管理类风湿关节炎疼痛的方法

2022-06-30 网络 网络

类风湿关节炎(RA)以对称性双手、腕、足等多关节肿痛为首发表现,常伴有乏力、低热、肌肉酸痛、体重下降等全身症状。其中疼痛是类风湿关节炎最为主要的症状,即便对炎症性疾病进行了最佳控制,但疼痛仍然会持续出

类风湿关节炎(RA)以对称性双手、腕、足等多关节肿痛为首发表现,常伴有乏力、低热、肌肉酸痛、体重下降等全身症状。其中疼痛是类风湿关节炎最为主要的症状,即便对炎症性疾病进行了最佳控制,但疼痛仍然会持续出现。类风湿关节炎的疼痛是由多种机制引起的,涉及炎症、周围和中枢神经的反应,以及随着疾病的进展而引起关节结构的改变。

类风湿关节炎疼痛会严重影响患者的生活质量,引起睡眠障碍、抑郁、焦虑等,甚至会导致消化系统功能紊乱进一步加重疾病。因此,临床上需要重视对类风湿关节炎的管理。

类风湿关节炎疼痛的治疗方式主要有非药物治疗、药物治疗、介入治疗和手术治疗。

非药物治疗

主要是通过心理干预、自我调节措施(如针灸、瑜伽、生物反馈疗法)等缓解疼痛。

药物治疗

非甾体类抗炎药(NSAIDs):

NSAIDs是目前临床证据最充分、最常用的镇痛药物,也是RA患者疼痛治疗的首选药物。常用的NSAIDs有对乙酰氨基酚、吲哚美辛、萘普生、布洛芬、双氯芬酸钠、氟比洛芬酯、酮咯酸、洛索洛芬钠或以上药物的复合制剂。或是使用选择性COX-2抑制剂,包括塞来昔布、艾瑞昔布等。

外用NSAIDs和静脉注射制剂使用方便,是目前临床应用较多的镇痛药物之一。长期使用NSAIDs应注意可能会增加胃肠道溃疡、出血、心血管不良事件等风险;存在胃肠道溃疡病史、凝血障碍及肾衰竭的患者应慎用。如需要长期服药,可以同时辅以胃黏膜保护剂及质子泵抑制剂。

阿片类镇痛药物:

阿片类药物主要适用于使用NSAIDs等疗效较差,或无法耐受NSAIDs产生的消化道、心血管等不良反应的中、重度慢性疼痛患者。常见药物包括强阿片类药物,如吗啡、羟考酮、芬太尼、丁丙诺啡等,弱阿片类药物,如可待因、曲马多等。

阿片类药物给药途径多样,可以口服、针剂和贴剂(如丁丙诺啡透皮贴、芬太尼透皮贴等)。不良反应包括恶心、呕吐、嗜睡、呼吸抑制、便秘等,长期使用可能导致成瘾。老年患者应用阿片类药物时要注意应用最低有效剂量,尽量选用缓释剂型或透皮贴剂。

抗惊厥与抗抑郁药物:

抗惊厥药物主要应用于治疗慢性神经病理性疼痛和纤维肌痛,特别对于烧灼样、撕裂样和麻木样疼痛的神经病理性疼痛。临床常用药物有普瑞巴林、卡马西平、加巴喷丁、托吡酯、唑尼沙胺、拉莫三嗪、奥卡西平、左乙拉西坦等。

介入治疗

如果患者出现了神经根性疼痛,可考虑介入治疗,包括骶髂关节内注射、内侧支阻滞术和射频消融术等。

手术治疗

对RA患者可进行关节镜下滑膜切除术减缓疾病进展及慢性疼痛。手术时机为关节疼痛、没有明显的结构破坏、药物治疗6个月以上无效的患者。而对于晚期RA患者失败率高,不建议采用。

对关节软骨和软骨下骨中到重度破坏的关节,全关节置换术可使关节疼痛消失、畸形矫正和功能改善。

总之,由于类风湿关节炎疼痛会对患者生活质量造成严重影响,因此,对于类风湿关节炎疼痛需要积极治疗,以改善患者的生活质量。

 

参考文献:

【1】葛均波主编.内科学(第9版)[M].北京.人民卫生出版社.p:807.

【2】Walsh DA, et al. Mechanisms, impact and management of pain in rheumatoid arthritis. Nat Rev Rheumatol 2014 Oct;10(10):581-92.

【3】康鹏德,黄泽宇,李庭, 等.肌肉骨骼系统慢性疼痛管理专家共识[J].中华骨与关节外科杂志,2020,13(1):8-16.

【4】类风湿关节炎的诊断与治疗骨科专家共识[J].中国医学前沿杂志,2013, (3):49-52.

【5】中华医学会风湿病学分会. 2018中国类风湿关节炎诊疗指南[J].中华内科杂志,2018,57 (4): 242-251.

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