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Differenzialtherapeutische Aspekte in der Schmerztherapie mit retardierten, oralen, stark wirksamen Opioiden

Applikationsintervalle, Metabolismus und Immunsuppression

Differential therapeutic aspects of analgesia with oral sustained-release strong opioids

Application intervals, metabolism and immunosuppression

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Zusammenfassung

Für die Langzeittherapie chronischer starker Schmerzen wird die regelmäßige orale Gabe stark wirksamer Opioide in retardierter Form empfohlen. Mittlerweile stehen in Deutschland zahlreiche Arzneimittel zur Verfügung. Moderne Galeniken ermöglichen die bis zu nur einmal tägliche Dosisapplikation ohne klinisch relevante, negativ chronobiologische Interferenzen. Dieses Therapieschema zeichnet sich durch eine verbesserte Compliance und Schlafqualität der Patienten aus; Vorteile, die wie bei anderen chronischen Erkrankungen Einfluss auf den Therapieerfolg haben. Randomisierte kontrollierte Studien zeigen keine signifikanten klinischen Unterschiede bzgl. Wirksamkeit und Verträglichkeit der verschiedenen oralen Opioide. Vorteilhaft gegenüber Morphin erscheinen jedoch bei Hydromorphon und Oxycodon die fehlende Immunsuppression und insbesondere bei Hydromorphon die geringere Intoxikationsgefahr bei (auch altersbedingt) eingeschränkter Nierenfunktion. Daher können, obwohl Morphin bei starken chronischen Schmerzen als Referenzsubstanz gilt, Hydromorphon bzw. Oxycodon bei bestimmten Patientengruppen (z. B. höheres Alter, Multimorbidität, Tumorerkrankung) die bessere Alternative darstellen.

Abstract

The oral “around-the clock” administration of sustained-release strong opioids has been recommended for the long-term treatment of patients suffering from chronic severe pain. At present a plethora of products are available in Germany. Modern galenics even allow for only once-daily oral application without clinically relevant negative chronobiological interference. This application scheme has been shown to improve compliance and sleep quality, factors that influence treatment outcome. Randomized controlled studies revealed no relevant differences between the different strong opioids with respect to efficacy and tolerability. However, hydromorphone and oxycodone appear to be advantageous over morphine due to a lack of immunosuppression. Hydromorphone has the additional benefit of a lower risk of intoxication by accumulation of active metabolites in patients with decreased renal function. As a result, although morphine has been regarded as the standard for the treatment of chronic severe pain, hydromorphone and oxycodone may be better and safer alternatives for certain patient groups (e.g. older age, multimorbidity, cancer).

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Dieser Artikel entstand mit freundlicher Unterstützung der Firma Janssen-Cilag GmbH, Neuss.

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Der korrespondierende Autor weist auf folgende Beziehungen hin: Berater- und Referententätigkeit für folgende Firmen: Janssen-Cilag, Pfizer, AWD, Stada, Ratiopharm.

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  1. Institut für Pharmakologie, Universitätsklinikum Köln, Köln, Deutschland

    K. Güttler

  2. Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland

    R. Sabatowski

  3. Universitäts SchmerzCentrum, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland

    R. Sabatowski

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Güttler, K., Sabatowski, R. Differenzialtherapeutische Aspekte in der Schmerztherapie mit retardierten, oralen, stark wirksamen Opioiden. Schmerz 22, 562–570 (2008). https://doi.org/10.1007/s00482-008-0657-5

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