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Durchbruchschmerzen und kurz wirksame Opioide

Breakthrough pain and short-acting opioids

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Zusammenfassung

Die bisherige Opioidtherapie besteht in der Gabe retardierter Opioide nach fixem Zeitschema und einer zusätzlich möglichen Bedarfsmedikation. Bei der Notwendigkeit einer Bedarfsmedikation unterscheiden neuere Untersuchungen die nichtausreichende Einstellung der Tagesdosierung oder des Zeitintervalls („end-of-dose failure“) von sog. Durchbruchschmerzen, deren Attacken trotz optimaler Einstellung plötzlich – ereignisabhängig („incident pain“) oder ereignisunabhängig („spontaneous pain“) – auftreten können und üblicherweise nur kurze Zeit andauern. Entsprechend dieser Zeitdynamik scheint eine schnelle und kurzzeitige Erhöhung der Opioidplasmakonzentration sinnvoll zu sein. Obwohl in einer aktuellen europäischen Umfrage die Durchbruchschmerzen der Mehrheit von Tumorpatienten mit nichtretardierten Opioiden zufriedenstellend behandelt wurden, untersucht ein Großteil momentaner klinischer Studien, ob die Anwendung transmukosal- bzw. intranasal-verabreichten Fentanyls aufgrund der verkürzten Zeit bis zur maximalen Plasmakonzentration einen möglichen Vorteil bietet. In diesen Studien zeigt sich zwar ein statistisch signifikanter Unterschied in der Schmerzlinderung und der Anzahl an Schmerzattacken im Vergleich zu nichtretardierten Opioiden, dessen Ausmaß jedoch einen klinischen Vorteil nicht erkennen lässt. Dies mag u. a. daran liegen, dass die Patienten, die möglicherweise davon profitieren könnten, bisher noch nicht eindeutig identifiziert worden sind.

Abstract

Conventional opioid therapy consists of the regular administration of extended-release opioids following fixed time intervals and, as needed, the supplemental use of an immediate-release formulation. For the patient needs of such rescue medication, recent studies distinguished different scenarios, such as an inadequate daily opioid dose or time interval (end-of-dose failure) from so-called breakthrough pain where the attacks can suddenly occur either spontaneously (idiopathic pain) or due to certain provocations (incident pain) despite optimal dose adjustment. In line with this time course, a fast and short-lasting elevation of the opioid plasma concentration seems to be reasonable. Although in a recent European survey breakthrough pain attacks in the majority of cancer pain patients were sufficiently treated with immediate-release opioids, currently running clinical trials examine whether the application of transmucosal or intranasal fentanyl with their known reduced time to maximum plasma concentrations show a possible advantage in comparison to immediate-release opioids. In these clinical trials the pain intensity and number of pain episodes were significantly reduced following transmucosal or intranasal fentanyl; however, the magnitude of these effects does not convincingly appear to be clinically relevant. Among other reasons this may be related to the fact that those patients who would perhaps benefit from such treatment have not yet been identified.

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Interessenkonflikt

Der korrespondierende Autor weist für sich und seine Koautoren auf folgende Beziehung hin: M.S. frühere Beratertätigkeit für Grünenthal, Develco.

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  1. Klinik für Anästhesiologie mit Schwerpunkt Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburgerplatz 1, 13353, Berlin, Deutschland

    T. Beutlhauser, J. Oeltjenbruns &  M. Schäfer

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  1. T. Beutlhauser
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Correspondence to M. Schäfer.

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Beutlhauser, T., Oeltjenbruns, J. & Schäfer, M. Durchbruchschmerzen und kurz wirksame Opioide. Anaesthesist 62, 431–439 (2013). https://doi.org/10.1007/s00101-013-2193-7

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