Yücel Zülf KURŞUN, Fuat YILDIZ, Ömer KAYMAZ, Selami Ateş ÖNAL

Ağrılı kanser hastalarının tedavisinde analjezik basamak tedavisinin yeri

Amaç: Bu çalışmada, kliniğimize başvuran 1736 hasta, özellikleri, analjezik basamak tedavileri ve tedavi yöntemleri geriye dönük olarak değerlendirildi. Gereç ve Yöntem: Ocak 1997-Aralık 2010 tarihleri arasında Fırat Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon Anabilim Dalı Algoloji Bilim Dalına maligniteye bağlı ağrı nedeniyle başvuran 1736 hastanın 269u çalışma dışı bırakılarak toplam 1467 hasta değerlendirilmeye alındı. Çalışmamızda hastaların %85.5i analjezik basamak tedavisine göre tedavi edil- miştir. Basamak tedavisiyle yeterli ağrı kontrolü sağlanamayan %14.5 oranındaki olguya minimal invaziv analjezik girişim yöntemleri uygulanmıştır. Bulgular: Adjuvan ilaç olarak antidepresan, kortikosteroid, antikonvülzan, nöroleptik, benzodiazepin, lokal anestezik, bi- fosfanat ve kalsitonin kullanım oranları sırasıyla; %61.0, %7.1, %4.0, %4.0, %1.6, %12.3, %1.2 ve %2.8 olarak bulunmuştur. Sonuç: Sonuç olarak ağrılı kanser hastalarının ağrısının şiddetli olması; hastada ağrı tedavisini zorlaştırmaktadır. Analjezik basamak tedavisiyle tedavi edilemeyen hastalar, minimal invaziv analjezik girişim yöntemleriyle tedavi edilmektedir. Ağrı te- davisinde başarıya ulaşmak, olguların multidisipliner tıbbi uzman kadrosu ile değerlendirilmeleri ve bu ekibin hazırlayacağı tedavi planlaması ile olasıdır. Böylece hiçbir kanser hastasının kontrol altına alınamayan ağrı ile yaşamayacağı kanısındayız. Ağrı tedavisinde başarıya ulaşmak için adjuvan ilaçlara erişmek kolay olmalıdır. Adjuvan ilaçların, ağrı tedavisi yapan Algoloji hekimleri tarafından rahatça reçete edilmesi gerektiği kanısındayız.

Analgesic step ladder treatment in cancer patients with pain

Objectives: TIn this study, we retrospectively evaluated the characteristics of 1736 patients presenting to our clinic, including analge- sic step treatments and method of treatments. Methods: A total of 1467 patients, excluding 269 out of 1736, with pain due to malignancy were included in this study. Patients presented to the Algology Division of the Department of Anesthesiology and Reanimation of Firat University School of Medicine. Among the patients included in the study, 85.5% were treated according to the analgesic step ladder protocol of the WHO. Minimally invasive analgesic interventions were applied in 14.5% of the cases in which adequate pain control could not be achieved with step ladder treatment. Results: Te adjuvant pain medications used were antidepressants, corticosteroids, anticonvulsants, neuroleptics, benzodiazepines, local anesthetics, bisphosphonates, and calcitonin and their rate of usage were 61.0%, 7.1%, 4.0%, 4.0%, 1.6%,12.3%,1.2%, and 2.8%, respectively. Conclusion: Because pain in the cancer patients is mostly severe, pain management can be difcult in these patients. Te patients who cannot be treated with the analgesic step ladder method have been treated with minimally invasive analgesic intervention methods. A multidisciplinary medical expert group evaluation of the cases and a treatment planned by this team are cornerstones of achieving success in pain management. We believe in this way, no patient with cancer will live with uncontrolled pain. Access to adjuvant drugs should be easy in order to achieve success in pain management. We believe that expert algology physicians who treat pain should easily prescribe adjuvant drugs.

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1. Herdon CM. Pharmacologic management of cancer pain. J Neurosci Nurs 2003;35(6):321-6.
2. Foley KM. Controlling cancer pain. Hosp Pract (1995) 2000;35(4):101-8, 111-2.
3. Polomano RC, Farrar JT. Pain and neuropathy in cancer survivors. Surgery, radiation, and chemotherapy can cause pain; research could improve its detection and treatment. Am J Nurs 2006;106(3 Suppl):39-47.
4. Önal SA. Kanser ağrısı. Erdine S. (Editör). Ağrı 3. Baskı. İstanbul: Nobel Tıp Kitabevi 2007;551-62.
5. Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. Validity of the brief pain inventory for use in document- ing the outcomes of patients with noncancer pain. Clin J Pain 2004;20(5):309-18.
6. Breivik H. Opioids in cancer and chronic non-cancer pain therapy-indications and controversies. Acta Anaesthesiol Scand 2001;45(9):1059-66.
7. Boström B, Sandh M, Lundberg D, Fridlund B. Cancer pa- tients experiences of care related to pain management be- fore and after palliative care referral. Eur J Cancer Care (Engl) 2004;13(3):238-45.
8. Lucas LK, Lipman AG. Recent advances in pharmacotherapy for cancer pain management. Cancer Pract 2002;10 Suppl 1:S14-20.
9. Aşık İ. Kanser ağrı tedavisi. Tüzüner F, Alkış N, Aşık İ, Yılmaz AA. (Editörler). Anestezi, Yoğun Bakım, Ağrı 1.Baskı. İstanbul: Nobel Tıp Kitabevi 2010;1613-35.
10. Stjernswärd J, Colleau SM, Ventafridda V. The World Health Or- ganization Cancer Pain and Palliative Care Program. Past, pres - ent, and future. J Pain Symptom Manage 1996;12(2):65-72.
11. Orhan ME, Bilgin F, Ergin A, Dere K, Güzeldemir ME. Pain treatment practice according to the WHO analgesic ladder in cancer patients: eight years experience of a single center. Agri 2008;20(4):37-43.
12. Ventafridda V, Tamburini M, Caraceni A, De Conno F, Naldi F. A validation study of the WHO method for cancer pain relief. Cancer 1987;59(4):850-6.
13. Karslı B, Yeğin A. Akdeniz Üniversitesi Tıp Fakültesi Algoloji Bilim Dalında 2001-2003 yılları arasında izlenen kanser ağrılı olguların retrospektif değerlendirilmesi. Ağrı 2005;33:253-8.
14. Anonim. (2011). Kanser İstatistikleri. Erişim: http://www.turk- kanser.org.tr/. Erişim tarihi: 17.12.2012.
15. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain re- lief: a 10-year prospective study. Pain 1995;63(1):65-76.
16. Practice guidelines for cancer pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Cancer Pain Section. Anesthesiology 1996;84(5):1243-57.
17. Lamer TJ. Treatment of cancer-related pain: when orally ad- ministered medications fail. Mayo Clin Proc 1994;69(5):473- 80.
18. Güzeldemir ME. Ağrı ve Tedavisi. 1. Baskı. Ankara: GATA Basımevi 2000;61-80.
19. Güldoğuş F. Sempatik sinir blokları. Tüzüner F, Alkış N, Aşık İ, Yılmaz A.A. (Editörler). Anestezi, Yoğun Bakım, Ağrı 1.Baskı. İstanbul: Nobel Tıp Kitabevi 2010;1809-17.
20. Coluzzi PH. Cancer pain management: newer perspec- tives on opioids and episodic pain. Am J Hosp Palliat Care 1998;15(1):13-22.
21. Oxberry SG, Simpson KH. Pharmacotherapy for cancer pain. Continue education in anesthesia. Critical Care Pain 2005;5:203-6.
22. Ventafridda V, De Conno F, Panerai AE, Maresca V, Monza GC, Ripamonti C. Non-steroidal anti-infammatory drugs as the frst step in cancer pain therapy: double-blind, within-patient study comparing nine drugs. J Int Med Res 1990;18(1):21-9.
23. Rodríguez M, Barutell C, Rull M, Gálvez R, Pallarés J, Vidal F, et al. Efcacy and tolerance of oral dipyrone versus oral mor- phine for cancer pain. Eur J Cancer 1994;30(5):584-7.
24. Drourr NR, Bajwa ZH, Warfeld CA. Cancer pain. Semin Anes- th 1997;16:105-11.
25. Ferrante FM. Principles of opioid pharmacotherapy: practical implications of basic mechanisms. J Pain Symptom Manage 1996;11(5):265-73.
26. Krajnik M, Zylicz Z, Finlay I, Luczak J, van Sorge AA. Potential uses of topical opioids in palliative care--report of 6 cases. Pain 1999;80(1-2):121-5.
27. Mystakidou K, Parpa E, Tsilika E, Katsouda E, Kouloulias V, Kouvaris J, et al. Pain management of cancer patients with transdermal fentanyl: a study of 1828 step I, II, & III transfers. J Pain 2004;5(2):119-32.
28. Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer 2001;84(5):587-93.
29. Şahin S. Kronik ağrı tedavisinde adjuvan ilaçlar. Klinik Gelişim 2007;20:159-70.
30. Magni G. The use of antidepressants in the treatment of chronic pain. A review of the current evidence. Drugs 1991;42(5):730-48.
31. Ettinger AB, Portenoy RK. The use of corticosteroids in the treatment of symptoms associated with cancer. J Pain Symp- tom Manage 1988;3(2):99-103.
32. Farr WC. The use of corticosteroids for symptom manage- ment in terminally ill patients. Am J Hosp Care 1990;7(1):41-6.
33. Babacan CA, Çizmeci P. Ağrı tedavisinde kullanılan ilaçlar. Türkiye Klinikleri J Surg Med Sci 2007;3:22-33.
34. Khojainova N, Santiago-Palma J, Kornick C, Breitbart W, Gon- zales GR. Olanzapine in the management of cancer pain. J Pain Symptom Manage 2002;23(4):346-50.
35. Brose WG, Cousins MJ. Subcutaneous lidocaine for treat- ment of neuropathic cancer pain. Pain 1991;45(2):145-8.
36. Lussier D, Portenoy RK. Adjuvant analgesics in pain manage- ment. in: Doyle D, Hanks G, Cherny N (Editörler). Textbook of Palliative Medicine. 3. Baskı. England: Oxford University Press 2003;349-77.
37. Onal SA. Adjuvant analgesics in pain management. Agri 2006;18(4):10-23.
38. Alıcı S, Çekici S. Malign hastalıklarda bifosfanatların rolü. Van Tıp Dergisi 2002;9:66-72.
39. Elomaa I, Blomqvist C, Porkka L, Lamberg-Allardt C, Borg- ström GH. Treatment of skeletal disease in breast cancer: a controlled clodronate trial. Bone 1987;8 Suppl 1:S53-6.
40. Conte PF, Giannessi PG, Latreille J, Mauriac L, Koliren L, Cal- abresi F, et al. Delayed progression of bone metastases with pamidronate therapy in breast cancer patients: a random- ized, multicenter phase III trial. Ann Oncol 1994;5 Suppl 7:S41-4.
41. Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist 2004;9(5):571-91.
42. Roth A, Kolarić K. Analgetic activity of calcitonin in patients with painful osteolytic metastases of breast cancer. Results of a controlled randomized study. Oncology 1986;43(5):283-7.