39 BOLEčINA PRI BOLNIKU Z NAPREDOv ALIM RAKOM Branka Stražišar, Slavica Lahajnar Čavlovič Bolniki v napredovali fazi neozdravljive bolezni imajo pogosto bolečino, ki je v tretji- ni primerov prezrta in premalo zdravljena, zahteva zdravljenje znotraj paliativne oskrbe. Poleg fizične, nociceptivne,nevorpatske in nociplastične komponente igrajo veliko vlogo pri bolečini teh bolnikov še psihološka, socialna in duševna razsežnost. Zaradi neobvladane stiske se lahko razvije stanje, ko bolnik čuti samo še nesoraz- merno močno bolečino - tako imenovana totalna bolečina. Zdravljenje raka pogosto povzroča bolečino, lahko gre za posledice operacije, kemoterapije, obsevanja, hor- monske ali tarčne terapije. Za ustrezno zdravljenje bolečine je potrebno najprej oceniti jakost bolečine po ustre- zni bolečinski lestvici, določiti mehanizem nastanka in skupaj z bolnikom načrtovati način zdravljenja bolečine, ki je primeren njegovem splošnem stanju. Pri bolniku z rakom se vzrok bolečine lahko odpravi z antitumorskim zdravljenjem. Glede na ja- kost bolečine se po WHO lestvici odločamo o vrsti analgetika. Na vseh treh stopnjah uporabljamo nefarmakološke metode, kot so psihološka podpora in rehabilitacijske intervencije. Za zdravljenje srednje močne bolečine uporabimo šibke opioide kot sta tramadol in kodein v kombinaciji z neopioidnimi analgetiki. Kot alternativa šib- kim opioidom lahko uporabimo nizke odmerke močnih opioidov. Zdravilo izbire za srednjo do močno bolečino so močni opioidi. Izberemo bolniku prijazno pot vnosa, najbolj priporočljiv je oralni vnos. Fentanil in buprenorfin sta najvarnejši zdravili za zdravljenje bolečine pri kronični ledvični odpo- vedi. Podkožni pristop je enostaven in učinkovit in je izbira, kadar oralna pot ni možna, omogoča zdravljenje več simptomov hkrati. Žilni pristop je možen za titracijo, kadar želimo hitro znižati jakost bolečine. Intraspinalno dovajanje zdravil in druge invazivne tehnike so lahko del zdravljenja hude in neobvladane bolečine. Tri in petdeset do se- demdeset odstotkov bolnikov z rakavo bolečino potrebuje alternativno pot vnosa opi- oidov dneve in ure pred smrtjo. Pogosto takrat uporabimo podkožni pristop. Titracija je proces, pri katerem se odmerek opioida hitro spreminja za dosego zmanj- šanja bolečine brez neželenih učinkov. Za zdravljenje prebijajoče bolečine se pripo- ročajo oblike opioidov s takojšnjim delovanjem pri bolnikih, ki že prejemajo dolgo delujoče opioide za zdravljenje kronične bolečine. Pri nevropatski bolečini bolnikom predpišemo antidepresiv in/ali antikonvulziv. 40 Patients with a progressive stage of disease often face with pain, which in one third of patients is not sufficiently treated and thus needs a palliative approach. Pain in malignant diseases has an important physical, nociceptive component, but also psy- chological, social and spiritual dimension. In addition to nociceptive and neuro- pathic pain, in terminal patients not rarely a specific condition develops, when a patient feels nothing but very severe pain – the so called »condition of total pain« The treatment of malignant disease is a frequent reason for pain in patients with malignant diseases; the pain can follow or accompany the surgical procedure, chemotherapy, radiation therapy as well as hormonal and target antitumor therapy. The appropriate pain treatment includes evaluation of pain intensity according to adequate pain scale, determination of exact origin of pain and development of pain management plan in cooperation with the patient. The most effective way of pain management is eliminating the cause of pain with antitumor treatment. The selec- tion of most appropriate analgesic medication is based on intensity of pain accord- ing to WHO pain scale, in all three stages of pain treatment the nonpharmacological pain management methods can be used, such as psychological support and rehabil- itation interventions. Fort the treatment of mild and moderate pain weak opioid analgesics can be used, such as tramadol and codeine combined with nonopioid analgesics. As an alternative of weak opioid analgesics, »strong« opioid analgesic in low dosage can be used. For moderate to severe pain the drug of choice is opioid, applied in a patient friend- ly way, preferably through the mouth. For the treatment of pain in patients with chronic kidney failure phentanyl and buphrenorphine are most appropriate. Subcu- taneous application is easy and effective and should be used when oral application is not possible, it enables treatment of more symptoms at the same time. Intrave- nous application is best when drug titration should be performed for an immediate pain relief. Drug titration is the process of adjusting the dose of medication for the maximum benefit without adverse effects. Fort the treatment of breakthrough pain, in patients already treated with opioid the forms of opioid with immediate action/effect should be used. The drugs for the management of neuropathic pain are antidepressants and/or an- ticonvulsives. An important part of treatment of malignant pain are intraspinal methods of drug application. 53%–70% of patients with cancer-related pain require an alternative route for opioid administration in the months and hours before death. In such situation subcutaneous application is the most appropriate.