#1
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Zoster
Óâàæàåìûå êîëëåãè.Ïîäåëèòåñü îïûòîì ëå÷åíèÿ äàííîãî íåäóãà.
Åñòü íåñêîëüêî âîïðîñîâ:1.Êóïèðîâàíèå áîëåâîãî ñèíäðîìà, íå ïîääàþøåãîñÿ ÍÏÂÑ (áëîêàäû íå â ñ÷¸ò).Êàêàÿ âàøà òàêòèêà äàëüøå? 2.Âàøå îòíîøåíèå ê Ýïèãåí-èíòèìó? Ñàì ýòîò ñïðåé íå íàçíà÷àë,íî ñëûøàë ìíîãî ðàçíûõ ìíåíèé. 3.Êàêóþ ïðîôèëàêòèêó ðåöåäèâà âû ïðåäïî÷èòàåòå? Áóäó ðàä îáñóäèòü ñâîè ñõåìû ëå÷åíèÿ, è âûñëóøàòü âàøè.Ñïàñèáî. |
#2
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Âîò íåêòîðûå âûäåðæêè èç ïåðåâîäíîãî ñïðàâî÷íèêà "Áîëü è àíàëãåçèÿ" èçä-âî Ëèòòåðà
(êñòàòè âñåì ðêîìåíäóþ - poket size è âñÿ "ãàéäëàéíñîâàÿ" èíôîðìàöèÿ ïî îáåçáîëèâàíèþ áåç êîììåð÷åñêèõ íàçâàíèé è ðåêëàìû) 1. Ïðîòèâîâèðóñíàÿ òåðàïèÿ: Ôàìöèêëîâèð 250/8 â ñóò., Âàëàöèêëîâèð 1ãð/7 â ñóò, Àöèêëîâèð 800ìã/5 â ñóò. ëå÷åíèå íàäî íà÷èíàòü â ïåðâûå 72 ÷àñà. 2 Îñòðàÿ áîëü Àñïèðèí 300-600 êàæäûå 4 ÷àñà (äåòÿì íåëüçÿ) Ïàðàöåòàìîë 0.5-1.0 êàæä. 4 ÷àñà íå áîëüøå 4 ãð/ñóò ÍÏÂÏ ïî ñâîèì ñõåìàì. Ïðè ñèëüíîé áîëè - îïèîèäû äëÿ ïðèåìà âíóòðü. Ëèäîêàèíîâàÿ ìàçü èëè êîìáèíàöèÿ ëèäîêàèíà è ïðèëîêàèíà â âèäå êðåìà ìîæíî íàíîñèòü íà íåèçúÿçâë¸ííóþ êîæó. Íå äîêàçàíî, ÷òî ñèñòåìíûå êîðòèêîñòåðèäû èçîëèðîâàííî ìîãóò ïðåäóïðåæäàòü ïîñòãåðï. íåâðàëãèþ, íî â îäíîì áîëüøîì èññëåäîâàíèè áûëî óñòàíîâëåíî, ÷òî áîëü è íàðóøåíèå ñíà â îñòðîé ôàçå ðàçðåøàëîñü áûñòðåå, êîãäà ïðåäíèçîëîí äàâàëñÿ â ñíèæàþùåì ðèòìå îò 40 ã/ñóò â äåíü 21 äåíü â êîìáèíàöèè ñ àöèêëîâèðîì. Èñïîëüçîâàíèå àìèòðèïòèëëèíà, áëîêàäû èëè îïèîèäîâ ïðè íåîáõîäèìîñòè ìîæåò ïðåäóïðåæäàòü ãèïåð÷óâñòâèòåëüíîñòü ÖÍÑ, îäíàêî öåííîñòü ýòèõ ýòèõ ìåðîïðèÿòèé íóæäàåòñÿ â äîêàçàòåëüñòâå åù¸. |
#3
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Óâàæàåìûé Åâãåíèé!
Åñëè áóäåò èíòåðåñíûì ôðàãìåíò ìíåíèÿ ýêñïåðòîâ: The most common complication of HZ is postherpetic neuralgia (PHN), defined as significant pain or dysaesthesia present > or = 3 months after HZ. PHN results from damage and secondary changes within components of the nervous system subserving pain. Therapy for acute HZ is intended to reduce acute pain, hasten rash healing and reduce the risk of PHN and other complications. Antiviral drugs are close to achieving these aims but do not entirely remove risk of PHN. Oral steroids show no protective effect against PHN. Adequate analgesia during the acute phase may require strong opioid drugs. Nerve blocks and tricyclic antidepressants (TCAs) may reduce the risk of PHN although firm evidence is lacking. PHN requires thorough evaluation and development of a management strategy for each individual patient. Initial therapy is with TCAs (e.g., nortriptyline) or the anticonvulsant gabapentin. Topical lidocaine patches frequently reduce allodynia. Strong opioids are sometimes required. Topical capsaicin cream is beneficial for a small proportion of patients but is poorly tolerated. NMDA antagonists have not proved beneficial with the exception of ketamine. Transcutaneous Electrical Nerve Stimulation (TENS) may be effective in some cases. Èç Expert Opin Pharmacother. 2004 Mar;5(3):551-9. Management of herpes zoster (shingles) and postherpetic neuralgia. Johnson RW, Whitton TL. Íåäàâíèå ýêñïåðèìåíòàëüíûå è êëèíè÷åñêèå ðàáîòû ïîêàçûâàþò ýôôåêòèâíîñòü ðàííåãî íàçíà÷åíèÿ ãàáàïåíòèíà: Berger A, Dukes E, McCarberg B, Liss M, Oster G. Change in opioid use after the initiation of gabapentin therapy in patients with postherpetic neuralgia. Clin Ther. 2003 Nov;25(11):2809-21. Kuraishi Y, Takasaki I, Nojima H, Shiraki K, Takahata H. Effects of the suppression of acute herpetic pain by gabapentin and amitriptyline on the incidence of delayed postherpetic pain in mice. Life Sci. 2004 Apr 9;74(21):2619-26. È ñîâñåì íåäàâíåå ïî ïîñòãåðïåòè÷åñêîé íåâðàëãèè: Neurology. 2004 Sep 28;63(6):959-65. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H; Quality Standards Subcommittee of the American Academy of Neurology. A systematic review of the literature on postherpetic neuralgia was performed. The authors identified studies using the National Library of Medicine's Medline database and Cochrane Library database. The authors determined absolute reduction rate, number needed to treat (NNT), 95% CI for NNT, and number needed to harm (NNH) for successful therapies of postherpetic neuralgia. Tricyclic antidepressants, gabapentin, pregabalin, opioids, and lidocaine patch were found to be effective in reducing the pain of postherpetic neuralgia. |
#4
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Äàà, ãàáàïåíòèí âåñò÷ü õîðîøàÿ, ïðàâäà îí ïîäîðîæå êëîïèäîãðåëÿ áóäåò.
Ïîêà ïðèõîäèëîñü ëå÷èò ôèíëåïñèíîì... |
#5
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Óâàæàåìûé êîëëåãè, î ÷¸ì ðå÷ü,êîíå÷íî èíòåðåñíî.Áóäó òîëüêî ðàä íîâûì ñòàòüÿì.Ìîé åìýéë çíàåòå.
Íî âîïðîñ îñòàåòñÿ: 1.Ïðîôèëàêòèêà? À âîò êîðòèêîñòåðîéäû, ìíå ëè÷íî íå î÷åíü êàæåòñÿ ðàçóìíûì ïðè ãåðïåñå(ññëûòüñÿ ìîãó íå íà ìíîãèõ:Ñàìóýëüñ,Ñàãàð è ÌàêÃèð).Åñëè åñòü äàííûé ïî ýòîìó âîïðîñû,áóäó ðàä, íî ïîõîæå ðàçîáëà÷åíèå êóëüòà ãëþêîêàðòèêîéäîâ íà÷èíàåòñÿ. |
#6
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Ann Pharmacother. 1998 Oct;32(10):1099-103.
Oral corticosteroids for pain associated with herpes zoster. Ernst ME, Santee JA, Klepser TB. Division of Clinical and Administrative Pharmacy, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA. It is apparent from published studies that corticosteroids do not prevent the development of postherpetic neuralgia. Earlier trials that indicated some benefit in both acute neuralgia and the prevention of postherpetic neuralgia are of limited use to clinicians due to problems with uncontrolled study designs, small sample sizes, and the absence of statistical analysis of the results. The lack of a consensus definition of postherpetic neuralgia, the variable agents and dosages used, and the different pain scales reported are of concern when trying to interpret the results of these studies for their clinical significance. In more recent larger and well-designed studies, similar rates of postherpetic neuralgia were observed in the corticosteroid and control groups. As a result of these findings, corticosteroids should not be recommended for the prevention of postherpetic neuralgia. Despite lack of efficacy in preventing postherpetic neuralgia, limited studies suggest corticosteroids such as prednisone (40-60 mg/d tapered over 3 wk) are well tolerated and may confer slightly significant benefits in reducing the duration of acute neuralgia and improving quality-of-life measures. However, the clinical significance and application of these findings remain to be addressed. If corticosteroids are used for acute neuralgia, clinicians are advised to select their patients carefully. The patients treated in these studies were generally healthy and free of comorbid diseases, such as hypertension, diabetes mellitus, and psychiatric disorders, which can be exacerbated in the presence of corticosteroids. Although dissemination of herpes zoster has been reported infrequently, it remains a potential risk with use of corticosteroids. Until the results of these studies are repeated in more diverse patient populations, corticosteroids appear to have a limited role in the management of acute neuralgia associated with herpes zoster. |
#7
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Ëó÷øàÿ ïðîôèëàêòèêà Îïîÿñûâàþùåãî ëèøàÿ - â äåòñòâå óêîëîòüñÿ âàêöèíîé "Îêàâàêñ", êîòîðàÿ â 2005-2006 ãã áóäåò çàðåãèñòèðîâàíà â ÐÔ. Îí èçáàâëÿåò îò âåòðÿíêè è ñîîòâåòñòâåííî herpes-zoster.
Õîðîøèé ïðåïàðàò äëÿ ëå÷åíèÿ â íà÷àëå ïðîÿâëåíèÿ ãåðïåñà-çîñòåð - ôàìâèð. Çàòåì ïî ñèëå äåéñòâèÿ èäóò - âàëòðåêñ, è àöèêëîâèð. |
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#8
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Öèòàòà:
Ìîæåò êàê ìîæíî áîëåå ðàííåå íàçíà÷åíèå ïðîòèâîâèðóñíûõ ïðåïàðàòîâ â îïòèìàëüíîé äîçèðîâêå? |
#9
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Íå çíàë, ÷òî áóäåò ïðèâèâêà
2 Mikhail: À âîò äîçèðîâêè ó âñåõ ðàçíûå. Ðåêîìåíäóåìûå äîçèðîâêè ,ê ïðèìåðó,íà àöèêëîâèð 5ìã\êã\ñóòêè.Íî âñå ñ÷èòàþò, ÷òî ÷åì áîëüøå òåì íàäåæíåå.Òàê ãäå æå èñòèíà êîëëåãè? |
#10
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Äàâíî äîêàçàíî, ÷òî ôàìöèêëîâèð ïðè ðàííåì ïðèåìå â áîëüøèíñòâå ñëó÷àåâ ïðåäîòâðàùàåò ðàçâèòèå ïîñòãåðïåòè÷åñêîé íåâðàëãèè, çà ñ÷¸ò áîëüøîé êîíöåíòðàöèè â øâàííîâñêèõ êëåòêàõ. Äîçèðîâêè âåçäå îäèíàêîâûå. Îíè óòâåðæäåíû ôàðìàêîëîãè÷åñêèì êîìèòåòîì Ìèíçäðàâñîöðàçâèòèÿ ÐÔ è ïðèâåäåíû â àííîòàöèÿõ ê ïðåïàðàòàì.
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#11
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Ïîëíîñòüþ èçáàâèòüñÿ îò íåâðàëãèè íåëüçÿ (ïàòîãåíåç îäíàêî, âèðóñà ).  ðÿäå ñëó÷àåâ êëèíèêà ñîõðàíÿåòñÿ äî ïîëóãîäà.
Ðàíåå íàçíà÷åíèå ïðîòèâîâèðóñíûõ ïðåïàðàòîâ åñòåñòâåííî ñãëàäèò êëèíèêó, íî ïîëíîñòüþ íå èñêëþ÷èò.  ñâîåé ïðàêòèêå ó íàñ â äåðåâíå èñïîëüçóþò ôèíëåïñèí è ðàçëè÷íûå ïðåïàðàòû ÍÑÏÂÏ (îðòîôåí, èáóïðîôåí) íàïðèìåð áðóñòàí è.ò.ä. Ïðèìåíåíèå ãîìîíîâ ïðè âèðóñíîé èíôåêöèè ñ òî÷êè çðåíèÿ èììóíîëîãèè âåðõ íåãðàìîòíîñòè. |
#12
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Äåéñòâèòåëüíî ãîðìîíàëüíûå ïðåïàðàòû (êîðòèêîñòåðîèäû) óñèëèâàþò ïîðàæåíèå.
Ôàìâèð ïðè ïðèåìå â ïåðâûå äíè çàùèùàåò îò äåéñòâèÿ âèðóñà øâàííîâñêèå êëåòêè è åäèíñòâåííûé ïðåäîòâðàùàåò ðàçâèòèå ïîñòãåðïåòè÷åñêîé íåâðàëãèè. |
#13
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Èâàí, âû ïðàâû, îäíàêî... Âû ñëèøêîì êàòåãîðè÷íû â ñâîèõ îòâåòàõ. Ïîëíîñòüþ ôàìâèð (õîòÿ îí ìíå î÷åíü íðàâèòñÿ) íåâðàëãèþ íå óñòðàíèò è âîò ïî÷åìó. Äëÿ ýòîãî íóæíî ñîçäàòü êîíöåíòðàöèþ ïðåïàðàòà â êëåòêå åùå äî òîãî êàê âèðóñ àêòèâèðîâàëñÿ. Ðàññìîòðèì ïàòîãåíåç Çîñòåðà: ñèäèò â ãàíãëèèÿõ, çàòåì àêòèâèðóåòñÿ è íà÷èíàåò äâèãàòüñÿ ïî ïåðèíåâðàëüíîìó ïðîñòðàíñòâó (óòðèðóþ êîíå÷íî), ýòî ñîâïàäàåò ñ íà÷àëîì êëèíèêè (áîëü, ÷óâñòâî ææåíèÿ è ïîêàëûâàíèå) è âñå çàâåðøàåòñÿ âûñûïàíèåì íà êîæå. Ðåãðåññ èäåò â îáðàòíîì ïîðÿäêå. Êîãäà íà÷àëàñü êëèíèêà òî óæå âèðóñ â êëåòêå! Ýòî õàðàêòåðíî äëÿ ëþáîé âèðóñíîé èíôåêöèè áóäü òî ãðèïï èëè ÃËÏÑ. À çàäóìûâàëèñü âû î ïàòîãåíåçå áîëè ïðè ïîñòãåðïåòè÷åñêîé íåâðàëãèè? Íàìåðåííî îñòàâëÿþ ýòîò âîïðîñ áåç îòâåòà.
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#14
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Postherpetic neuralgia
Search date January 2004 David Wareham Oral antiviral agents (aciclovir, famciclovir, valaciclovir, netivudine) Aciclovir versus placebo We found one systematic review (search date 1998).[7] It included results from 5 RCTs comparing aciclovir alone versus placebo. It found important heterogeneity among studies making it difficult to summarise results. Meta-analysis was not conducted. The first RCT (376 people) compared aciclovir (4 g/day for 7 days) versus placebo. It found no significant difference between aciclovir and placebo for pain at 3 or 6 months (at 3 months: AR for pain 24% in both groups; at 6 months AR 14% with aciclovir v 13% placebo; CI not reported in the review). The second RCT (187 people; aciclovir 4 g/day for 10 days) found that aciclovir significantly reduced pain compared with placebo at 1–3 months (AR for pain 4.2% with aciclovir v 16.7% with placebo; P = 0.012). However, it found no significant difference at 4–6 months (3.9% v 6.3%; CI not reported in the review). The third RCT (83 people; aciclovir 4 g/day for 7 days) found that aciclovir significantly reduced pain at 3 months (AR 10% v 40%; P = 0.0082). The fourth RCT (46 people; aciclovir 4 g/day for 10 days) found that aciclovir significantly reduced pain at 3 months (7% v 38%; P = 0.05), but the difference was not significant at 6 months (5% with aciclovir v 26% with placebo; P = 0.07). The fifth RCT (65 people; aciclovir 2 g/day for 10 days) found no significant difference in pain between aciclovir and placebo (time to outcome and AR not reported in the review). Famciclovir versus placebo We found one systematic review (search date 1998, 1 RCT, 419 people).[7] The multicentre RCT in the review compared two different doses of famciclovir in immunocompetent adults (age > 18 years) and defined duration of postherpetic neuralgia as time to pain resolution. It found that both doses of famciclovir significantly reduced the duration of pain after acute herpes zoster compared with placebo (median duration of pain with 500 mg [138 people] 63 days, with 750 mg [135 people] 61 days, with placebo [146 people] 119 days; lower dose v placebo P = 0.02, higher dose v placebo P = 0.005). Aciclovir versus other antiviral agents We found one systematic review (search date 1998, 1 RCT, 1141 people).[7] The RCT in the review compared valaciclovir (a precursor of aciclovir) given three times daily for 7 or 14 days versus 7 days of aciclovir. When the results from the two valaciclovir regimens were combined, those treated with valaciclovir had a lower prevalence of pain at 6 months (AR 18.6% with valaciclovir v 25.7% with aciclovir; P = 0.02). We found one double blind RCT comparing netivudine versus aciclovir (511 people), which found no significant difference between groups in time to the first pain free period, but found a significantly shorter time to complete resolution of postherpetic neuralgia with aciclovir compared with netivudine (P = 0.007).[8] It found that the proportion of patients with persistent pain at 6 months was lower in people treated with aciclovir compared with netivudine (10% with aciclovir v 15% with netivudine; P value not reported).[8] Addition of amitriptyline We found no systematic review or RCTs. Valaciclovir versus famciclovir We found no systematic review. One RCT (597 immunocompetent people aged > 50 years) compared valaciclovir (1 g 3 times daily) versus famciclovir (500 mg 3 times daily) started within 72 hours of appearance of the rash and given for 7 days.[9] It found no significant difference between groups in resolution of postherpetic neuralgia (HR 1.01, 95% CI 0.82 to 1.24). The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. Bowsher D. Pain Research Institute, Walton Hospital, Liverpool, United Kingdom. Seventy-two patients older than 60 years of age who received a diagnosis of herpes zoster (HZ) were entered into a randomized, double-blind, placebo-controlled trial of daily amitriptyline 25 mg. Treatment with either amitriptyline or placebo continued for 90 days after diagnosis. Pain prevalence at 6 months was the primary outcome. Results showed that early treatment with low-dose amitriptyline reduced pain prevalence by more than one-half (p < 0.05; odds ratio, 2.9:1) This finding makes a strong case for the pre-emptive administration of amitriptyline, in combination with an antiviral drug, to elderly patients with acute herpes zoster. Does treatment of acute herpes zoster prevent or shorten postherpetic neuralgia? Alper BS, Lewis PR. Pennsylvania State University/Good Samaritan Hospital Family and Community Medicine Residency Program, Lebanon, USA. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] OBJECTIVE: Our goal was to determine if any treatment of acute herpes zoster alters the incidence or duration of postherpetic neuralgia (PHN), a common sequela in elderly patients. SEARCH STRATEGY: We systematically searched MEDLINE and The Cochrane Library. We also examined the reference lists of identified trials and reviews. SELECTION CRITERIA: We included all randomized controlled trials of treatments of zoster published in English that included assessment of pain at any time after rash healing. DATA COLLECTION/ANALYSIS: Forty-two trials met inclusion criteria, and 2 reviewers independently evaluated them for methodologic quality and the statistical and clinical significance of results. MAIN RESULTS: Four placebo-controlled trials of oral acyclovir with 692 patients provided marginal evidence for reduction in pain incidence at 1 to 3 months following zoster onset. Famciclovir significantly reduced duration but not incidence of PHN in one placebo-controlled trial of 419 patients. Valacyclovir significantly reduced duration but not incidence of PHN in one acyclovir-controlled trial of 1141 patients. Steroids had no effect on PHN. Amitriptyline for 90 days reduced pain incidence at 6 months in one placebo-controlled trial of 80 patients. A single trial of percutaneous electrical nerve stimulation (PENS) in 50 patients suggested a decrease in pain incidence at 3 and 6 months compared with famciclovir. CONCLUSIONS: There is limited evidence that current interventions prevent or shorten PHN. Famciclovir and valacyclovir have been shown to reduce the duration of PHN in single published trials. Well-designed and larger trials of amitriptyline and PENS should be conducted. |
#15
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Óâàæàåìûå êîëëåãè!
Âîò ñàìàÿ ñâåæà èíôîðìàöèÿ ïî ëå÷åíèþ ÏÃÍ: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ñðàçó óâèäèòå ôàèë pdf êîòîðûé ìîæíî ñêà÷àòü. Äàòèðîâàí ñåíÿáð¸ì 2004! |