Medikamentöse Behandlung des CRPS

Zusammenfassung

Das komplexe regionale Schmerzsyndrom (CRPS) ist gekennzeichnet durch einen charakteristischen stadienhaften Ablauf mit den Hauptsymptomen Schmerzen, trophischen und entzündlichen Veränderungen sowie Funktionseinschränkung bis -verlust. Während das letzte mit intensiver Physio- und Ergotherapie behandelt werden muss, können die ersten drei Symptome medikamentös beeinflusst werden: Hauptpfeiler der medikamentösen Therapie der neuropathischen Schmerzen sind Antidepressiva, Antiepileptika und Opioide, während die eigentlichen akuten nozizeptiven Schmerzen und die akute Entzündung auf nicht-steroidale Analgetika und Steroide ansprechen. Zusätzlich wirken auch Calcitonin und die Osteoklasten hemmenden Biphosphonate schmerzlindernd und knochenerhaltend. Der Einsatz von Sympathikolytika außerhalb von lokoregionalen Anästhesieverfahren (welche an anderer Stelle besprochen werden) ist umstritten. Allgemein gibt es im Gebiet der medikamentösen Schmerzbehandlung spezifisch des komplexen regionalen Schmerzsyndroms nur sehr geringe Evidenz; die meisten Erkenntnisse werden aus der Behandlung anderer chronischer neuropathischer Schmerzsyndrome (wie diabetische Polyneuropathie oder post-Zoster-Schmerzen) übernommen oder beruhen auf pathophysiologischen Überlegungen.

Abstract

The main symptoms of excruciating pain, trophic and inflammatory changes, as well as functional impairment of limbs are the hallmark of the complex regional pain syndrome (CRPS). While functional impairments have to be treated by physical and occupational therapy, the former three symptoms are amendable to drug treatment: antidepressants, antiepileptic drugs and opioids are the most important drug classes for alleviating neuropathic pain whereas acute nociceptive pain may be positively influenced by non-steroidal anti-inflammatory drugs and steroids. In addition, calcitonin and the biphosphonates inhibit osteoclasts and therefore loss of bone mass and may thus also reduce pain. The use of sympatholytic agents beyond locoregional anesthesia techniques (which are covered elsewhere in this issue) is not unequivocal. In general, the evidence level for treatment strategies specifically for the complex regional pain syndrome is very poor; most recommendations and algorithms rely on results derived from studies testing drugs against other conditions where chronic (neuropathic) pain is prevalent, like diabetic polyneuropathy or postherpetic neuralgia, or medications are used on the basis of pathomechanistic considerations.

Schlüsselwörter

komplexes regionales Schmerzsyndrom (CRPS) - neuropathisch - Behandlung - Antidepressiva - Opiate

Key words

complex regional pain syndrome (CRPS) - neuropathic - treatment - antidepressants - opioids

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