Neuropathic pain in diabetic nephropathy - update on analgesic strategies
Neuropathic pain in diabetic nephropathy - update on analgesic strategies
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DOI：
10.1093/ndt/14.10.2285
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发表时间：
1999-10-01
影响因子：
6.1
通讯作者：
Luft, D
中科院分区：
文献类型：
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作者：
Luft, D
选择适当的治疗方法治疗神经性糖尿病神经病变可能会影响生活质量，无论是在预后上还是在病理上都是重要的疼痛应考虑已证实的疗效、不良事件的数量和严重程度、毒性、与糖尿病足综合征的发展相关的药物因素以及与缩短预期寿命相关的因素。多年来代谢控制的改善已被证明可以降低糖尿病神经疾病的发生率。显然，很难在后面描述的药物中比较所有这些变量，因为1型糖尿病患者[1]和可能也有2型糖尿病患者[2，3]都有病变。在不久的将来，除了没有疗效的公分母，只有在极少数情况下不同的药物被比较强化糖尿病的治疗，代谢步骤在糖尿病神经病变发病机制中的重要作用可能是直接的。疗效的粗略估计可能是需要治疗(NNT)的患者数量，以获得特定药物的靶向，有效抑制山梨醇的积累，减少氧化应激，这是一种物质特定的有益效果在一名患者[4]。然而，阻止晚期糖基化终末产物的形成、改善神经血流、逆转药物治疗的factthatNNT’sarederivedfromstudieswithdifferent持续时间以及膜脂代谢的不同末端变化或替代神经生长因子，都阻碍了直接比较。目前，在可预见的INT中，这可能无法直接进行比较。NNT的相关性被以下事实进一步削弱：由于大多数研究中纳入的患者数量较少，似乎不可能完全消除神经病理性糖尿病病变的发展，95%的可信区间有时是因为只有一小部分患者的血糖正常。这意味着神经病的范围非常大。因此，已发现的不同物质的NNT的差异在未来几年仍将是一个临床问题。此外，糖尿病的强化治疗通常不具有统计学意义。显然，在临床实践中，所有有风险的患者对给定药物的明显反应，以及对某些神经性疾病患者的对症治疗是必要的，这比NNT所示的要好得多，因为不仅有特定的，也有非特定的影响，包括病理性疼痛。有症状的远端对称性多发性神经病的盛行率被观察到，这是主要的安慰剂效应。糖尿病患者神经性疼痛的原因，从20%到40%不等。无法用简单的止痛药治疗并因此需要专门护理的疼痛患者的比例在很大程度上是未知的。物理措施由于糖尿病的微血管并发症和大血管病变聚集在患者中，因此糖尿病患者作为治疗神经性疼痛的第一步，尤其是肾病患者特别需要应用物理措施治疗，即使对于神经性疼痛的效果也是有用的。涂抹面霜、按摩和冷暖涂抹都很难量化。针灸和经皮电神经刺激有对应和非印刷的要求：医学博士Dieter Luft在几个试验中进行了测试，尽管存在困难
The choice of an adequate treatment for neuropathic Diabetic neuropathies may impair quality of life, they are both prognostically and pathogenetically important pain should take into account proven efficacy, number and severity of adverse events, toxicity, pharmacofactors for the development of the diabetic foot syndrome and associated with a reduced life expectancy. kinetics, contraindications, limitations for treatment due to comorbid conditions, and—last not least—Improvement of metabolic control over the years has been proven to reduce the incidence of diabetic neuro-costs. Obviously, it is difficult to compare all these variables for the drugs to be described later, since there pathy in type 1 [1] and presumably also in type 2 diabetic patients [2, 3]. In the near future, besides is no common denominator for efficacy, and only in rare instances have different drugs been compared intensified diabetes treatment, metabolic steps important in the pathogenesis of diabetic neuropathy may be directly. A rough estimate of efficacy may be the number of patients needed to treat (NNT) to obtain targeted by specific drugs effectively inhibiting the accumulation of sorbitol, reducing oxidative stress, a substance specific beneficial effect in one patient [4]. Direct comparisons are, however, hampered by the stopping the formation of advanced glycation end products, improving nerve blood flow, reversing factthatNNT’sarederivedfromstudieswithdifferent durations of drug treatment and with different endpochanges in membrane lipid metabolism, or substituting nerve growth factors. At present, and in the forseeable ints which may not be directly comparable. The relevance of the NNT is further weakened by the fact that future, it seems to be impossible to completely eliminate the development of neuropathic diabetic lesions due to the small number of patients included in most studies, the 95% confidence intervals are sometimes because normoglycaemia is achieved in only a small part of all patients. This implicates that neuropathy extremely large. Consequently, the differences of NNT’s for different substances that have been found will remain a clinical problem for the years to come. Besides intensive treatment of diabetes which is indi-are frequently not statistically significant. Clearly, in clinical practice, the apparent response to a given drug cated in all patients at risk, additionally symptomatic treatment is necessary in some patients with neuro-is much better than indicated by the NNT, because not only specific but also unspecific effects including pathic pain. The prevalence of symptomatic distal symmetrical polyneuropathy, being the predominant placebo effects are observed [5]. cause of neuropathic pain in diabetic patients, ranges from 20 to 40%. The proportion of patients suffering from pain not treatable with simple analgesics and thus requiring specialized care is largely unknown. Physical measures Since diabetic micro-and macroangiopathic complications cluster in patients, it is the patient with diabetic As the first step in treating neuropathic pain it is useful nephropathy who is particularly in need of treatment to apply physical measures even though the effects of for neuropathic pain. application of creams, massage, and cold and warm applications are difficult to quantitate. Acupuncture and transcutaneous electrical neural stimulation have Correspondence and offprint requests to: Dieter Luft, MD, been tested in a few trials and despite the difficulties