Update on guidelines for the treatment of chronic musculoskeletal pain
Update on guidelines for the treatment of chronic musculoskeletal pain
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DOI：
10.1007/s10067-006-0203-8
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发表时间：
2006-01-01
影响因子：
3.4
通讯作者：
Schnitzer, Thomas J.
中科院分区：
文献类型：
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作者：
Schnitzer, Thomas J.
慢性肌肉骨骼疼痛是当今人口老龄化的主要负担，而且日益严重。美国风湿病学会（ACR）、美国疼痛学会（APS）和欧洲抗风湿病联盟（EULAR）等专业组织在过去5年中相继发布了治疗指南，帮助临床医生实现有效的疼痛管理。安全性是所有这些指南的核心关注点，特别是对于需要长期治疗的骨关节炎等慢性疾病。因此，人们一致认为扑热息痛应该成为一线镇痛药，因为它具有良好的副作用和安全性，尽管它在缓解疼痛方面不如抗炎药有效。环加氧酶-2 (COX-2) 选择性抗炎药的开发目标是有效缓解疼痛，且不会产生与传统非选择性非甾体抗炎药 (NSAID) 相关的严重胃肠道 (GI) 副作用。临床试验证据支持这些益处，COX-2 抑制剂在临床实践和官方指南中得到了广泛采用。最近，越来越多的数据表明 COX-2 抑制剂会产生严重的心血管和/或心肾效应和/或严重的皮肤不良反应 (SCAR)，特别是在抗炎剂量或长期使用时。欧洲和美国的监管机构对这些数据做出了回应，撤回了罗非考昔和伐地考昔，并加强了对所有抗炎药物的处方建议。对于心血管和/或心肾风险增加的患者，例如充血性心力衰竭、高血压等患者，现在应更加谨慎地使用 COX-2 抑制剂和非选择性 NSAID。监管建议和良好的临床实践是以最低有效剂量和尽可能短的时间使用抗炎药物。目前还没有更新的官方指南包含这些新数据和监管建议。国际多学科小组，即疼痛管理工作组，提出了治疗中度至重度肌肉骨骼疼痛的新建议。这些指南是针对 COX-2 抑制剂和其他 NSAID 的最新发展而制定的，重点关注扑热息痛作为慢性疼痛管理的基准药物；当需要更强的镇痛效果时，与非甾体抗炎药相比，基于更好的胃肠道和心血管特征，建议添加弱阿片类药物。
Chronic musculoskeletal pain is a major-and growing-burden on today's ageing populations. Professional organisations including the American College of Rheumatology (ACR), American Pain Society (APS) and European League Against Rheumatism (EULAR) have published treatment guidelines within the past 5 years to assist clinicians achieve effective pain management. Safety is a core concern in all these guidelines, especially for chronic conditions such as osteoarthritis that require long-term treatment. Hence, there is a consensus among recommendations that paracetamol should be the first-line analgesic agent due to its favourable side effect and safety profile, despite being somewhat less effective in pain relief than anti-inflammatory drugs. Cyclooxygenase-2 (COX-2)-selective anti-inflammatory drugs were developed with the goal of delivering effective pain relief without the serious gastrointestinal (GI) side effects linked with traditional non-selective non-steroidal anti-inflammatory drugs (NSAIDs). Clinical trial evidence supported these benefits, and COX-2 inhibitors were widely adopted, both in clinical practice and in official guidelines. Recently, accumulating data have linked COX-2 inhibitors with serious cardiovascular and/or cardiorenal effects and/or serious cutaneous adverse reactions (SCARs), particularly at anti-inflammatory doses or when used long term. Regulatory authorities in both Europe and the USA have responded to these data with the withdrawal of rofecoxib and valdecoxib, and the strengthening of prescribing advice on all anti-inflammatory drugs. COX-2 inhibitors and non-selective NSAIDs should now be used with increased caution in patients at increased cardiovascular and/or cardiorenal risk, e.g., patients with congestive heart failure, hypertension, etc. Regulatory advice and good clinical practice are to use anti-inflammatory drugs at the lowest effective dose and for the shortest possible time. There are as yet no updated official guidelines that incorporate these new data and regulatory advice. An international multidisciplinary panel, the Working Group on Pain Management, has generated new recommendations for the treatment of moderate-to-severe musculoskeletal pain. These guidelines, formulated in response to recent developments concerning COX-2 inhibitors and other NSAIDs, focus on paracetamol as the baseline drug for chronic pain management; when greater analgesia is desired, the addition of weak opioids is recommended based on a preferable GI and cardiovascular profile, compared with non-steroidal anti-inflammatory drugs.