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DGRh-Empfehlungen zur Implementierung aktueller Sicherheitsaspekte in die NSAR-Therapie muskuloskelettaler Schmerzen

DGRh recommendations for the implementation of current security aspects in the NSAID treatment of musculoskeletal pain

  • Empfehlungen und Stellungnahme von Fachgesellschaften
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Zusammenfassung

NSAR lindern Schmerz und Entzündung durch Hemmung der COX-2 und konsekutive Verminderung der Synthese schmerzvermittelnder Prostaglandine. Unerwünschte Wirkungen limitieren die NSAR-Therapie. Die wichtigsten unerwünschten Wirkungen entstehen gastrointestinal durch Reduzierung der Synthese COX-1-abhängiger protektiver Prostaglandine und kardiovaskulär durch COX-2-Inhibition bzw. durch Verschiebung des Verhältnisses der Syntheserate COX-2- und COX-1-abhängiger pro- und antithrombotisch wirkender Prostaglandine. Besonders gefährdet sind Patienten mit einschlägig erhöhtem Risikoprofil. Strenge Überwachung der Indikation, die Wahl eines selektiven COX-2-Inhibitors oder/und die Komedikation mit einem PPI (ggf. auch Misoprostol) bei GI-Risikopatienten sowie der Einsatz kardioneutraler NSAR (Naproxen, niedrig dosiertes Ibuprofen) bzw. die Vermeidung eher kardial schädigender NSAR (z. B. Coxibe, Diclofenac, hochdosiertes Ibuprofen) bei CV-Risikopatienten sind geeignete Präventivmaßnahmen zur Senkung des NSAR-Risikos. Kontraindikationen wie z. B. eine Niereninsuffizienz (GFR < 30 ml/min) (KI für alle NSAR), Ulkusanamnese (KI für tNSAR) oder kardio- bzw. cerebrovaskuläre Vorerkrankungen (KI für Coxibe) sowie Medikamenteninteraktionen müssen beachtet werden. Therapeutische Entscheidungen werden für jeden Patienten individuell getroffen. Die Behandlungsnotwendigkeit sollte regelmäßig überprüft werden. Das Potenzial nichtmedikamentöser Behandlungsmaßnahmen sollte genutzt werden.

Abstract

NSAIDs exert their anti-inflammatory and analgesic effects by inhibition of COX‑2, a key enzyme for proinflammatory prostanoid synthesis. Therapy with NSAIDs is limited by their typical gastrointestinal, cardiovascular and renal side effects, which are caused by inhibition of COX‑1 (gastrointestinal toxicity), COX‑2 (cardiovascular side effects) or both COX-isoenzymes (renal side effects). Appropriate prevention strategies should be employed in patients at risk. If gastrointestinal risk factors are present, co-administration of a proton pump inhibitor or misoprostol is recommended; in patients with cardiovascular risk, coxibs, diclofenac and high-dose ibuprofen should be avoided. Furthermore, drug interactions and contraindications should be considered. In patients with renal impairment (GFR < 30 ml/min) all NSAIDs must be avoided. Ulcer anamnesis is a contraindication for traditional NSAIDs. Preexisting cardio- or cerebrovascular diseases are contraindications for coxibs. Treatment decisions should be individually based with a continuous monitoring of the risk – benefit ratio and exploitation of non-pharmacological treatment options.

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Abbreviations

ASS:

Acetylsalicylsäure

COX:

Cyclooxygenase

COX-1:

Cyclooxygenase-1

Coxib:

COX-2-selektives NSAR

CV:

kardiovaskulär

CVD:

kardiovaskuläre Erkrankung

EMA:

European Medicines Agency

FDA:

Food and Drug Administration

GFR:

glomeruläre Filtrationsrate

GI:

gastrointestinal

H.p.:

Helicobacter pylori

H2RA:

H2-Rezeptorantagonisten

HWZ:

Halbwertzeit

JIA:

Juvenile Idiopathische Arthritis

KHK:

koronare Herzkrankheit

KI:

Kontraindikation

MD:

Magen-Darm

MI:

Myokardinfarkt

NNT:

„Number needed to treat“

NSAR:

nichtsteroidales Antirheumatikum

NYHA:

New-York-Heart-Association-Klassifikation

OA:

Osteoarthrose

OR:

Odds-Ratio

OTC:

„Over-The-Counter“

pAVK:

periphere arterielle Verschlusskrankheit

PG:

Prostaglandin

PGs:

Prostaglandine

PGE2:

Prostaglandin E2

PGI2:

Prostazyklin

TX:

Thromboxan

PMR:

Polymyalgia rheumatica

PPI:

Protonenpumpeninhibitoren

PsA:

Psoriasisarthritis

RA:

Rheumatoide Arthritis

SpA:

Spondyloarthritis

SSNRI:

selektive Serotonin-Noradrenalin-Wiederaufnahmehemmer

SSRI:

selektive Serotonin-Wiederaufnahmehemmer

tNSAR:

traditionelles nicht COX-2-selektives NSAR

UAW:

unerwünschte Arzneimittelwirkung

VAS:

Visuelle Analogskala

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  1. Abt. Rheumatologie, Klaus Miehlke Klinik, Leibnizstr. 23, 65191, Wiesbaden, Deutschland

    W. W. Bolten

  2. Praxiszentrum Rheumatologie, München, Deutschland

    K. Krüger

  3. Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM), Bonn, Deutschland

    S. Reiter-Niesert

  4. Institut für Klinische Pharmakologie, Med. Hochschule, Hannover, Deutschland

    D. O. Stichtenoth

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Bolten, W.W., Krüger, K., Reiter-Niesert, S. et al. DGRh-Empfehlungen zur Implementierung aktueller Sicherheitsaspekte in die NSAR-Therapie muskuloskelettaler Schmerzen. Z Rheumatol 75, 103–116 (2016). https://doi.org/10.1007/s00393-015-0018-6

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