加巴喷丁联合阿米替林治疗阿片耐受的重度癌痛的临床回顾性研究

Clinical efficacy of gabapentin combined with amitriptyline in patients with opioid tolerance and severe cancer pain: a retrospective study

目的通过回顾性研究,评价加巴喷丁联合阿米替林治疗阿片耐受(opioid tolerance)的重度癌痛(cancer pain)的临床疗效。方法以2015年9月至2016年9月间,德阳市人民医院肿瘤科诊断明确的仅能姑息对症治疗的阿片耐受的重度癌痛患者为研究对象。按接受的镇痛治疗方案分为两组,对照组29例:仅给予吗啡(吗啡缓释片、吗啡注射液)治疗;观察组28例:给予加巴喷丁、阿米替林及吗啡(吗啡缓释片、吗啡注射液)治疗。治疗目标为背景痛(background cancer pain)数字评分法(numberical rating scale,NRS)≤3分,两组患者均根据疼痛程度调整药物用量,当出现爆发痛(breakthrough pain,BTP)时采用盐酸吗啡注射液皮下注射。比较两组患者疼痛稳定后焦虑、抑郁、生存质量、日需吗啡量。结果 (1)焦虑、抑郁状态改善:与治疗前相比,两组患者焦虑、抑郁评分均下降(P<0.05),但观察组较对照组下降更明显(P<0.05);(2)日需吗啡量:相比治疗前,疼痛控制稳定需要增加一定量的吗啡,但观察组增加量较对照组少(P<0.05);(3)生存质量:与治疗前相比,两组患者的躯体功能、角色功能及社会功能无明显改变(P>0.05),但情绪功能改善(P<0.05),对照组患者失眠、总健康较治疗前无明显改善(P>0.05),且恶心呕吐、便秘、食欲丧失较治疗前症状加重(P<0.05)。观察组失眠、食欲丧失、总健康得到改善(P<0.05),恶心呕吐、便秘较治疗前无明显变化(P>0.05)。结论加巴喷丁联合阿米替林不仅可增强吗啡对阿片耐受的重度癌痛的疼痛控制,且不增加恶心呕吐、便秘,还可以改善焦虑、抑郁、失眠和食欲丧失等症状,提高总健康评分。

Objective To determine the clinical efficacy of gabapentin combined with amitriptyline in the patients with opioid tolerance and severe cancer pain. Methods Clinical data of cancer patients with opioid tolerance and severe cancer pain who received palliative care treatment in our department from September 2015 to September 2016 were collected and retrospectively analyzed in this study. They were divided into control group （n = 29, morphine alone, morphine sustained release tablets and/or morphine injection） and observation group （n = 28, gabapentin, amitriptyline and morphine sustained release tablets and/or morphine injection ）. The goal of pain relief was background cancer pain less than 3 points by numberical rating scale （NRS）. The dosages of corresponding drugs were adjusted according to the severity of pain, and morphine hydrochloride injection was injected subcutaneously when breakthrough pain episodes appeared. Anxiety, depression, quality of life, and amount of morphine daily requirement were compared between the 2 groups after the condition became stable. Results The scores of anxiety and depression were reduced in the both groups after the treatment （ P 〈 0.05 ） , but the decreases were more significant in theobservation group （P 〈 O. 05）. For the amount of morphine daily requirement, a certain larger amount of morphine was needed for pain control than the amount before the treatment, but the observation group needed relatively less （P 〈 O. 05 ）. Compared with the patients＇ conditions before treatment, there were no obvious changes in their physical, role and social functions in the both groups （ P 〉 O. 05 ）, but the emotional function had been improved （ P 〈 0.05 ）. However, insomnia and total body health had no obvious improvement in control group as compared to pre-treatment （ P 〉 0. 05 ）, and the symptoms such as nausea vomiting, constipation, and loss of appetite even worsened （ P 〈 0.05 ）. In the observation group, the symptoms of insomnia, loss of appetite and total body health were improved （ P 〈 0.05 ）, while nausea, vomiting, and constipation had no significant changes （ P 〉 0.05 ）. Conclusion Gabapentin combined with amitriptyline can enhance analgesic effect of morphine, induce no side effects, such as nausea, vomiting, and constipation, but improve the symptoms of anxiety, depression, insomnia and loss of appetite, and promote total body health in the patients with opioid tolerance and severe cancer pain.