晚期癌症相关症状的用药
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">晚期肿瘤常常会<span style="color: black;">显现</span>影响生活质量的<span style="color: black;">有些</span>症状，如<span style="color: black;">病痛</span>、食欲<span style="color: black;">衰退</span>、恶病质、焦虑、便秘、谵妄、抑郁、腹泻、<span style="color: black;">呼气</span>困难、乏力、呃逆、失眠、口腔问题、恶心、呕吐、多汗、终末期烦乱不安、终末期<span style="color: black;">呼气</span>问题等等，妥善处理是<span style="color: black;">针对</span><span style="color: black;">加强</span>生活质量是非常<span style="color: black;">要紧</span>的。以下就结合<span style="color: black;">有些</span>文献来谈谈晚期肿瘤病人的<span style="color: black;">有些</span><span style="color: black;">药品</span>对症处理。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1、癌症<span style="color: black;">病痛</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">疼痛是晚期肿瘤病人<span style="color: black;">平常</span>的症状，<span style="color: black;">亦</span>是严重影响<span style="color: black;">病人</span>生活质量的<span style="color: black;">重点</span>的<span style="color: black;">原由</span>，<span style="color: black;">亦</span>常常会有<span style="color: black;">由于</span><span style="color: black;">病痛</span>严重<span style="color: black;">没</span>法<span style="color: black;">掌控</span><span style="color: black;">引起</span>轻生现象的<span style="color: black;">显现</span>。<span style="color: black;">药品</span>止痛治疗是缓解癌症<span style="color: black;">病痛</span><span style="color: black;">重点</span><span style="color: black;">办法</span>，<span style="color: black;">乃至</span>可能是<span style="color: black;">病人</span><span style="color: black;">独一</span>可能接受并获益的有效治疗<span style="color: black;">办法</span>。止痛药的<span style="color: black;">运用</span>应该遵循WHO癌症三阶梯止痛治疗原则，按<span style="color: black;">病痛</span>的程度<span style="color: black;">选取</span>合适的药 物。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic1.zhimg.com/80/v2-447619b87ffc9abf767e50389dac8e18_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">轻度<span style="color: black;">病痛</span>：相当于1-4级的<span style="color: black;">病痛</span>，病人虽有痛感但可忍受，能正常生活；给予非阿片类（非甾类抗炎药）加减辅助止痛药。<span style="color: black;">重视</span>：非甾类止痛药存在最大有效剂量（天花板效应注）的问题。常用<span style="color: black;">药品</span><span style="color: black;">包含</span>扑热息痛、阿司匹林、双氯芬酸盐、芬必得（布洛芬缓释胶囊）、意施丁（吲哚美辛控释片）、消炎痛、布洛芬、加合百服宁和吲哚美辛等等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">中度<span style="color: black;">病痛</span>：相当于5～6级的<span style="color: black;">病痛</span>，病人<span style="color: black;">病痛</span><span style="color: black;">显著</span>，<span style="color: black;">不可</span>忍受，影响<span style="color: black;">睡觉</span>。给予弱阿片类加减非甾类抗炎药和辅助止痛药。弱阿片类<span style="color: black;">药品</span><span style="color: black;">亦</span>存在天花板效应。常用<span style="color: black;">药品</span>有可待因、曲马多、强痛定、奇曼丁（曲马多缓释片）和双克因（可待因控释片）等等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">重度<span style="color: black;">病痛</span>：相当于7-10级的<span style="color: black;">病痛</span>，<span style="color: black;">病痛</span>剧烈，<span style="color: black;">不可</span>入睡，可伴有被动体位或植物神经功能<span style="color: black;">错乱</span>表现。给予阿片类加减非甾类抗炎药和辅助止痛药。强阿片类<span style="color: black;">药品</span><span style="color: black;">没</span>天花板效应，但可产生耐受，需适当<span style="color: black;">增多</span>剂量以克服耐受现象。以往认为用吗啡止痛会成瘾，<span style="color: black;">因此</span>不愿给病人用吗啡，<span style="color: black;">此刻</span>证明这个观点是错误的—<span style="color: black;">运用</span>吗啡的癌痛病人很少产生成瘾性。常用<span style="color: black;">药品</span>有吗啡片、美菲康（吗啡缓释片）、美施康定（吗啡控释片，可直肠给药）等等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">神经病理性<span style="color: black;">病痛</span>：阿米替林，卡马西平，地塞米松，加巴喷丁；</p>内脏<span style="color: black;">病痛</span>：丁溴东莨菪碱。
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">临床<span style="color: black;">科研</span><span style="color: black;">显示</span>，奥施康定联合加巴喷丁缓解癌痛临床疗效<span style="color: black;">明显</span>，并可改善<span style="color: black;">病人</span>的免疫功能,<span style="color: black;">加强</span>其生活质量。<span style="color: black;">针对</span>严重的<span style="color: black;">病痛</span><span style="color: black;">能够</span><span style="color: black;">思虑</span>鞘内<span style="color: black;">止疼</span>泵给药。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">对<span style="color: black;">病痛</span>的处理采取主动预防用药。止痛剂应有规律按时给予，而不是必要时才给，下一次用药应在前一次<span style="color: black;">药品</span>药效消失之前给予，得以<span style="color: black;">连续</span><span style="color: black;">止疼</span>。<span style="color: black;">经过</span>正确治疗，除<span style="color: black;">少许</span>病例外都能得到良好的<span style="color: black;">掌控</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2、消化系统症状</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">晚期肿瘤病人常常存在不同程度的消化系统症状，<span style="color: black;">包含</span>食欲<span style="color: black;">衰退</span>、厌食、恶心、呕吐、便秘、腹泻。严重的会<span style="color: black;">显现</span>恶液质体质，针对不同的症状，<span style="color: black;">必须</span>采用不同的<span style="color: black;">药品</span>处理。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">厌食：肿瘤<span style="color: black;">病人</span>就诊时有25%～40%<span style="color: black;">出现</span>食欲不振，厌食的现象，严重影响<span style="color: black;">病人</span>的生活质量。虽然早在1993年FDA<span style="color: black;">已然</span><span style="color: black;">准许</span>甲地孕酮用于厌食、恶液质的治疗，但<span style="color: black;">相关</span>甲地孕酮<span style="color: black;">可否</span>能<span style="color: black;">增多</span>食欲、纠正厌食是有争议的。多项<span style="color: black;">科研</span>认为甲地孕酮并<span style="color: black;">不可</span>纠正厌食。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">恶心、呕吐：灭吐灵，氟哌啶醇，丁溴东莨菪碱，地塞米松，苯海拉明，奥曲肽（用于恶心与呕吐的基本<span style="color: black;">药物</span>相同，但用药剂量、剂型及给药途径有所差异。）；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">便秘：乳果糖口服液，番泻叶，比沙可啶，矿物油灌肠剂；</p>腹泻：口服补液盐，易蒙停，蒙脱 石散，严重的<span style="color: black;">能够</span>用奥曲肽<span style="color: black;">控制</span>肠液的产生。
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">呃逆：呃逆是膈肌以及肋间肌<span style="color: black;">没</span><span style="color: black;">认识</span>的、阵挛性的收缩，<span style="color: black;">引起</span>吸气时声门<span style="color: black;">忽然</span>关闭，气<span style="color: black;">身体</span>流受阻而发出特征性的声音。<span style="color: black;">导致</span>呃逆的<span style="color: black;">原由</span>有器质性的，<span style="color: black;">亦</span>有可能是精神性<span style="color: black;">原由</span><span style="color: black;">导致</span>。<span style="color: black;">长时间</span>反复<span style="color: black;">爆发</span>的顽固呃逆可能严重<span style="color: black;">困惑</span>癌症<span style="color: black;">病人</span>。<span style="color: black;">针对</span>短暂<span style="color: black;">出现</span>的呃逆，可能<span style="color: black;">经过</span>快速饮水等简单的非<span style="color: black;">药品</span><span style="color: black;">办法</span>缓解。而<span style="color: black;">针对</span>反复<span style="color: black;">爆发</span>的难治性呃逆，则<span style="color: black;">必须</span>针对<span style="color: black;">详细</span>病因个体化治疗。治疗呃逆的<span style="color: black;">药品</span>常用的为胃复安，多潘立酮，<span style="color: black;">亦</span><span style="color: black;">能够</span><span style="color: black;">选取</span>氯丙嗪以及巴氯芬。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">乏力：癌症<span style="color: black;">病人</span>乏力<span style="color: black;">出现</span>率高达70%~100%。尽管癌症<span style="color: black;">关联</span>性乏力的<span style="color: black;">出现</span>率很高，但其病理生理学机制仍尚不<span style="color: black;">知道</span>。可能的机制<span style="color: black;">包含</span>肌肉代谢产物的<span style="color: black;">反常</span>堆积，细胞因子<span style="color: black;">反常</span>产生，神经肌肉功能<span style="color: black;">反常</span>改变，三磷酸腺苷合成<span style="color: black;">反常</span>，5羟色胺调节<span style="color: black;">反常</span>以及迷走神经传入冲动<span style="color: black;">反常</span>。<span style="color: black;">日前</span>对乏力症状的处理尚缺乏有效的治疗<span style="color: black;">办法</span>，<span style="color: black;">因此呢</span>不少癌症<span style="color: black;">病人</span>认为乏力是癌症及癌症治疗<span style="color: black;">关联</span>的最痛苦症状。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">口干：口干是许多晚期癌症<span style="color: black;">病人</span>的<span style="color: black;">平常</span>症状。<span style="color: black;">导致</span>口干的<span style="color: black;">原由</span>的<span style="color: black;">重点</span><span style="color: black;">原由</span>较<span style="color: black;">繁杂</span>，<span style="color: black;">包含</span>唾液腺分泌减少，口腔粘膜病变、某些<span style="color: black;">药品</span>的不良反应等<span style="color: black;">原由</span>。毛果芸香碱是用于治疗口干的有效<span style="color: black;">药品</span>，其<span style="color: black;">功效</span>是<span style="color: black;">经过</span>刺激唾液腺分泌缓解口干。约50%的口干<span style="color: black;">病人</span>接受毛果芸香碱治疗有效。<span style="color: black;">弥补</span>体液、口腔清洁、冰块等非<span style="color: black;">药品</span>疗法，<span style="color: black;">亦</span>可能在<span style="color: black;">必定</span>程度上缓解口干症状。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3、精神系统症状</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">失眠、焦虑、抑郁、谵妄、临终躁动等症状都是晚期及终末期癌症<span style="color: black;">病人</span><span style="color: black;">平常</span>的痛苦症状。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">失眠：<span style="color: black;">疾患</span>本身的<span style="color: black;">原因</span>以及对<span style="color: black;">疾患</span>的焦虑常常<span style="color: black;">引起</span>晚期肿瘤<span style="color: black;">病人</span>的<span style="color: black;">睡觉</span><span style="color: black;">阻碍</span>，<span style="color: black;">针对</span>恶性肿瘤<span style="color: black;">关联</span>性<span style="color: black;">睡觉</span><span style="color: black;">阻碍</span>的治疗<span style="color: black;">必须</span>综合治疗<span style="color: black;">干涉</span>，纯粹<span style="color: black;">运用</span><span style="color: black;">药品</span>治疗是<span style="color: black;">不睬</span>想的，应该以认知<span style="color: black;">行径</span>治疗为主，<span style="color: black;">药品</span>治疗为辅，综合改善恶性肿瘤<span style="color: black;">病人</span>的<span style="color: black;">睡觉</span><span style="color: black;">阻碍</span>问题。<span style="color: black;">药品</span><span style="color: black;">能够</span><span style="color: black;">选取</span>艾司唑仑，曲唑酮，唑吡坦。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">抑郁：阿米替林，西酞普兰，米氮平</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">焦虑：安定，劳拉西泮，咪达唑仑</p>谵妄：氟哌啶醇，左美丙嗪
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">多汗：恶性肿瘤直接或间接<span style="color: black;">功效</span>产生的内生性致热源、某些<span style="color: black;">药品</span>治疗不良反应、全身<span style="color: black;">衰尽</span>等<span style="color: black;">原由</span><span style="color: black;">导致</span>多汗，<span style="color: black;">海量</span>出汗常常是不良预后的一个征兆。<span style="color: black;">因此呢</span>，缓解多汗的治疗<span style="color: black;">亦</span>应针对相应病因而决策。<span style="color: black;">倘若</span>多汗与发热<span style="color: black;">相关</span>，可<span style="color: black;">选取</span>对乙酰氨基酚及非甾体类抗炎药。<span style="color: black;">倘若</span>多汗与发热<span style="color: black;">没</span>关，或用非甾体类抗炎药<span style="color: black;">没</span>效时，<span style="color: black;">能够</span><span style="color: black;">选取</span>抗分泌<span style="color: black;">药品</span>：阿米替林，普鲁本辛，沙利度胺，<span style="color: black;">亦</span><span style="color: black;">能够</span><span style="color: black;">选取</span>中医中药，辩证施治。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">参考文献 </p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">David C. Currow. et al.A randomised, double blind, placebo-controlled trial of megestrol acetate or dexamethasone in treating symptomatic anorexia in people with advanced cancer.Sci Rep. 2021; 11: 2421.</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Steger M,Schneemann M,Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther.2015, 42(9):1037-50.</p>
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