Leitliniengerechte medikamentöse Therapie des chronischen Rückenschmerzes

Zusammenfassung

Der chronische lumbale Rückenschmerz (syn.: chronischer Kreuzschmerz) ist eine der in der Medizin am häufigsten vorkommende Erkrankung mit einer immensen volkswirtschaftlichen Bedeutung. Die Ätiologie ist dabei vielfältig, wobei gerade in den letzten Jahren genetisch bedingte Prädispositionen wie z. B. Polymorphismen im Interleukin-1-Gen identifiziert wurden. Darüber hinaus scheinen muskuläre Erkrankungen wie z. B. das M.-piriformis-Syndrom oder auch myofasziale Schmerzsyndrome eine wichtige Rolle zu spielen. In Bezug auf die medikamentöse Schmerztherapie sollte das Medikament die Schmerzen wirksam unterdrücken, auch in der Langzeitanwendung nebenwirkungsarm bleiben, keine Gewöhnung hervorrufen und Chronifizierungsprozessen entgegenwirken. Der vorliegende Artikel fasst dabei die aus unterschiedlichen Leitlinien empfohlene Vorgehensweise zur medikamentösen Therapie zusammen und wertet kritisch neuere Daten zu einzelnen Substanzen. Auf die im Rahmen eines schmerztherapeutischen Gesamtkonzepts notwendigen nichtmedikamentösen Therapieformen wird in diesem Artikel nicht eingegangen.

Abstract

Chronic low back pain is one of the most frequent diseases in medicine with a high economic burden. The aetiology is heterogenous and multicausal, but recently genetic factors leading to a predisposition such as polymorphism in the interleukin-1 gene have been identified. Muscular diseases like piriformis muscle syndrome or myofascial pain syndrome appear to play an additional role in the pathogenesis. Medical pain treatment should use medications that are potent to reduce low back pain, should exhibit minor side effects and no potential for drug abuse and should prevent chronification. The present article summarises different and recent guidelines for the medical treatment of low back pain and evaluates recent studies investigating different substances. The review also includes a concise summary of non-medication treatment of low back pain but does not go into detail.

Schlüsselwörter

Rückenschmerz - Sensibilisierung - Schmerztherapie

Keywords

low back pain - sensitization - pain treatment

• Literatur

• 1 Andersson GB. Epidemiological features of chronic low-back pain. Lancet 1999; 354: 581-585
• 2 Balagué F, Mannion AF, Pellisé F et al. Non-specific low back pain. Lancet 2012; 379: 482-491
• 3 Wenig CM, Schmidt CO, Kohlmann T et al. Costs of back pain in Germany. Eur J Pain 2009; 13: 280-286
• 4 Borenstein D. Chronic low back pain. Musculosceletal Med 1996; 22: 439-456
• 5 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344: 363-370
• 6 Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). Kreuzschmerzen. (DEGAM-Leitlinie; 3). Düsseldorf: DEGAM; 2003. http://www.degam.de/leitlinien/3_kreuzschmerzen.html
• 7 Chenot JF, Becker A, Niebling W et al. Aktualisierung der DEGAM-Leitlinie Kreuzschmerzen. Z Allg Med 2007; 83: 487-494
• 8 Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ). Empfehlungen zur Therapie von Kreuzschmerzen. 3.. Auflage. 2007. http://www.akdae.de/Arzneimitteltherapie/TE/Archiv/Kreuzschmerzen.pdf
• 9 Burton AK, Eriksen HR, Leclerc A et al. European guidelines for prevention in low back pain. European Commission Research Directorate General; 2004
• 10 van Tulder M, Becker A, Bekkering T et al. European guidelines for the management of acute nonspecific low back pain in primary care. European Commission Research Directorate General; 2005. http://www.backpaineurope.org/web/files/WG1_Guidelines.pdf
• 11 Hildebrandt J, Ursin H, Mannion AF et al. European guidelines for the management of chronic non-specific low back pain. 2005. http://www.backpaineurope.org/web/files/WG2_Guidelines.pdf
• 12 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale VersorgungsLeitlinie Kreuzschmerz – Langfassung. Version 1.X. 2010. http://www.versorgungsleitlinien.de/themen/kreuzschmerz
• 13 Werber A, Schiltenwolf M. Chronischer Rückenschmerz. Nervenarzt 2012; 83: 243-257
• 14 de Schepper EI, Damen J, van Meurs JB et al. The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic. Spine (Phila Pa 1976) 2010; 35: 531-536
• 15 Cheung KM, Karppinen J, Chan D et al. Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals. Spine (Phila Pa 1976) 2009; 34: 934-940
• 16 Endean A, Palmer KT, Coggon D. Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. Spine (Phila Pa 1976) 2011; 36: 160-169
• 17 Hopayian K, Song F, Riera R et al. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J 2010; 19: 2095-2109
• 18 Ramsook RR, Malanga GA. Myofascial low back pain. Curr Pain Headache Rep 2012; 16: 423-432
• 19 Shiri R, Karppinen J, Leino-Arjas P et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010; 171: 135-154
• 20 Shiri R, Karppinen J, Leino-Arjas P et al. The association between smoking and low back pain: a meta-analysis. Am J Med 2010; 123: 87 e7-35
• 21 Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine 2008; 75: 388-396
• 22 Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Familial predisposition and heritability estimation. Joint Bone Spine 2008; 75: 383-387
• 23 Battie MC, Videman T, Levalahti E et al. Heritability of low back pain and the role of disc degeneration. Pain 2007; 131: 272-280
• 24 Roffey DM, Wai EK, Bishop P et al. Causal assessment of occupational sitting and low back pain: results of a systematic review. Spine J 2010; 10: 252-261
• 25 Roffey DM, Wai EK, Bishop P et al. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J 2010; 10: 89-99
• 26 Roffey DM, Wai EK, Bishop P et al. Causal assessment of occupational standing or walking and low back pain: results of a systematic review. Spine J 2010; 10: 262-272
• 27 Roffey DM, Wai EK, Bishop P et al. Causal assessment of workplace manual handling or assisting patients and low back pain: results of a systematic review. Spine J 2010; 10: 639-651
• 28 Roffey DM, Wai EK, Bishop P et al. Causal assessment of occupational pushing or pulling and low back pain: results of a systematic review. Spine J 2010; 10: 544-553
• 29 Reme SE, Tangen T, Moe T et al. Prevalence of psychiatric disorders in sick listed chronic low back pain patients. Eur J Pain 2011; 15: 1075-1080
• 30 Seok H, Son BK, Ha YR et al. Clinical influence of emotional depression on chronic low back pain. J Korean Acad Rehab Med 2003; 27: 568-574
• 31 Gerhardt A, Hartmann M, Schuller-Roma B et al. The prevalence and type of Axis-I and Axis-II mental disorders in subjects with non-specific chronic back pain: results from a population-based study. Pain Med 2011; 12: 1231-1240
• 32 Mense S. Pathophysiologie des Rückenschmerzes und seine Chronifizierung. Schmerz 2001; 15: 413-417
• 33 Maihöfner C, Nickel FT, Seifert F. Neuropathische Schmerzsyndrome und Neuroplastizität in der funktionellen Bildgebung. Schmerz 2010; 24: 137-145
• 34 Kobayashi Y, Kurata J, Sekiguchi M et al. Augmented cerebral activation by lumbar mechanical stimulus in chronic low back pain patients: an FMRI study. Spine (Phila Pa 1976) 2009; 34: 2431-2436
• 35 Laine L, Curtis SP, Cryer B et al. Risk factors for NSAID-associated upper GI clinical events in a long-term prospective study of 34 701 arthritis patients. Aliment Pharmacol Ther 2010; 32: 1240-1248
• 36 Chan FK, Hung LC, Suen BY et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. N Engl J Med 2002; 347: 2104-2110
• 37 Chan FK, Lanas A, Scheiman J et al. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR): a randomised trial. Lancet 2010; 376: 173-179
• 38 Höer A, Gothe H, Schiffhorst G et al. Comparison of the effects of diclofenac or other non-steroidal anti-inflammatory drugs (NSAIDs) and diclofenac or other NSAIDs in combination with proton pump inhibitors (PPI) on hospitalisation due to peptic ulcer disease. Pharmacoepidemiol Drug Saf 2007; 16: 854-858
• 39 Wallace JL, Syer S, Denou E et al. Proton pump inhibitors exacerbate NSAID-induced small intestinal injury by inducing dysbiosis. Gastroenterology 2011; 141: 1314-1322
• 40 Shau WY, Chen HC, Chen ST et al. Risk of new acute myocardial infarction hospitalization associated with use of oral and parenteral non-steroidal anti-inflammation drugs (NSAIDs): a case-crossover study of Taiwan's National Health Insurance claims database and review of current evidence. BMC Cardiovasc Disord 2012; 12: 4 [Epub ahead of print]
• 41 Chang CH, Shau WY, Kuo CW et al. Increased risk of stroke associated with nonsteroidal anti-inflammatory drugs: a nationwide case-crossover study. Stroke 2010; 41: 1884-1890
• 42 Fosbol EL, Folke F, Jacobsen S et al. Cause-specific cardiovascular risk associated with nonsteroidal antiinflammatory drugs among healthy individuals. Circ Cardiovasc Qual Outcome 2010; 3: 395-405
• 43 Aljadhey H, Tu W, Hansen RA et al. Comparative effects of non-steroidal anti-inflammatory drugs (NSAIDs) on blood pressure in patients with hypertension. BMC Cardiovasc Disord 2012; 12: 93 [Epub ahead of print]
• 44 MacDonald TM, Richard D, Lheritier K et al. The effects of lumiracoxib 100 mg once daily vs. ibuprofen 600 mg three times daily on the blood pressure profiles of hypertensive osteoarthritis patients taking different classes of antihypertensive agents. Int J Clin Pract 2010; 64: 746-755
• 45 Klawe C, Maschke M. Flupirtine: pharmacology and clinical applications of a nonopioid analgesic and potentially neuroprotective compound. Expert Opin Pharmacother 2009; 10: 1495-1500
• 46 Li C, Ni J, Wang Z et al. Analgesic efficacy and tolerability of flupirtine vs. tramadol in patients with subacute low back pain: a double-blind multicentre trial. Curr Med Res Opin 2008; 24: 3523-3530
• 47 Überall MA, Müller-Schwefe GH, Terhaag B. Efficacy and safety of flupirtine modified release for the management of moderate to severe chronic low back pain: results of SUPREME, a prospective randomized, double-blind, placebo- and active-controlled parallel-group phase IV study. Curr Med Res Opin 2012; 28: 1617-1634
• 48 Deshpande A, Furlan A, Mailis-Gagnon A et al. Opioids for chronic low-back pain. Cochrane Database Syst Rev 2007; (03) CD004959
• 49 Reinecke H, Sorgatz H. S3-Leitlinie LONTS. Schmerz 2009; 23: 440-447
• 50 Urquhart DM, Hoving JL, Assendelft WW et al. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev 2008; (01) CD001703
• 51 Holt S, Schmiedl S, Thürmann PA. PRISCUS-Liste potenziell inadäquater Medikation für ältere Menschen. Dtsch Ärztebl 2010; 107: 543-551
• 52 Skljarevski V, Ossanna M, Liu-Seifert H et al. A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain. Eur J Neurol 2009; 16: 1041-1048
• 53 Mazza M, Mazza O, Pazzaglia C et al. Escitalopram 20 mg versus duloxetine 60 mg for the treatment of chronic low back pain. Expert Opin Pharmacother 2010; 11: 1049-1052
• 54 Skljarevski V, Zhang S, Desaiah D et al. Duloxetine Versus Placebo in Patients With Chronic Low Back Pain: A 12-Week, Fixed-Dose, Randomized, Double-Blind Trial. J Pain 2010; 11: 1282-1290
• 55 Romanò CL, Romanò D, Bonora C et al. Pregabalin, celecoxib, and their combination for treatment of chronic low-back pain. J Orthop Traumatol 2009; 10: 185-191
• 56 Kaki AM, El-Yaski AZ, Youseif E. Identifying neuropathic pain among patients with chronic low back pain: use of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale. Reg Anesth Pain Med 2005; 30: 422-428
• 57 Freynhagen R, Baron R, Gockel U et al. Pain detect: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22: 1911-1920