medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2020-20-118-122medsovet-5945Research ArticleПОДДЕРЖИВАЮЩАЯ ТЕРАПИЯ В ОНКОЛОГИИSUPPORTIVE THERAPY IN ONCOLOGYРациональный подход к снижению дозы опиоидов при терапии костной боли. Клинический разборA rational approach to opioid dose reduction in the treatment of bone pain. Clinical discussionhttps://orcid.org/0000-0002-5042-830XРозенградС. А.RozengardS. A.

Розенгард Сергей Аркадьевич, кандидат медицинских наук, заведующий отделением анестезиологии и реанимации

197758, Россия, Санкт-Петербург, пос. Песочный, ул. Ленинградская, д. 68

Sergey A. Rozengard, Cand. of Sci. (Med.), Head of Anaesthesiology and Reanimation Department

68, Leningradskaya St., Pesochnyy Settlement, St Petersburg, 197758, Russia

rozengard.s@mail.ruhttps://orcid.org/0000-0001-7195-6307РязанкинаА. А.RyazankinaA. A.

Рязанкина Алла Алексеевна, врач анестезиолог-реаниматолог, отделение анестезиологии и реанимации

197758, Россия, Санкт-Петербург, пос. Песочный, ул. Ленинградская, д. 68

Alla A. Ryazankina, Anesthesiologist-Reanimatologist, Anaesthesiology and Reanimation Department

68, Leningradskaya St., Pesochnyy Settlement, St Petersburg, 197758, Russia

alla-rjazankina@mail.ruhttps://orcid.org/0000-0002-8906-0370ЛатиповаД. Х.LatipovaD. Kh.

Латипова Дилором Хамидовна, кандидат медицинских наук, врач-онколог отделения химиотерапии

197758, Россия, Санкт-Петербург, пос. Песочный, ул. Ленинградская, д. 68

Dilorom Kh. Latipova, Cand. of Sci. (Med.), Oncologist, Chemotherapy Department

68, Leningradskaya St., Pesochnyy Settlement, St Petersburg, 197758, Russia

dilat77@mail.ruhttps://orcid.org/0000-0003-3619-0750МалыгинА. Ю.MalyginA. Yu.

Малыгин Артур Юрьевич, ординатор отделения химиотерапии

197758, Россия, Санкт-Петербург, пос. Песочный, ул. Ленинградская, д. 68

Artur Yu.  Malygin,  Resident  Medical  Practitioner, Chemotherapy Department

68, Leningradskaya St., Pesochnyy Settlement, St Petersburg, 197758, Russia

arturmalygin197@gmail.comhttps://orcid.org/0000-0003-0341-3823КаспаровБ. С.KasparovB. S.

Каспаров Борис Сергеевич, кандидат медицинских наук, врач-онколог, заместитель главного врача по амбулаторной помощи, заведующий клинико-диагностическим отделением

197758, Россия, Санкт-Петербург, пос. Песочный, ул. Ленинградская, д. 68

Boris S. Kasparov, Cand. of Sci. (Med.), Oncologist, Deputy Chief Medical Officer for Outpatient Care, Head of Clinical Diagnostic Department � Practitioner, Chemotherapy Department

68, Leningradskaya St., Pesochnyy Settlement, St Petersburg, 197758, Russia

dr.boriskasparov@gmail.comНациональный медицинский исследовательский центр онкологии им. Н.Н. ПетроваРоссияPetrov National Medical Cancer Research CentreRussian Federation202020122020020118122Copyright © Розенград С.А., Рязанкина А.А., Латипова Д.Х., Малыгин А.Ю., Каспаров Б.С., 20202020Розенград С.А., Рязанкина А.А., Латипова Д.Х., Малыгин А.Ю., Каспаров Б.С.Rozengard S.A., Ryazankina A.A., Latipova D.K., Malygin A.Y., Kasparov B.S.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/5945

На сегодняшний день упростилась выписка наркотических препаратов, но стало очевидно, что монотерапия болевого синдрома наркотическими препаратами не всегда эффективна. Пациенты самостоятельно прибегают к замене опиоидов на НПВС, мотивируя этот выбор лучшей эффективностью даже при угрозе осложнений. В представленном случае у пациента сохранялся болевой синдром 2-й степени, связанный с поражением костной ткани, несмотря на максимальную суточную дозу трамадола, с осложнениями в виде тошноты. Необходимость изменить лечебную схему привела к успешной комбинации трамадола и декскетопрофена, причем доза каждого препарата была средней. Мы рассматриваем комбинацию наркотических препаратов и НПВС (декскетопрофена) как опиоид-сберегающую и полагаем, что эффект декскетопрофена при костных болях связан с его влиянием на нейропатический и центральный компонент болевого синдрома. Нами разобраны основные механизмы и варианты системной фармакотерапии болевого синдрома при костных метастазах. Известно, что некоторые НПВС обладают центральными эффектами. Например, анальгетический эффект кеторолака после травмы седалищного нерва объясняется его способностью угнетать синтез алгогенных пептидов в задних рогах спинного мозга и снижением активации астроцитов. Однако именно комбинация декскетопрофена и трамадола в мире признана наиболее эффективной.

Narcotic drugs have become more available for use, but it is obvious that monotherapy of pain syndrome with narcotic drugs is not always effective. Patients sometimes change prescribed opiates to NSAIDs on their own, because it is more effective despite the high risk of complications. In this case patient has a grade 2 pain syndrome associated with bone metastases despite taking the maximum daily dose of tramadol complicated by nausea. Treatment was successfully changed with medium doses of tramadol and dexketoprophen. We consider the combination of narcotic drugs and NSAIDs as opiate-sparing and suggest that dexketoprophen is effective for treatment of pain associated with bone metastases because of the effect on neuropathiс and central components of pain syndrome. We have analyzed the main mechanisms and options for systemic pharmacotherapy of pain syndrome in bone metastases. Some NSAIDs are known to have central analgesic effects. For example, the analgesic effect of ketorolac after an injury of sciatic nerve is explained by its ability to inhibit the synthesis of algogenic peptides in the posterior horns of the spinal cord and the decrease in astrocyte activation. However, it is the dexketoprofen/tramadol combination that is recognized as the most effective in the world.

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The authors declare that there are no conflicts of interest present.