【晨读】骨关节炎药物治疗的选择过程是什么?（三）
英语晨读 ·
山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。
本次文献选自Yu S P , Hunter D J . What is the selection process for osteoarthritis pharmacotherapy?[J]. Expert Opinion on Pharmacotherapy, 2020(9):1-5.
Other pain management alternatives include opioid-based medications, which have demonstrated no clinically meaningful effects on pain, with associated side effects of dizziness, nausea, vomiting and constipation, along with increases in adverse events of cardiovascular events, falls and fractures. The dependency potential of these medications also raises concern in the setting of the current opioid crisis. In situations where no other pharmacological or surgical options are available, opioids can be considered, but it has been recommended that tramadol should be conditionally used over non-tramadol opioids with a short duration period.
其他治疗疼痛的替代药物包括阿片类药物，这些药物对疼痛没有临床意义，伴随的副作用有头晕、恶心、呕吐和便秘，以及心血管事件、跌倒和骨折等不良事件的增加。在当前阿片类药物危机的背景下，这些药物的潜在依赖性也在增加。在没有其他药物或手术选择的情况下，阿片类药物可以考虑，但已建议有条件地使用曲马多，而不是较短时间使用非曲马多的阿片类药物。
Duloxetine, a serotonin-noradrenaline reuptake inhibitor, is another option targeting the concept of central pain sensitization in knee OA. Efficacy has been demonstrated in multiple chronic pain settings. It has only been investigated primarily in knee OA, with no significant differences in effect on pain when indirectly compared with NSAIDs and opioids. The use of this drug in OA is generally off-label in most countries.
度洛西汀，一种羟色胺-去甲肾上腺素再摄取抑制剂，鉴于膝关节骨性关节炎中枢性疼痛敏化的概念，是另一种治疗选择。疗效已在多种慢性疼痛疾病中得到证实。目前主要是针对膝关节骨关节炎研究，与非甾体抗炎药和阿片类药物间接相比，对疼痛的影响没有显著差异。在大多数国家，这种药物治疗OA属于超说明书用药。
Intra-articular injection therapies are often utilized especially in the setting of symptomatic monoarthritis, in an attempt by clinicians to minimize the need for systemic therapies. Currently available intra-articular pharmacologic therapies that are not 'biological’, are corticosteroids and viscosupplements (hyaluronate). In reference to current guidelines for knee OA, intra-articular injections are preferred as the last non-operative alternative where other conservative modalities have failed, or not recommended at all based on their limited efficacy profiles.
有症状的单关节炎中，临床医生经常使用关节内注射治疗，期望最小化系统用药。目前可用的关节内药物治疗不是“生物”的，是皮质类固醇和增粘剂(透明质酸盐)。根据目前的膝关节骨性关节炎治疗指南，当其他保守治疗方式失败或因其疗效有限而完全不推荐时，关节内注射是最后的非手术治疗选择。
In osteoarthritis, intra-articular corticosteroids do have positive effects over that of placebo, but it is short-lasting of up to 6 weeks duration from Cochrane reviews in terms of pain and function improvements . In patients who present with acute OA exacerbations with clinical features of joint effusion and inflammation, intra-articular corticosteroids may be contemplated, but the quality of evidence for corticosteroids, even in the short term is low, with high risk of bias. In patients with indolent OA symptoms, repeated injections are considered inappropriate. Recent studies demonstrated the potential that specific corticosteroid preparations or frequency of injections may accelerate cartilage loss. Infection post intra-articular corticosteroid, remains the main adverse event concern with the rate of septic arthritis post arthrocentesis being estimated at 1 in 2000 to 1 in 15,000. Reactive flares to intra-articular corticosteroid can also occur, usually about 6–12 hours post-injection, and resolve spontaneously in up to 3 days.
关于骨关节疼痛和功能的循证医学综述显示：关节腔内皮质类固醇确实比安慰剂有积极的作用，但它的持续时间很短，最长持续6周。对于临床表现为关节积液和炎症的急性OA加重的患者，可以考虑关节内糖皮质激素注射，但其证据质量低，即使在短期内也很低，有较高的偏倚风险。对于有稳定的OA患者，反复注射被认为是不合适的。最近的研究表明，特定的皮质类固醇制剂或注射频率可能加速软骨丢失。关节内皮质类固醇感染仍然是主要的不良事件，估计发生率在1/15000—1/2000。关节内皮质类固醇的反应性白点也会发生，通常在注射后6-12小时左右，并在3天内自行消失。