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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2018, Vol. 12 ›› Issue (01) : 131 -140. doi: 10.3877/cma.j.issn.1674-134X.2018.01.026

所属专题： 文献；

骨关节炎专栏

骨关节炎的非药物及药物阶梯治疗
许杰1,†()   
  1. 1. 510120　广州，中山大学孙逸仙纪念医院关节外科
  • 收稿日期:2018-01-15 出版日期:2018-02-01
  • 通信作者: 许杰

Non-drug and drug staged therapies for osteoarthritis

Jie Xu1()   

  • Received:2018-01-15 Published:2018-02-01
  • Corresponding author: Jie Xu
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引用本文：

许杰. 骨关节炎的非药物及药物阶梯治疗[J]. 中华关节外科杂志(电子版), 2018, 12(01): 131-140.

Jie Xu. Non-drug and drug staged therapies for osteoarthritis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2018, 12(01): 131-140.

图1 骨关节炎患者的筛查评估[1]
图2 骨关节炎的阶梯治疗[1]
非药物治疗建议
●所有病人都应接受患者教育项目。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●所有被基础治疗社区医师推荐行运动锻炼的病人，都应该在物理治疗师的指导下参加力量和有氧运动锻炼以及水上或陆上运动
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●BMI大于25 kg/m2的病人应被转介至营养师以进行体重管理。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●可以考虑将患有髋、膝、腕骨性关节炎的病人转介至物理治疗师以使用辅助设备如夹板、托架、吊带、矫正鞋或者助行器。
(证据等级：专家共识；证据质量：不足证据)
●对于针灸感兴趣的病人可转介至注册针灸治疗师。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●可以考虑对患膝骨性关节炎的病人进行局部热敷或冷敷。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●不推荐对膝骨性关节炎病人进行浴疗、超声疗法和电疗法。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：良)
保健品应用建议
●不推荐对骨关节炎病人补充硫酸软骨素和氨基葡萄糖。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●由于缺乏疗效证据，对于那些希望补充氨基葡萄糖和硫酸软骨素的患者，建议在3个月的疗程后症状没有改善的情况下停止服用。
(证据等级：专家共识；证据质量：无可支持试验)
●除非出现高质量试验证明临床疗效，否则不推荐使用其他保健品。
(证据等级：专家共识；证据质量：不足证据)
表1 用NSAID治疗发生严重不良事件的危险因素
? 心血管并发症 胃肠道并发症 肾脏并发症
年龄 >65岁 >65岁 >65岁
既往史 心衰 酒精性肝病 心衰
? 冠心病 幽门螺杆菌感染 脱水
? 糖尿病 溃疡病史 高血压
? 高血压 类风湿关节炎 先前存在肾脏疾病
? 心肌梗塞 上消化道出血 ?
? 脑卒中 ? ?
? 类风湿关节炎 ? ?
联合使用药物 ? 定期使用多种NSAID，抗栓药(如阿司匹林，华法林)，口服糖皮质激素 ACE抑制剂血管紧张素受体阻滞剂直接肾素抑制剂利尿剂
局部用药治疗建议
●建议应用辣椒素或珠卡赛辛以缓解手或膝骨关节炎导致的疼痛。
? (证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
? ●对于轻中度膝骨关节炎疼痛，建议在开始进行口服NSAIDs治疗前可局部使用双氯芬酸。
? (证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
? ●对于75岁以上的病人，开始NSAIDs治疗时，应优先选用局部剂型而非口服剂型。
? (证据等级：专家共识；证据质量：无可支持试验)
? ●当疼痛缓解不充分时，考虑局部治疗作为口服药物的辅助治疗。
(证据等级：专家共识；证据质量：无可支持试验)
对乙酰氨基酚治疗建议
●对乙酰氨基酚是无相关肝病的骨关节炎患者的首选镇痛药。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●应使用最大剂量2周以评估对乙酰氨基酚的效应。
(证据等级：专家共识；证据质量：无可支持试验)
NSAID应用的建议
●口服NSAID可用于对足量对乙酰氨基酚治疗不敏感的病人。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●在开始服用NSAID治疗前，应评估病人的消化道溃疡、心血管、肾脏并发症的风险。
(证据等级：专家共识；证据质量：无可支持试验)
●对于中度胃溃疡风险的病人，建议非选择性NSAIDs与PPI合用，或服用选择性COX-2抑制剂(如塞来昔布)。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●对于高度胃溃疡风险的病人，避免使用口服NSAID，改用替代药物。
(证据等级：专家共识；证据质量：无可支持试验)
●如果胃溃疡高危患者一定要服用NSAIDs，建议选择性COX-2抑制剂与PPI合用。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●慎用于有心血管事件风险人群，当选择口服时，推荐使用萘普生。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●禁用于肌酐清除率<30 mL/min的病人，如有可能，避免在有基础肾功能不全的病人肌酐清率<60 ml/min上使用
(证据等级：专家共识；证据质量：无可支持试验)
表2 安全性监测
大体时间 说明
患者：每天进行自我评估 ?基本指引
医生：于用药第3，7，14天进行随访评估 ?饭后用药物可有助于减少胃部不适。
? ?劝告患者避免用药超过每日最大剂量。
? ?患者应考虑来自所有非处方来源的对乙酰氨基酚。
? ?实验室检查：
? ?对乙酰氨基酚→基线肝功能测试应在肝毒性高风险患者中进行。
? ?NSAIDs→有肾脏疾病的患者和服用影响肾功能的药物(如利尿剂，ACEIs)的患者应检测血肌酐及内生肌酐清除率。肾功能应在7到10 d内重新评估。
? ?药物相互作用：
? ?已有研究观察到在接受乙酰氨基酚和NSAID药治疗的患者中国际标准比值(INR)增高。
? ?在镇痛治疗的初始阶段，应频繁地监测INR，并劝告患者注意出血迹象。
? ?NSAID应用注意：
? ?高血压
? ?应测量基线血压，然后每2至4周测量进行监测。
? ?未控制的高血压或服用降压药的患者需要更频繁的监测(即每1～2周)。
? ?尽可能避免同时使用超过1种NSAID产品；唯一的例外是服用低剂量阿司匹林进行心血管保护的患者。
表3 有效性评价
参数 大体时间 说明
疼痛缓解评估 患者：每天进行自我评估 ?如果疼痛控制满意：
?在开始治疗之前，重要的是要建立一个病人可接受的疼痛控制和功能水平评价指标 医生：于用药第3，7，14天进行随访评估? ?继续目前的治疗，并找到最低的有效剂量。
?可通过视觉模拟量表或量化疼痛的单独测量来实现(例如，步行，锻炼，做园艺等的能力) ? ?如果14 d后没有改善：
? ? ?切换备用药物
? ? ?如果对两种药物的充分试用失败，则进行进一步评估
? ? ?如果疼痛正在改善但未达到最优：
? ? ?确保最佳治疗(最大治疗剂量，定期给药等)
? ? ?考虑添加适当的辅助治疗(例如局部镇痛剂等)
阿片类药物和曲马多的使用建议
●将口服阿片类药物作为最后的药物治疗手段，特别是在等待手术的患者可以短期使用。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
●将曲马多作为最后的药物治疗手段。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
局部注射疗法建议
●可以考虑关节内注射皮质醇，短期缓解NSAIDs和对乙酰氨基酚治疗无效病人的症状。如果希望长期缓解症状，则需要考虑替代疗法。
(证据等级：系统综述[SRs]、Meta分析、随机对照试验[RCTs]；证据质量：优)
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