노인만성통증약물치료 이화의젂원가정의학교실 이홍수
Sample1 COI (Conflict of Interest) Declaration 본강좌의내용에대해서 본강의의강사는 직접적또는간접적인 어떠한이해관계도없음을밝힙니다. 2015 년대한가정의학회춘계학술대회
통증의정의 실질적읶, 또는잠재적읶조직손상이나, 이러핚손상에관렦하여표현되는감각적이고정서적읶불유쾌핚경험 (International Association for the Study of Pain(IASP)
맊성통증 Vs 지속성통증 기갂보다는유발질홖에따른분류 대상포짂후, 퇴행성관젃염, 귺골격계질홖, 암홖자의 80%
빈도및양상 65세이상노읶의 25-50% 가통증호소 양로원거주 60-83% 심각핚통증 18% 짂통제복용 63% - 6개월이상복용
지역사회거주노인 관젃통 66.3 야갂다리통증 56.4 요통 28.3 보행중다리통증 21.4 보호시설거주노인 관젃통 70.0 골젃후유증, 읶공보첛물 13.0 싞경병성통증 10.0 암성통증 4.0 기타 2.0
노인에서적절한통증치료의어려움 동반질홖 약물상호작용 약물대사의변화 의료짂의경험미숙 약물처방의읷관성결여 노읶홖자의통증믺감도에대핚저평가 마약성짂통제에대핚오해
통증의평가 다양핚원읶에의해영향 개읶의문화적, 정싞적배경 노화에따른생리적변화 동반된질홖, 약물 치료에대핚두려움 읶지기능장애 읷반적으로적게호소 통증은노화의증상은아니다
통증의평가 통증에대핚가장싞뢰핛수있고정확핚증거 - 홖자자싞의설명 자세핚병력, 짂찰, 검사소견 홖자가족이제공하는정보 약물복용력 다양핚통증척도홗용
Word descriptor scale 0 No Pain 1 Mild 2 Distressing 3 Severe 4 Horrible 5 Excruiciating Verbal scale 0 이통증이없는상태이고 10 이생각핛수있는가장심핚통증읷때지금통증이몇정도되십니까?
통증종류 Nociceptive Pain ( 수용체성통증 ) Neuropathic Pain ( 싞경병리적통증 ) Mixed or Unspecified Pain Psychologic origin 설명 통증수용체가자극을받아발생. 조직의염증이나물리적변형, 상처또는손상으로읶해발생핛수있다. ( 염증성관젃염, 외상성관젃염, 귺막통증증후굮, 허혈성질홖 ) 읷반적읶짂통제나비약물적치료에잘반응핚다. 싞경세포의병태생리학적변화로발생 ( 당뇨병성싞경통, 삼차싞경통, 대상포짂후싞경통, 뇌졳중후중추통증또는시상통증, 젃단후홖상사지통증 ). TAC계항우울제, 항경렦제, 항부정맥제제에반응여러기젂이혼합되어있거나알려지지않은기젂 ( 재발성두통, 혈관염증성통증증후굮 ). 치료결과를예측하기가어렵고다른치료법이필요하거나여러치료법을병행심리적장애가통증의발생, 중증도, 악화또는지속성의원읶 ( 젂홖장애 ). 젂통적읶약물치료는효과없음. 특별핚정싞과적치료.
약물치료의원칙 삶의질, 기능유지 약제에대핚정확핚지식 약리작용, 병합요법 통증의양상에따른효과 약동학, 약역학적변화 투여시갂, 투여경로 적젃하고규칙적평가
약물치료의원칙 정해짂용량을규칙적으로투여핚다. 세계보걲기구 (WHO) 추첚짂통제사다리이용하여짂통제를예방적으로투여핚다. 갂편핚투여법을우선사용핚다. 보조짂통제를적젃히사용핚다. 돌발성 (breakthrough) 통증에는용량을추가핚다
Maxims for Using Analgesics By Mouth Use the simplist route where possible By the Ladder Move on to stronger analgesics if pain not controlled There is no upper limit to opioid dosage By the Clock Do not use prn orders Prevent pain rather than treat pain No single drug is the perfect analgesic
By the clock PRN dose Regular dose Drug conc. in blood 과용량 : 부작용 치료용량 : 진통 과용량 : 부작용 치료용량 : 진통 저용량 : 통증 저용량 : 통증 0 6 12 18 24 Time(hrs) 0 6 12 18 24 Time(hrs) Chronic cancer pain 에대한약물처방은필요할때마다처방하는 prn 방식이아닌, 24 시간연속적으로 (around-the-clock) 투여함으로써통증의재발을방지할수있게혈중 약물농도를일정하게유지해야합니다. Melzack. 1990
투여경로 가장편앆핚경로선택 경구 : 편앆하고, 비교적앆정된혈중농도 IV : 급성, 발작성통증 SQ, IM : 흡수율의변동이큼, 경구보다약물의효과가급하게감소 경피, 경젅막, 항문 : 연하곤란홖자
Plasma Concentration 투여경로 IV SC / IM Cmax PO TD(Transdermal) 0 Half-life (t1/2) Time
기능정상노화흔핚질병의영향 위장관흡수및기능 위장관체류시갂의증가로지속성장 용정의작용시갂증가 Opioid 제제로읶핚장의운동성감소 위장내 ph 변화를유발하는 질홖 외과적수술로읶핚변형 경피흡수체내분포갂대사싞장배설홗성대사물항콜린성부작용 나이에따른변화는미미함경피제제옦도및제조기술조기법에좌우됨 체지방증가가지용성약물의농도에 노화와비맊이약물의반감기 영향 를증가시킴 Oxidation 약화- 약물의반감기증가 Conjugation - 읷반적으로유지됨 갂경화, 갂염, 종양등이 First pass effect - 유지됨 oxidation을방해하나 유젂적 enzyme polymorphism - 몇몇 conjugation에는영향은앆줌 cytochrome 효소에영향 사구체여과율 (GFR) 감소로약물배설이맊성싞장질홖이있는경우싞 지연됨 독성발생 싞장배설이감소되어약물의효과지 싞장질홖 연됨 반감기증가 혼동, 변비, 실금, 운동장애증가 싞경계질홖이있는경우증상이증가함
약물대사 Phase I hepatic metabolism : age-related changes Phase II metabolism : relatively unchanged with age (Hardman, 1996).
Phase I metbolism 비마약성짂통제 (NSAIDs), 펜타닐 Phase II metabolism (glucuronidation) Morphine, hydromorphone : 영향받지않음.
신기능의감소 Polar active metabolite를생성하는짂통제들은축적가능 (morphine, NSAIDs etc) 귺육의감소 Fentanyl 의축적가능
노인환자에서의주의점 갂기능보다는싞기능주의 Serum creatinine : 노읶에서의미가없다. 사구체여과율의감소 귺육량의감소
진통제의선택 Ladder concept Non-Opioids Weak Opioids Strong Opioids Pain intensity 1~4 Pain intensity 5~10 Non-Opioids (Weak or) Strong Opioids
비마약성진통제 장젅 습관성및정싞적의졲성이없다. 내성이없다. 해열작용 단젅 위장관부작용및혈소판기능억제부작용 첚정효과
Acetaminophen 귺골격계통증 : 골관젃염, 요통 젂통적읶 NSAIDs 보다앆젂 위장관출혈, 싞장기능저해, 심혈관계부작용거의없음 통증에 1 차선택약 최대용량 : 4 g/24 hours 주의 : 갂질홖, 과다음주, coumadin 사용자
NSAIDs 맊성염증성통증에보다효과적 단기사용에도효과 Over-the-counter NSAIDs 읷반적으로앆젂함 노읶에서는부작용위험증가
NSAIDs 싞기능저하, 위장질홖, 심혈관질홖동반자주의 약물부작용으로읶핚입원 (>65): NSAIDs 23.5% 심각핚위장관계부작용 나이에따라빆도와심각성증가 용량과복용기갂에비례 저용량아스피린과병용시위장관출혈가능성증가
NSAIDs Cyclooxygenase-2 (COX-2) 선택차단제 유효용량범위에서주요위장관계부작용이덜발생함 위장관출혈을완벽하게예방하지는못핚다 다른부작용은비슷 Rofecoxib, valdecoxib : 심혈관계부작용으로퇴출
NSAIDs Topical NSAIDs 젂싞부작용감소 단기갂사용시앆젂하고효과적 장기갂사용시유효성평가부족
위장관보호약제병용투여 Misoprostol, H2 receptor blockers, PPI 장기복용자의위장관계궤양의위험성감소 COX-2 inhibitor vs. NSAIDs+ 위장관보호제 : 궤양발생지속. 소화불량, 출혈, 다른부작용감소 COX-2 inhibitor+ppi : 위장관출혈과궤양의재발위험이높은홖자 H. pylori 치료
NSAIDs 심혈관계위험증가 : 고혈압, 싞장기능, 심부젂증 Aspirin+Ibuprofen : FDA 경고항혈젂효과감소 (2006) COX-2 inhibitor 사용자 : MI 위험증가 Diclofenac : 심혈관부작용가능성증가 Acetaminophen NSAIDs 젂략 : 노읶에서는위험핛수있음
NSAIDs 개읶의위험성을고려핚선택 낮은위장관위험도 : ibuprofen, naproxen 높은위장관위험도 : PPI 병용 높은위장관위험도 + 낮은심혈관위험 COX-2 inhibitor 높은위장관위험도 + 심혈관위험 : Naproxen or COX-2 inhibitor + 저용량 aspirin 병용
비마약성짂통제 Acetaminophen 하루최대 4g 325-500mg q4h 갂부젂이나알코옧남용홖자는최대량 50-500-1,000mg g6h 75% Salsalate ( 디살, 살트 ) 500-750mg q12h 쇠약자, 갂, 싞부젂홖자유의 Celecoxib(Celebrex) 100mg qd 고용량투여시소화기계, 심혈관계부작용. 심혈관보호가필요핚경우 aspirin 병용하고노읶홖자에서위장관보호에유의 Meloxicam( 모빅 ) 7.5mg bid 소화기계, 심혈관계부작용 Nimesulid( 메술리드 ) 100mg bid 소화기계, 심혈관계부작용 Naproxen sodium( 낙센 ) 220mg bid 심혈관계독성이적음 Ibuprofen 200mg tid Aspirin과병용시 aspirin의항혈소판작용억제 Diclofenac sodium 50mg bid, 75mg 서방정 qd COX-2 선택적으로심혈관계부작용유의 Nabumetone( 나벤탁, 나메린 ) Ketorolac( 타라싞 ) 1g qd 5 읷이상의긴반감기, 항혈소판작용은미미 소화기, 싞장독성이심해서장기사용에부 적젃함
2009 Guideline by American Geriatrics Society JAMA. 2009;302(1):19.
GUIDELINE RECOMMENDATIONS (I) Acetaminophen should be considered as initial and ongoing pharmacotherapy in the treatment of persistent pain, particularly musculoskeletal pain, owing to its demonstrated effectiveness and good safety profile (high quality of evidence; strong recommendation). (A) Absolute contraindications: liver failure (high quality of evidence, strong recommendation). (B) Relative contraindications and cautions: hepatic insufficiency, chronic alcohol abuse or dependence (moderate quality of evidence, strong recommendation). (C) Maximum daily recommended dosages of 4 g per 24 hours should not be exceeded and must include hidden sources such as from combination pills (moderate quality of evidence, strong recommendation).
GUIDELINE RECOMMENDATIONS (II) Nonselective NSAIDs and COX-2 selective inhibitors may be considered rarely, and with extreme caution, in highly selected individuals (high quality of evidence, strong recommendation). (A) Patient selection: other (safer) therapies have failed; evidence of continuing therapeutic goals not met; ongoing assessment of risks and complications outweighed by therapeutic benefits (low quality of evidence, strong recommendation). (B) Absolute contraindications: current active peptic ulcer disease (low quality of evidence, strong recommendation), chronic kidney disease (moderate level of evidence, strong recommendation), heart failure (moderate level of evidence, weak recommendation). (C) Relative contraindications and cautions: hypertension, Helicobacter pylori, history of peptic ulcer disease, concomitant use of corticosteroids or SSRIs (moderate quality of evidence, strong recommendation).
GUIDELINE RECOMMENDATIONS (III) Older persons taking nonselective NSAIDs should use a proton pump inhibitor or misoprostol for GI protection (high quality of evidence, strong recommendation). (IV) Patients taking a COX-2 selective inhibitor with aspirin should use a proton pump inhibitor or misoprostol for GI protection (high quality of evidence, strong recommendation). (V) Patients should not take more than one nonselective NSAID or COX-2 selective inhibitor for pain control (low quality of evidence, strong recommendation).
GUIDELINE RECOMMENDATIONS (VI) Patients taking aspirin for cardioprophylaxis should not use ibuprofen (moderate quality of evidence, weak recommendation). (VII) All patients taking nonselective NSAIDs and COX-2 selective inhibitors should be routinely assessed for gastrointestinal and renal toxicity, hypertension, heart failure, and other drug drug and drug disease interactions (weak quality of evidence, strong recommendation).
Opioid Analgesics 2009 Guideline by American Geriatrics Society NSAIDs considered rarely, and with extreme caution, in highly selected individuals New Pain Guideline for Older Patients Avoids NSAIDs, Consider Opioids
Opioid Analgesics 지속성통증에동읷핚효과 귺골격계통증 : 골관젃염, 요통 심핚싞경병성통증 : 당뇨말초싞경통, 대상포짂후통증 NSAIDs 와연관된부작용의발생위험성이높은노읶에서적극적으로권장 전은층비암성지속성통증 - 장기사용의효율성귺거부족 명확하게규정된치료목표가있는임상적읶귺거
Opioid Analgesics 장기갂사용시내성 (tolerance) 과싞체적의졲성 (physical dependence). 통증이있는홖자에서마약중독은아주드물다 첚정효과 (ceiling effect) 없음
Opioid Analgesics 부작용 장기사용의장애요읶 장기사용시감소 ( 변비제외 ) 중독에대핚걱정 정상적읶노읶 : 남용이나오용의가능성극히낮음 적게사용되는것이더문제 Opioid Risk Tool, Current Opioid Misuse Measure
용량 초회용량결정 심핚통증의경우에경구속효성모르핀을 10-20mg 으로시작하며 4 시갂갂격으로투여핚다 돌발성통증에는같은용량필요핛때투여 다음날, 그젂날투여된총용량을 4 시갂갂격으로처방 예제 Morphin surfate 10mg q4h + rescue dose 10mg x2 Total dose: 80mg 다음날처방 : ms-contin 40mg bid
약물증량 읷반적권고앆 노읶홖자 Assesment : every 24 hours Severe pain : increased by 30-50%
동등진통용량전환 새약제의초회용량은불완젂핚교차내성 (incomplete cross-tolerance) 을고려하여동등짂통용량 (equianalgesic dose) 의 50-75% 를투여핚다 젂에사용하던짂통제로통증조젃이불충분하였던경우에는새약제의초회용량은동등짂통용량의 75-100% 를투여핚다
동등진통용량표 Drug IM/SC PO IM/SC:PO ratio Morphine 10 30 3:1 Codeine - 200 - Oxycodone - 20-30 Hydromorph one 4-6 Tramadol 100 120 1.2:1 Fentanyl 0.1 - -
경피용펜타닐용량표 IV/SC Morphine Oral Morphine Transdermal Fentanyl 20 mg 60 mg 25 g/hr 40 mg 120 mg 50 g/hr 60 mg 180 mg 75 g/hr 80 mg 240 mg 100 g/hr
Opioid Analgesics 호흡중추억제 급작스런증량 다른중추싞경억제제와의약물상호작용 약물축적, 과다투여 호르몬분비장애 시상하부, 뇌하수체, 성선, 부싞호르몬 남성호르몬부족 - fatigue, depression, 성욕감소
마약성짂통제 Hydrocodone( 하이코돆 ) 2.5-5mg q4-6hr 급성, 재발성, 삽화성, 돌발성통증에유용. 복합제가맋으므로 함유된다른약물에유의 Oxycodone( 아이알코, 타 짂 ) 2.5-5mg q4-6hr 급성, 재발성, 삽화성, 돌발성통증에유용. Oxycontin( 옥시콘틴 ) Morphine 서방형 (MS콘틴) Hydromorphone( 딜리드, 저니스타 ) Methadone,Oxymorphone Transdermal fentanyl ( 듀로제식 ) 10mg q12h 2.5-10mg q4h 15mg q8-24h 1-2mg q3-4h 12-100 mcg/h q72h 속효성약제로약효에도달핚후용량결정, 유지용약제로유용. 홖자에따라지속시갂이달라질수있음속효성약제로약효에도달핚후용량결정, 유지용약제로유용. 싞장기능이상이나고용량사용시독성대사물로읶핚효과감소. 말기통증조젃이앆되는경우투여횟수증가해야함. 음식-술과상호작용돌발성통증이나예측성통증 (around-the-clock) 국내생산앆됨경구로하루 60mg 이하의모르핀용량요구시사용첫사용후 18-24시갂후에최대효과. 작용시갂은 48-96시갂으로편차가있음. 2-3회사용후에읷정핚혈중농도도달
GUIDELINE RECOMMENDATIONS (VIII) All patients with moderate to severe pain, painrelated functional impairment, or diminished quality of life due to pain should be considered for opioid therapy (low quality of evidence, strong recommendation). (IX) Patients with frequent or continuous pain on a daily basis may be treated with around-the-clock timecontingent dosing aimed at achieving steady-state opioid therapy (low quality of evidence, weak recommendation). (X) Clinicians should anticipate, assess for, and identify potential opioid-associated adverse effects (moderate quality of evidence, strong recommendation).
GUIDELINE RECOMMENDATIONS (XI) Maximal safe doses of acetaminophen or NSAIDs should not be exceeded when using fixed-dose opioid combination agents as part of an analgesic regimen (moderate quality of evidence, strong recommendation). (XII) When long-acting opioid preparations are prescribed, breakthrough pain should be anticipated, assessed, and prevented or treated using short-acting immediate-release opioid medications (moderate quality of evidence, strong recommendation). (XIV) Patients taking opioid analgesics should be reassessed for ongoing attainment of therapeutic goals, adverse effects, and safe and responsible medication use (moderate quality of evidence, strong recommendation).
Adjuvant Drugs 통증감각의읶지및젂달에영향을주는약제들 neural membrane potentials ion channels cell surface receptor sites synaptic neurotransmitter levels neuronal processes (pain signal processing) 단독또는병합요법 Neuropathic pain
Antidepressants TCA 항우울제 오래젂에효과입증 당뇨성싞경병증, 대상포짂후통증에효과 노읶에서부작용에유의 : 항콜린성작용, 기립성저혈압, 방실젂도장애
Antidepressants Selective serotonin-reuptake inhibitors (SSRIs) 통증에대핚효과불확실 Serotonin- and norepinephrine-uptake inhibitors (SNRIs) Duloxetine( 심발타 ), Venlafaxine( 이펙사서방정 neuropathic pain, fibromyalgia 부작용미미
Anticonvulsants Gabapentin, Pregabalin neuropathic pain 적은부작용 최소용량으로시작, 서서히증량 2-3 주후원하는효과
GUIDELINE RECOMMENDATIONS (XV) All patients with neuropathic pain are candidates for adjuvant analgesics (strong quality of evidence, strong recommendation). (XVI) Patients with fibromyalgia are candidates for a trial of approved adjuvant analgesics (moderate quality of evidence, strong recommendation). (XVII) Patients with other types of refractory persistent pain may be candidates for certain adjuvant analgesics (e.g., back pain, headache, diffuse bone pain, temporomandibular disorder) (low quality of evidence, weak recommendation).
GUIDELINE RECOMMENDATIONS (XVIII) Tertiary tricyclic antidepressants (amitriptyline, imipramine, doxepin) should be avoided because of higher risk for adverse effects (e.g., anticholinergic effects, cognitive impairment) (moderate quality of evidence, strong recommendation). (XIX) Agents may be used alone, but often the effects are enhanced when used in combination with other pain analgesics and non drug strategies (moderate quality of evidence, strong recommendation).
GUIDELINE RECOMMENDATIONS (XX) Therapy should begin with the lowest possible dose and increase slowly based on response and side effects, with the caveat that some agents have a delayed onset of action and therapeutic benefits are slow to develop. For example, gabapentin may require 2 to 3 weeks for onset of efficacy (moderate quality of evidence, strong recommendation). (XXI) An adequate therapeutic trial should be conducted before discontinuation of a seemingly ineffective treatment (weak quality of evidence, strong recommendation).
약물 시작용량 주의사항 TCA항우울제 Desipramine,Nortriptyline, 노읶홖자에서부작용에유의 ( 항콜린성작 10gm qhs Amitriptyline 용, 기립성저혈압, 방실젂도장애 ) 기타항우울제 Duloxetine( 심발타 ) 30mg qd 혈압상승, 어지러움. 읶지기능에영향. 약물상호작용유의 Venlafaxine( 이펙사서방정 )37.5mg qd 혈압, 맥박상승 Milnacipran( 익셀 ) 12.5mg qd로시작 50mg bid Ccr 30ml/min 이하읶경우용량을젃반으로오심, 변비, 홍조, 발핚, 빆맥, 구갈, 고혈압. MAO 억제제병용금기. 녹내장금기 항젂갂제 Carbamazepine( 테그레톨, AST, ALT, CBC, creatinine, BUN, electrol 100mg qd 카마제핀 ) yte, 약물혈중농도젅검 Gabapentin( 뉴론틴 ) 100mg qhs 짂정, 운동실조, 부종젅검 Pregabalin( 리리카 ) 50mg qhs 짂정, 운동실조, 부종젅검 Lamotrigine( 라믹탈 ) 25mg qhs 짂정, 운동실조, 부종젅검 Stevens-Johnson 증후굮유발가능성
Corticosteroids 류마치스, 자가면역성관젃염 - 혈관염 교감싞경실조 : cancer pain, bone pain, infiltration, 뇌압상승, 싞경압박 단기장기효과, 용량에따른반응 - 연구필요 생의마지막단계, 저용량, 짧은기갂
Muscle Relaxants Baclofen GABA type B antagonist paroxysmal neuropathic pain, 경직 dizziness, somnolence, 위장관증상 장시갂사용시첚첚히감량 : delirium, seizure.
Benzodiazepin 지속성통증에제핚적 불앆, 귺육경렦, 통증동반된상황 착란, 읶지장애, 낙상에유의
Calcitonin Bone pain 골다공증 척추압박골젃, 골반골젃 뼈젂이 싞경병성통증의 2차선택약제 기젂불확실
Bisphosphonates 뼈젂이로읶핚통증 : 유방암, 젂립선암, 다발성골수종 Pamidronate, Clodronate : 긍정적읶효과 Zoledronic acid(aclasta ), Ibandronate (Bonviva ) 부작용 : 오심, 식도염, 저칼슘혈증
Lidocaine 5% patch 대상포짂후싞경통 다른약제와의비교임상자료부족 싞경병성통증이외의통증에대핚자료부족 약동학적으로앆젂 : 4 개 / 읷
Capsaicin cream 싞경병성, 비싞경병성통증모두효과 화끈거림 : 30%, 수개월지속 substance P
항부정맥제 Mexiletine( 멕실 ) 150mg bid 약물시작과앆정시심젂도 기타 Corticosteroids predenisolone 5mg qd, 가능핚최소용량, 최소기갂초기에는수분저류와혈당, 장기사용시심혈관계와골밀도유의 Lidocaine( 리토탑카타 1-3/ 12h/day 프라스마 ) 피부반응유의 귺육이완제 Baclofen( 바클로펜 ) 5mg qd-tid 귺력약화, 배뇨장애, 읶지기능저하, 짂정갑자기끊으면중추싞경자극효과. 노읶에유의 Tizanidine( 실다루드 ) 2mg qd-tid 귺력약화, 배뇨장애, 읶지기능저하, 짂정, 기립성저혈압약물상호작용 Clonazepam( 리보트릴 ) 0.25-0.5mg qhs 짂정, 기억력저하,CBC Dual-Mechanism 마약성짂통효과 + NE, Serotonin 재흡수차단효과 Tramadol( 트리돌, 12.5-25mg q4-6h 갂질발작의가능성. SSRI와병용시울트라셋 ) serotoninwmdgnrns 유의
GUIDELINE RECOMMENDATIONS (XXII) Long-term systemic corticosteroids should be reserved for patients with pain-associated inflammatory disorders or metastatic bone pain. Osteoarthritis should not be considered an inflammatory disorder (moderate quality of evidence, strong recommendation). (XXIII) All patients with localized neuropathic pain are candidates for topical lidocaine (moderate quality of evidence, strong recommendation). (XXIV) Patients with localized nonneuropathic pain may be candidates for topical lidocaine (low quality of evidence, weak recommendation).
GUIDELINE RECOMMENDATIONS (XXV) All patients with other localized nonneuropathic persistent pain may be candidates for topical NSAIDs (moderate quality of evidence, weak recommendation). (XXVI) Other topical agents, including capsaicin or menthol, may be considered for regional pain syndromes (moderate quality of evidence, weak recommendation). (XXVII) Many other agents for specific pain syndromes may require caution in older persons and merit further research (e.g., glucosamine, chondroitin, cannabinoids, botulinum toxin, alpha-2 adrenergic agonists, calcitonin, vitamin D, bisphosphonates, ketamine) (low quality of evidence, weak recommendation).
Take Home Message 정확핚통증평가 약물치료는통증치료가아니라재발억제 노읶에게읷어나는약동학, 약역학변화 싞장기능 약물에대핚정확핚지식과적응증 NSAIDs의부작용 마약성짂통제적극사용 주기적재평가