesita co-analgezice