Refraktäre Dyspnoe bei fortgeschrittener COPD: Palliative Therapie mit Opioiden

Vor allem in sehr fortgeschrittenen Krankheitsstadien der COPD mit „refraktärer Dyspnoe“ können neben einer Therapie der Grunderkrankung palliative Therapiemaßnahmen wie eine medikamentöse Therapie mit Opioiden zur Linderung der Dyspnoe erforderlich sein. Es gibt deutliche Hinweise darauf, dass diese wirksame Therapie bislang nur bei einem geringen Teil derjenigen COPD-Patienten eingesetzt wird, die davon profitieren könnten.

Abstract

Dyspnea is a leading symptom in COPD. Bronchodilators (long acting anticholinergics and long acting beta agonists) are the mainstay of medical treatment. Non pharmacological therapies like pulmonary rehabilitation, long-term oxygen therapy or lung volume reduction can help to further improve dyspnea. Nevertheless, patients with advanced disease may develop refractory dyspnea. Randomized controlled trials demonstrated that the palliative treatment with low-dose systemic opioids is an effective treatment option in these patients. A low starting dose (e. g. 1.0 mg morphine, immediate release) is recommended. Subsequent doses are titrated to achieve the lowest effective dose based on whether dyspnea relief has been achieved and whether any side effects have developed. This low-dose opioid treatment has been demonstrated to be safe for symptom reduction in severe COPD and is not associated with increased hospital admissions or deaths. Physicians should offer a trial of low-dose oral opioids to patients with refractory dyspnea that affects their daily activities and quality of life.

Kernaussagen

• Dyspnoe ist letztlich die bewusste unangenehme Wahrnehmung eines vermehrten Atemantriebs. Sie korreliert wenig mit körperlichen Untersuchungsbefunden, Laborwerten oder den Ergebnissen apparativer Untersuchungen.

• Dyspnoe ist ein multidimensionales Symptom, das aus dem Zusammenwirken von physiologischen und affektiven Mechanismen resultiert. Insbesondere Angst, Panik oder Depression können das Dyspnoe-Empfinden verstärken.

• Die Basis jeder Therapie von Dyspnoe ist eine möglichst optimale Behandlung der Ursachen bzw. der Grund- und Begleiterkrankungen. Die palliative Therapie von Dyspnoe ergänzt diese kausale Therapie.

• Die am besten etablierte medikamentöse Therapie der Dyspnoe ist die Behandlung mit niedrigdosierten systemischen Opioiden.

• In der Regel sollte eine palliative Opioidtherapie bei stabiler refraktärer Dyspnoe im Rahmen einer COPD mit 1,0 – 2,5 mg unretardiertem oralem Morphin begonnen werden. Die Dosis wird unter sorgfältiger klinischer Überwachung titriert. Mögliche Nebenwirkungen wie Obstipation, Müdigkeit oder Übelkeit müssen beachtet werden.

• Bis heute finden sich in der wissenschaftlichen Literatur keine eindeutigen Belege für eine erhöhte Mortalität durch Atemdepression beim Einsatz derart niedrigdosierter Opioide zur Therapie von refraktärer Dyspnoe bei fortgeschrittener COPD.

• Die palliative Therapie der refraktären Dyspnoe bei fortgeschrittener COPD ist integraler Bestandteil der ärztlichen Versorgung dieser Patientengruppe.

Schlüsselwörter

COPD - Dyspnoe - Palliativtherapie - Opioide - Opiate

Keywords

COPD - dyspnea - palliative care - opioids - medical therapy

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