CJASN 에 만성신질환 환자에서의 통증조절에 대한 내용이 나와 있어 인용합니다.
Anticonvulsants and tricyclic antidepressants are the two classes of drugs for which there is most evidence of efficacy. Systematic reviews have found that anticonvulsants and tricyclic antidepressants are effective in reducing neuropathic pain due to diabetic peripheral neuropathy and postherpetic neuralgia
(그래서 요새 amitriptyline 을 많이 사용해보고 있는데, 아직까지 드라마틱한 효과를 보지는 못했다.)
Gabapentin is structurally similar to the neurotransmitter γ-aminobutyric acid but, rather than bind to γ-aminobutyric acid receptors, its mechanism of action is thought to be through binding to calcium channels and modulating the influx of calcium. Gabapentin is almost exclusively cleared by the kidneys and substantial dose reduction is required as the GFR declines to avoid toxicity. Adverse effects include somnolence, dizziness, peripheral edema, and gait disturbances.
Evidence suggests that carbamazepine may be as effective as gabapentin for treating neuropathic pain in the general population and may have fewer adverse effects. Unlike gabapentin, it requires no dose adjustment in CKD.
(잘 몰랐던 carbamazepine 이라는 약. gabapentin 만큼 효과가 있고, CKD 에서 용량 조절이 불필요하단다.)
Tricyclic antidepressants are effective in the management of neuropathic pain but are less well tolerated than the gabapentinoids in patients with CKD because of anticholinergic, histaminergic, and adrenergic side effects resulting in symptoms such as dry mouth, orthostatic hypotension, and somnolence. Although dose reduction of tricyclic antidepressants is not necessarily required, patients with CKD will often respond to lower doses.
(TCA 또한 용량조절이 불필요하다. 부작용에 주의해야겠다.)
There are insufficient data or clinical experience with selective serotonin reuptake inhibitors and selective serotonin-norepinephrine reuptake inhibitors for neuropathic pain in CKD to make a recommendation. In the general population they tend to be less effective than anticonvulsants and tricyclic antidepressants but have fewer adverse effects.
(SSRI 는 효과가 입증이 안되었구나.)
Nonopioids should be used as initial pharmacologic management for nociceptive pain and for neuropathic pain if pain persists despite maximal tolerated dose of an adjuvant. Studies have failed to show that a weak opioid has markedly superior analgesic efficacy to acetaminophen or an NSAID.
2019. 12. 28