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Smertebehandling B. Husebø. WHO’s smertebehandlingstrapp IKKE-OPIOIDER ”SVAKE” OPIOIDER I KOMBINASJON MED I ”STERKE” OPIOIDER I KOMBINASJON MED I I II.

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Presentasjon om: "Smertebehandling B. Husebø. WHO’s smertebehandlingstrapp IKKE-OPIOIDER ”SVAKE” OPIOIDER I KOMBINASJON MED I ”STERKE” OPIOIDER I KOMBINASJON MED I I II."— Utskrift av presentasjonen:

1 Smertebehandling B. Husebø

2 WHO’s smertebehandlingstrapp IKKE-OPIOIDER ”SVAKE” OPIOIDER I KOMBINASJON MED I ”STERKE” OPIOIDER I KOMBINASJON MED I I II III + tilleggs- medikasjon! Tilleggsmedisin Antidepressiva Antiepileptika Kortison Laksansien Antiemetikum

3 Table 1 Systematic review of short - and long-term completed clinical trials in patients with dementia Analgesic drugsAcetaminophenNSAIDs AcetaminophenAcetaminophen Propoxyphene Darvocet Nonopioids OpioidsOxycodone Morphine Acetaminophen Lidocaine, localNot mentionedAcetaminophen Morphine Buprenorphine Pregabaline AuthorDouzjian MStein CMKovach CRAllen RSManfredi PLBuffum MDChibnallBenedetti FKovach CRHusebo BS Year Setting1 NH20 NHs6 NHs5 NHs1 NH3 NHS2 NHsLaboratory14 NHs18 NHs Study designObservational studyCluster randomized controlled study Observational studyCross-sectional studyRandomized, double- blind, placebo- controlled trial Randomized, double- blind, placebo- controlled, cross-over trial Placebo controlled, open/hidden paradigme Randomized, double- blind, control group trial Multicenter, cluster randomized controlled trial Daily dose1950mg acetaminonophenSubstitution of NSAIDs with 1950mg acetaminophen Not mentionedIndividual dosage20mg oxycodone or 20mg morphine 2600mg regularly scheduled (qid) or as- needed (prn) acetaminophen 3000mg acetaminophen1% solution of lidocaineNot mentionedStepwise protocol of pain treatment Trial duration24 weeks12 weeksAbout 8 weeks4 weeks8 weeks (4 weeks long- acting opioid, 4 weeks placebo) 4 weeks total (2 weeks scheduled and 2 weeks as-needed medication 8 weeks (4 weeks acetaminophen, 4 weeks placebo) One time application, repeated after one year 4 weeks8 weeks with follow-up 4 weeks after treatment Enrolment criteriaNH patients with ongoing psychotropic medication NH patients; ≥65 years; taking NSAIDs regularly; osteoarthitis NH patients with dementia unable to verbalize their needs Patients with and without speach abilities CMAI≥40, pain questionnaire with 4 questions NH patientsNH patients, FAST stage 5 or 6 AD patients vs mental unimpaired people NH patients, moderate to severe dementia, FAST 5 or 6 NH patients; ≥65 years; MMSE ≤ 20; CMAI≥39 No of subjects , about 48 received analgesics (AD n=28, control n=16) 114 (n=26 received analgesics) 352 Mean (range) age (years) > 7081 (65-101)86.7 (56-100)83.9 (61-105) (67-101)85.9 ± ± (65-104) FemaleNA80 %81 % %87 %75 % MMSENA195.5 ± (0-20)14±6 (1-29)6.0 ± 7.24 ±515.6 ± 1.9 (13-20)7.8 ±6.2 (0-20)7.5 (0-20) Primary outcomePsychotropic Summery Sheet Number of NSAIDs and acetaminophen used ADDPhiladephia Geriatric Center Pain Measure, MMSE, Charlson Comorbidity Index, Functunal Independence Measure CMAIDIS-DATDCMNRSDIS-DAT BEHAVE-AD CMAI Secondary outcomeNAVRS, NRS, MHAQ, SIP-NH, MMSE, change in GI symptoms FBP, MMSEMMSE, pain questionnaire with 4 questions MMSE, GDSCMAI, FAST, GMBH, BPRS, use of psychotropic medication MMSE, FABMOBID-2 Pain Scale, NPI-NH MMSE, ADL, FAST

4 Systematisk review om analgetisk effekt hos pasienter med demens (PubMed, EMBASE, Cochrane) 1 cross-sectional, 2 observational, 7 RCT RCT-studiene – 3 for paracetamol (Stein 2001, Buffum 2004, Chibnall 2005) – 1 for lidocain, localt (Benedetti 2006) – 1 for morfin, oxycodone (Manfredi 2003) – 1 med stepwise pain treatment (Husebø et al. 2011) – 1 ukjent medikasjon (Kovach 2006) – Ingen med NSAIDs, antiepileptika, svake opioider, plaster 2 studier i Europa Primary/secondary outcome measures? Svært varierende resultater Stort behov for ”mer”

5 Balanse mellom effekt og bivirkning II Start med det minst toksiske Paracetamol, Novalgin: regelmessig 1gx3 NSAIDs, ASA kun over kort tid Unngå: svake opioider, TCA, neuroleptika Antiepileptika: ved nevropatisk smerte Forsiktig dosejustering Opioider Ved moderat og alvorlig smerte Forsiktig dosejustering, etter hvert depotpreparat Forbigående lett sedasjon er å forvente – Evt. kombinasjon med paracetamol – Profylakse: kvalme og obstipasjon AGS Panel Persistent Pain Older Persons. JAGS 2002


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