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1.
Isr Med Assoc J ; 21(11): 710-715, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31713356

RESUMO

BACKGROUND: The policies and practices related to medical cannabis are currently in flux. These changes have been associated with many controversies, and there is a lack of consensus within the medical community regarding medical cannabis practices. OBJECTIVES: To validate clinical vignettes that can be used to examine and improve medical cannabis practices. METHODS: Ten physicians participated in a Delphi survey of two consequent rounds in which they quantified the eligibility of medical cannabis therapy for six clinical vignettes describing both chronic pain and cancer patients. RESULTS: Higher consensus was achieved for the vignettes of cancer patients, which were additionally rated as more eligible for medical cannabis therapy. The highest level of consent (4.3 out of 5) was achieved regarding a vignette of a metastatic cancer patient. While in some cases physicians consolidated their ratings toward the group's average, in other cases they remained stable in their responses. CONCLUSIONS: While controversies related to medical cannabis are expected to remain rampant, the validated vignettes may facilitate assessment of clinical practices, which is essential for a successful implementation of medical cannabis policies. These vignettes may additionally be used in medical training for appropriate patient selection for medical cannabis authorization.


Assuntos
Dor do Câncer/tratamento farmacológico , Dor Crônica/tratamento farmacológico , Tomada de Decisão Clínica , Maconha Medicinal , Neoplasias/tratamento farmacológico , Técnica Delfos , Humanos , Israel
2.
Nihon Yakurigaku Zasshi ; 154(5): 259-264, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-31735755

RESUMO

Chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS) is commonly diagnosed in men younger than 50 years old. It is characterized by pelvic pain, voiding symptoms and sexual dysfunction. The considerable discomfort or pain experienced has a negative impact on the quality of life of patients and is a huge economic burden because of the high recurrence rate and the low cure rate. Appropriate animal models are essential for the development of new drugs for the treatment of CP/CPPS, and several rodent models induced by different methods and over different time frames have been established. This article reviews studies of three in vivo rodent models of prostatitis, namely, chemical-induced, autoimmune-induced and hormone-associated models reported by us and other investigators. Recent clinical investigation has suggested that tadalafil improves the International Prostatic Symptom Score and the total National Institutes of Health Chronic Prostatitis Symptom Index score of patients with benign prostatic hyperplasia with CP/CPPS, which enables us to investigate the effect of tadalafil on the pelvic-pain-related behavior and prostatic inflammation in two of these prostatitis model types, experimental autoimmune prostatitis (EAP) and hormone/castration-induced prostatitis (HCP). Both models showed the pelvic-pain-related behavior and prostatic inflammation that are characteristic of chronic prostatitis. In EAP, tadalafil suppressed both the pelvic-pain-related behavior and the prostatic inflammation. In HCP, tadalafil suppressed the pelvic-pain-related behavior. These results mimic the clinical findings. Therefore EAP and HCP are suitable for the evaluation of the potency of drugs for the treatment of CP/CPPS.


Assuntos
Dor Crônica/tratamento farmacológico , Dor Pélvica/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Prostatite/complicações , Tadalafila/uso terapêutico , Animais , Modelos Animais de Doenças , Humanos , Masculino , Roedores
4.
Medicine (Baltimore) ; 98(43): e17647, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31651885

RESUMO

BACKGROUND: Opioids are frequently prescribed for the management of patients with chronic non-cancer pain (CNCP). Previous meta-analyses of efficacy and harms have combined treatment effects across all opioids; however, specific opioids, pharmacokinetic properties (ie, long acting vs short acting), or the type of formulation (ie, immediate vs extended release) may be a source of heterogeneity for pooled effects. METHODS: We will conduct a network meta-analysis (NMA) of randomized controlled trials evaluating opioids for CNCP. We will acquire eligible studies through systematic searches of EMBASE, MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Registry of Controlled Trials (CENTRAL). Eligible studies will have randomly allocated adult CNCP patients to an oral or transdermal opioid versus another type of opioid (or formulation) or placebo, and follow patients for ≥ 4 weeks. We will collect outcome data for pain intensity, physical function, nausea, vomiting, and constipation. Pairs of reviewers will, independently and in duplicate, abstract data from eligible trials and assess risk of bias using a modified Cochrane tool. We will assess coherence of our networks through both a global test, and by comparing direct and indirect evidence for each comparison with node-splitting. RESULTS: Using a frequentist approach, we will conduct random effects multiple treatment meta-analysis to establish treatment effects of individual opioids for each outcome. The certainty of evidence for pooled treatment effects will be assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. We will categorize interventions from most to least effective based on the effect estimates obtained from NMAs and their associated certainty of evidence, as follows: superior to both placebo and alternatives; superior to placebo, but inferior to alternatives; and no better than placebo. CONCLUSION: This NMA will determine the relative effectiveness and adverse effects of individual opioids among patients with CNCP. Our results will help inform the appropriateness of assuming similar beneficial and adverse effects of varying opioid formulations. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered with Prospective Register of Systematic Reviews, an international prospective register of systematic reviews (registration no.: CRD42018110331), available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=110331.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Preparações de Ação Retardada , Humanos , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
5.
J Opioid Manag ; 15(4): 285-293, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637681

RESUMO

OBJECTIVE: To compare dependence characteristics between patients with chronic pain treated within an addiction medicine setting with those attending specialist pain clinics. SETTING AND PATIENTS: Forty patients with chronic non-cancer pain taking opioid analgesics for >1 year were recruited from university-affiliated, tertiary teaching hospital clinics; 20 from an addiction medicine clinic (addiction clinic group) and 20 from specialist pain clinics (pain clinic group). DESIGN AND MAIN OUTCOME MEASURES: Data regarding demographics, past and current substance use, pain history and current daily opioid intake were collected. Patients completed three questionnaires: the Severity of Opioid Dependence Questionnaire, Leeds Dependence Questionnaire, and Pain Disability Index. A novel "Opioid Problem Checklist score" assessing drug-related problems was also determined for each patient. RESULTS: The addiction clinic group were younger, more likely to have experienced drug overdose and had a shorter duration of chronic pain. No significant differences in dependence questionnaire scores were found between groups. However, higher Pain Disability Index scores and higher Opioid Problem Checklist scores (indicating more drug-related problems) were found for the addiction clinic group. CONCLUSIONS: Some degree of dependence was present across both addiction and pain clinic groups, supporting the notion a state of dependence can be identified among chronic pain patients taking opioids long term. Aberrant behaviors were not common in the pain clinic sample, suggesting these patients are unlikely to meet Diagnostic and Statistical Manual of Mental Disorders-V criteria for Substance Use Disorder. However, opioid dependence carries significant risks for relapse, chronicity, morbidity and mortality, warranting specific medical management. Management of such risks should be considered routine care in chronic pain patients taking opioids long term.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Comportamento Aditivo , Dor Crônica , Transtornos Relacionados ao Uso de Opioides , Dor Crônica/tratamento farmacológico , Humanos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Clínicas de Dor , Avaliação de Sintomas
6.
BMJ ; 367: l5654, 2019 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619437

RESUMO

OBJECTIVE: To assess the efficacy of three months of antibiotic treatment compared with placebo in patients with chronic low back pain, previous disc herniation, and vertebral endplate changes (Modic changes). DESIGN: Double blind, parallel group, placebo controlled, multicentre trial. SETTING: Hospital outpatient clinics at six hospitals in Norway. PARTICIPANTS: 180 patients with chronic low back pain, previous disc herniation, and type 1 (n=118) or type 2 (n=62) Modic changes enrolled from June 2015 to September 2017. INTERVENTIONS: Patients were randomised to three months of oral treatment with either 750 mg amoxicillin or placebo three times daily. The allocation sequence was concealed by using a computer generated number on the prescription. MAIN OUTCOME MEASURES: The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (range 0-24) at one year follow-up in the intention to treat population. The minimal clinically important between group difference in mean RMDQ score was predefined as 4. RESULTS: In the primary analysis of the total cohort at one year, the difference in the mean RMDQ score between the amoxicillin group and the placebo group was -1.6 (95% confidence interval -3.1 to 0.0, P=0.04). In the secondary analysis, the difference in the mean RMDQ score between the groups was -2.3 (-4.2 to-0.4, P=0.02) for patients with type 1 Modic changes and -0.1 (-2.7 to 2.6, P=0.95) for patients with type 2 Modic changes. Fifty patients (56%) in the amoxicillin group experienced at least one drug related adverse event compared with 31 (34%) in the placebo group. CONCLUSIONS: In this study on patients with chronic low back pain and Modic changes at the level of a previous disc herniation, three months of treatment with amoxicillin did not provide a clinically important benefit compared with placebo. Secondary analyses and sensitivity analyses supported this finding. Therefore, our results do not support the use of antibiotic treatment for chronic low back pain and Modic changes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02323412.


Assuntos
Amoxicilina , Degeneração do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/complicações , Dor Lombar , Vértebras Lombares , Adulto , Amoxicilina/administração & dosagem , Amoxicilina/efeitos adversos , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Dor Crônica/diagnóstico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Avaliação da Deficiência , Método Duplo-Cego , Feminino , Humanos , Dor Lombar/diagnóstico , Dor Lombar/tratamento farmacológico , Dor Lombar/etiologia , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/patologia , Masculino , Pessoa de Meia-Idade , Noruega , Medição da Dor/métodos , Resultado do Tratamento
8.
Schmerz ; 33(5): 466-470, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31478143

RESUMO

Since the adoption of the law of March 6, 2017, any German physician can prescribe medical cannabis flowers and cannabis-based magistral and finished medicinal products. No specific indications for prescriptions are provided in the law. The statutory health insurance companies bear the costs once an application for cost coverage has been approved by the Medical Service of the Health Funds. The German associations of psychiatry (child, adolescents, and adults), neurology, palliative care, addictology, and pain medicine are watching these developments in the media, politics, and medical world with concern due to: the option to prescribe cannabis flowers despite the lack of sound evidence and against the recommendations of the German Medical Association; the lack of distinction between medical cannabis flowers and cannabis-based magistral and finished medical products; the indiscriminately positive reports on the efficacy of cannabis-based medicines for chronic pain and mental disorders; the attempts by the cannabis industry to influence physicians; the increase in potential indications by leaders of medical opinion paid by manufacturers of cannabis-based medicines. The medical associations make the following appeal to journalists: To report on the medical benefits and risks of cannabis-based medicines in a balanced manner. To physicians: to prescribe cannabis-based medicines with caution; to prefer magistral and finished medicinal products over cannabis flowers. To politicians: to consider data according to the standards of evidence-based medicine when making decisions and provide financial support for medical research into cannabis-based medicines.


Assuntos
Cannabis , Dor Crônica , Seguro Saúde , Jornalismo , Maconha Medicinal , Política , Padrões de Prática Médica , Dor Crônica/tratamento farmacológico , Alemanha , Humanos , Seguro Saúde/ética , Seguro Saúde/normas , Maconha Medicinal/uso terapêutico , Médicos/ética , Médicos/normas , Padrões de Prática Médica/ética , Padrões de Prática Médica/normas
9.
Schmerz ; 33(5): 437-442, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31531729

RESUMO

BACKGROUND: On March 10th 2017, the law amending narcotic and other regulations was expanded, thereby allowing physicians, irrespective of their specialization, to prescribe cannabis-derived medicines as magistral formulas or proprietary medicinal products at the expense of the German statutory health insurance (GKV). First prescription requires approval from the respective health insurance, which in turn commissions the Medical Advisory Board of the Statutory Health Insurance Funds (MDK) to prepare a medico-legal report. OBJECTIVES: Since § 31 Para. 6 of the German Social Code, Book V (SGB V) came into effect, a multitude of imponderables have been reported regarding reimbursement. Based on the experience of the MDK Nord, problems within the fields of patients, physicians and cannabis-derived medicines are illustrated. MATERIAL AND METHODS: Considering current literature, a retrospective review was conducted including approximately 2200 applications for reimbursement received in 2018 from patients residing in Hamburg and Schleswig-Holstein. RESULTS: A relevant problem within the field of patients resulted from the lack of a specific definition of the term "severe (chronic) disease". Although this term is mentioned several times in SGB V, it is not put into concrete terms. Circumstances like multimorbidity are not taken into account. Another problem consisted in an irreproducible anticipation of treatment with cannabis-derived medicines. Within the field of physicians, a major problem was caused by missing, fragmentary or inconsistent information regarding disease and/or therapy. Hence, initially, almost one-third of all applications could not be appraised. Amongst various cannabis-derived medicines, dried flowers were found to be the most problematic regarding doses and effective levels. Notably, a marked increase in numbers of applications for reimbursement of therapy with pure cannabidiol was noted. DISCUSSION: Numerous problems reported elsewhere and relating to prescription of cannabis-derived medicines were also observed by the MDK Nord. Many prescriptions reflected an uncertainty regarding therapeutic use of cannabis-derived medicines. Thus, one should consider restricting the prescription of cannabis-derived medicines to selected specialists. It should be noted that, in individual cases, e.g., patients suffering from neuropathic pain, treatment with cannabis-derived medicines seems to be a reasonable therapeutic option taking into account the risks and benefits.


Assuntos
Cannabis , Dor Crônica , Administração Financeira , Reembolso de Seguro de Saúde , Dor Crônica/tratamento farmacológico , Administração Financeira/normas , Administração Financeira/estatística & dados numéricos , Alemanha , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Maconha Medicinal/economia , Maconha Medicinal/uso terapêutico , Estudos Retrospectivos
10.
Schmerz ; 33(5): 449-465, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31541311

RESUMO

Since March 2017, the prescription of medical cannabis at the expense of the statutory health insurance is possible after approval by the respective medical services. Chronic pain is the most common indication, as health claims data and the accompanying survey show. From the point of view of the law, a prescription is indicated in cases of serious illness, missing or not indicated established therapeutic approaches and a not entirely remote prospect of improvement of the illness or its symptoms. This describes a broader indication spectrum than can currently be based on randomised controlled clinical trials. There is weak evidence of low efficacy for neuropathic pain. For pain related to spasticity and cancer-related pain there is evidence of improvements in quality of life, but effects on pain are of little relevance. For all other indications, only an individual therapeutic trial can be justified based on the available external evidence. However, this usually corresponds to the demand of "a not entirely remote prospect" of a noticeably positive effect of medical cannabis. It is also problematic that almost no long-term studies for the application and efficacy of flowers and extracts are available.Current knowledge on the use of cannabis-based drugs and, more clearly, medical cannabis for chronic pain is insufficient. The increase in the number of countries with marketing authorisations or exemptions for medicinal cannabis or cannabis-based drugs for chronic pain will also pave the way for larger empirical and population-based studies that will further improve the evidence base of research and clinical use.


Assuntos
Cannabis , Maconha Medicinal , Dor , Analgésicos/uso terapêutico , Cannabis/química , Dor Crônica/tratamento farmacológico , Humanos , Maconha Medicinal/normas , Maconha Medicinal/uso terapêutico , Dor/tratamento farmacológico , Qualidade de Vida
11.
Br J Anaesth ; 123(5): 655-663, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31558315

RESUMO

BACKGROUND: The Korean National Health Insurance Service (NHIS) was developed to provide population data for medical research. The aim of this study was to estimate trends in prescription opioid use in South Korea, and to determine the association between chronic opioid use and 5-yr mortality in cancer and non-cancer patients. METHODS: A population-based cohort study was conducted amongst the South Korean adult population using data from the NHIS. Those prescribed a continuous supply of opioids for ≥90 days were defined as chronic opioid users. Multivariable Cox regression analysis was used to assess the association between chronic opioid use and 5-yr mortality. RESULTS: The proportion of chronic weak opioid users increased from 1.03% in 2002 to 9.62% in 2015. The proportion of chronic strong opioid users increased from 0.04% in 2002 to 0.24% in 2015. In the 2010 cohort (n=822 214), compared with non-users, chronic weak opioid users had a significantly lower 5-yr mortality (hazard ratio [HR]: 0.93; 95% confidence interval [CI]: 0.89-0.96; P<0.001), and chronic strong opioid users had a significantly higher 5-yr mortality (HR: 1.45; 95% CI: 1.28-1.63; P<0.001). Similar results were observed in non-cancer patients, but chronic weak opioid users were not significantly associated with 5-yr mortality in cancer patients (P=0.063). CONCLUSIONS: In South Korea, chronic opioid use has increased since 2002. Chronic strong opioid use was associated with a higher 5-yr mortality, and chronic weak opioid use was associated with a slightly lower 5-yr mortality. However, the findings regarding chronic weak opioid users should be interpreted carefully because there might be residual confounders in this study. Further study is needed to confirm these retrospective findings.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/mortalidade , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/mortalidade , Modelos de Riscos Proporcionais , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores Socioeconômicos
13.
Surg Clin North Am ; 99(5): 867-883, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31446915

RESUMO

The current opioid crisis has raised awareness of the risks of misuse, addiction, and overdose with opioid prescribing for pain management in the perioperative and nonoperative care of surgical patients. Despite these risks, it is essential for surgical providers to provide safe and adequate functional pain control to enhance recovery. The purpose of this review is to outline the relevance of the US opioid crisis to surgical prescribing, describe strategies for opioid reduction using a stepwise therapy approach, and provide recommendations for improving the safety of opioid prescribing. Additional recommendations for risk assessment and naloxone coprescribing for high-risk patients are addressed.


Assuntos
Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Humanos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Estados Unidos/epidemiologia
14.
J Opioid Manag ; 15(2): 129-135, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343714

RESUMO

OBJECTIVES: To better understand how the contextual circumstances and lifestyle of commercial fishermen influence their access to healthcare and potentially contribute to the use and misuse of opioids. METHODS: The authors conducted in-person, semistructured interviews with 15 full-time fishing captains in Rhode Island between the months of May and July of 2017. RESULTS: The authors identified five major themes: Recurrent patterns of addiction and opiate use among crewmembers; chronic pain and injury as common constructs of life in the fishing industry; insufficient pain management resources; practical barriers to obtaining primary healthcare; and perceived lack of support from state government. CONCLUSIONS: Rhode Island commercial fishing captains perceived opioid misuse among crewmembers, work-related chronic pain, and inadequate healthcare access as barriers to sustainability of their industry.


Assuntos
Analgésicos Opioides , Dor Crônica , Uso Indevido de Medicamentos sob Prescrição , Dor Crônica/tratamento farmacológico , Humanos , Saúde do Trabalhador , Percepção , Atenção Primária à Saúde , Rhode Island
15.
J Opioid Manag ; 15(2): 137-146, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343715

RESUMO

OBJECTIVE: Existing studies indicate low levels of trust and shared decision making exist in the process of prescribing opioids for noncancer pain. Patient-provider communication has not been compared between patients receiving non-opioid pain medication, and those receiving opioids. This pilot study evaluated communication about pain management between patients with noncancer pain and their provider. DESIGN: Patient encounters with a primary care provider (PCP) were audio-recorded, followed by a short patient questionnaire to measure physician trust, depression, and anxiety. SETTING: Data were collected (October 2016-May 2017) at a primary care clinic in Saint Louis, MO. PATIENTS: Patients with noncancer chronic pain, receiving a nonsteroidal anti-inflammatory drug (NSAID) or an opioid with and without an NSAID. METHODS: Medical conversation analysis guided data interpretation of codes and themes. RESULTS: Themes were framed around stages of the routine PCP encounter (ie, opening, presenting complaint, examination, diagnosis, treatment, and closing). Themes within these stages included: managing stability (opening stage), fixation with pain (presenting complaint), changing the subject (examination stage), difficult conversations (diagnosis stage), patients chose protest or acceptance (treatment), and taking what you can get (closing). CONCLUSIONS: Much of the treatment of chronic pain, as a result of opioid prescriptions, revolves around negotiations about whether to use opioids or not. Patient education is required to disseminate realistic expectations regarding pain relief and risks of long-term opioid use. This may reduce patients' focus on pain severity and difficult conversations and increase shared decision making.


Assuntos
Analgésicos Opioides , Dor Crônica , Manejo da Dor , Relações Médico-Paciente , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Humanos , Projetos Piloto , Atenção Primária à Saúde
16.
J Opioid Manag ; 15(2): 147-158, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343716

RESUMO

Transdermal buprenorphine (TDB) has demonstrated effectiveness in treating a range of chronic pain conditions, including cancer pain, nociceptive pain, and neuropathic pain and has a favorable safety profile. Worldwide, clinical experience of its use is relatively limited. There is considerable misunderstanding about the pharmacology, mechanism of action, and safety of buprenorphine. There is also limited guidance on the appropriate use of TDB for chronic pain management. This article presents an overview of TDB and also provides practical recommendations for its use as part of a multifaceted strategy in chronic cancer and non-cancer pain.


Assuntos
Analgésicos Opioides/administração & dosagem , Buprenorfina/administração & dosagem , Dor Crônica , Neoplasias/complicações , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Humanos , Manejo da Dor , Medição da Dor , Adesivo Transdérmico
17.
Br J Anaesth ; 123(3): 335-349, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31303268

RESUMO

Systemic administration of the local anaesthetic lidocaine is antinociceptive in both acute and chronic pain states, especially in acute postoperative and chronic neuropathic pain. These effects cannot be explained by its voltage-gated sodium channel blocking properties alone, but the responsible mechanisms are still elusive. This narrative review focuses on available experimental evidence of the molecular mechanisms by which systemic lidocaine exerts its clinically documented analgesic effects. These include effects on the peripheral nervous system and CNS, where lidocaine acts via silencing ectopic discharges, suppression of inflammatory processes, and modulation of inhibitory and excitatory neurotransmission. We highlight promising objectives for future research to further unravel these antinociceptive mechanisms, which subsequently may facilitate the development of new analgesic strategies and therapies for acute and chronic pain.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/farmacologia , Anestésicos Locais/farmacologia , Dor Crônica/tratamento farmacológico , Lidocaína/farmacologia , Terapia de Alvo Molecular/métodos , Dor Aguda/metabolismo , Analgésicos/uso terapêutico , Anestésicos Locais/uso terapêutico , Anti-Inflamatórios não Esteroides/farmacologia , Anti-Inflamatórios não Esteroides/uso terapêutico , Dor Crônica/metabolismo , Humanos , Canais Iônicos/efeitos dos fármacos , Lidocaína/uso terapêutico , Transmissão Sináptica/efeitos dos fármacos
18.
Drugs ; 79(11): 1241-1247, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31267482

RESUMO

Naldemedine [Symproic® (Japan; USA); Rizmoic® (EU)], an orally available peripherally acting µ-opioid receptor antagonist (PAMORA), is approved in several countries for the treatment of opioid-induced constipation. In phase III trials, naldemedine was more effective than placebo at increasing the frequency of bowel movements in patients with constipation induced by opioid treatment for cancer pain or chronic non-cancer pain. Naldemedine was also associated with improvements in patient-rated constipation-related symptoms and quality of life. Naldemedine was generally well tolerated, including over the longer term. Because naldemedine specifically targets opioid receptors in the gastrointestinal (GI) tract and does not cross the blood-brain barrier, it does not cause opioid withdrawal symptoms or interfere with centrally mediated opioid analgesia. Consistent with its mechanism of action, the most commonly reported adverse events were GI in nature. In conclusion, current data indicate that naldemedine is an effective and generally well-tolerated treatment option for opioid-induced constipation in patients with cancer pain or chronic non-cancer pain, with the convenience of once-daily oral dosing.


Assuntos
Analgésicos Opioides/efeitos adversos , Constipação Intestinal/tratamento farmacológico , Naltrexona/análogos & derivados , Antagonistas de Entorpecentes/uso terapêutico , Dor do Câncer/tratamento farmacológico , Dor Crônica/tratamento farmacológico , Ensaios Clínicos Fase III como Assunto , Constipação Intestinal/induzido quimicamente , Humanos , Naltrexona/uso terapêutico , Qualidade de Vida
20.
Br J Anaesth ; 123(2): e333-e342, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153631

RESUMO

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.


Assuntos
Buprenorfina/administração & dosagem , Dor Crônica/tratamento farmacológico , Técnica Delfos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Assistência Perioperatória/métodos , Guias de Prática Clínica como Assunto , Analgésicos Opioides/administração & dosagem , Humanos , Manejo da Dor/métodos
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