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Analgetikakombinationen zur postoperativen Schmerztherapie

Übersicht zu Effektivität und Nebenwirkungen

Combined analgesics for postoperative pain therapy

Review of effectivity and side-effects

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Zusammenfassung

Hintergrund

Die kombinierte Gabe eines Nichtopioidanalgetikums und eines Opioidschmerzmittels ist ein allgemein akzeptiertes Verfahren zur Behandlung postoperativer Schmerzzustände. Ob auch eine Kombination verschiedener Nichtopioide einen Vorteil im Sinne einer verbesserten Analgesie und/oder einer Verringerung von opioidbedingten Nebenwirkungen bietet, ist dagegen noch offen.

Methodik

In einer systematischen Literaturrecherche wurde nach randomisierten, kontrollierten Studien gesucht, die die Auswirkungen einer Kombination von zwei Nichtopioidanalgetika hinsichtlich des postoperativen Opioidverbrauchs und der Schmerzintensität verglichen haben. Signifikante Unterschiede im postoperativen Opioidbedarf bzw. der postoperativen Schmerzen dienten als Hauptbewertungskriterium. Um die Studienresultate vergleichbar zu machen, wurde zusätzlich die prozentuale Reduktion des postoperativen Opioidbedarfs bzw. die prozentuale Reduktion postoperativer Schmerzen auf einer entsprechenden Stufenskala ermittelt.

Ergebnisse

Es konnten 25 Studien identifiziert werden; hierbei handelte es sich fast ausschließlich um die Kombination von nichtsteroidalen Antiphlogistika (NSAIDs) auf der einen und Paracetamol auf der anderen Seite. Lediglich in 3 Studien konnte eine signifikante Verbesserung der analgetischen Wirksamkeit der Kombinationstherapie gegenüber den beiden Einzelsubstanzen gezeigt werden. Demgegenüber stehen 15 Studien, deren Ergebnisse insgesamt als fraglich oder negativ eingestuft wurden. Hier fand sich entweder keine relevante Verbesserung in der Kombinationsgruppe, oder diese war nur einer der beiden Monotherapien signifikant überlegen. Sieben weitere Studien konnten aus formalen Gründen nicht bewertet werden. Eine nennenswerte Verringerung opioidtypischer Nebenwirkungen durch die Kombination von zwei Nichtopioidanalgetika konnte in keiner Studie gezeigt werden.

Schlussfolgerung

Eine Kombination von Nichtopioidanalgetika, speziell NSAIDs und Paracetamol, kann angesichts der schlecht dokumentierten Wirkverstärkung derzeit nicht empfohlen werden.

Abstract

Background

The supplementation of an opioid by a non-opioid analgesic is a widely accepted technique for the treatment of postoperative pain. However, it is still unclear whether a combination of different non-opioids has an advantage in terms of an improved analgesia and/or a reduction of the opioid-related adverse effects.

Methodology

A systematic analysis of the literature was performed searching for randomized, controlled trials studying the effects of a combination of two non-opioid analgesics in order to reduce postoperative opioid requirements and/or postoperative pain. Significant reduction of the postoperative opioid requirement and/or postoperative pain were defined as main rating criteria. To facilitate comparisons between the trials, the relative (proportional) reduction of postoperative opioid administration and the relative reduction of postoperative pain were calculated on defined pain scales.

Results

A total of 25 trials were identified, mainly studies comparing non-steroidal anti-inflammatory drugs (NSAIDs) with paracetamol. Only 3 trials found a statistically improved analgesic efficacy and 15 studies did not show any relevant improvement or the combination group was only significantly superior to one of the groups receiving monotherapy. A further seven studies could not be evaluated due to methodological issues. There was no evidence for a significant reduction of opioid-induced adverse effects.

Conclusion

A combination of non-opioid analgesics, in particular NSAIDs with paracetamol, cannot be recommended at present due to the lack of data showing improved effectiveness.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Die Durchführung der Analyse erfolgte mit Unterstützung der Firma Bristol-Myers Squibb.

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Authors and Affiliations

  1. Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Gießen-Marburg,Standort Marburg, Baldingerstraße, 35033, Marburg, Deutschland

    H. Lange, T. Steinfeldt, H. Wulf &  L.H.J. Eberhart

  2. Klinik und Poliklinik für Anästhesiologie, Universitätsklinik Würzburg, Würzburg, Deutschland

    P. Kranke

  3. Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Ulm, Ulm, Deutschland

    P. Steffen

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  1. H. Lange
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  2. P. Kranke
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  4. T. Steinfeldt
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  6. L.H.J. Eberhart
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Correspondence to L.H.J. Eberhart.

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Lange, H., Kranke, P., Steffen, P. et al. Analgetikakombinationen zur postoperativen Schmerztherapie. Anaesthesist 56, 1001–1016 (2007). https://doi.org/10.1007/s00101-007-1232-7

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  • DOI: https://doi.org/10.1007/s00101-007-1232-7

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