workshop nyeri 22-11-2008 print

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Curiculum vitaeCuriculum vitae

Lulus dokter FK Undip 1966Lulus dokter FK Undip 1966

Lulus Spesialis Saraf FK Unair 1975Lulus Spesialis Saraf FK Unair 1975

Dosen Luar Biasa FK UndipDosen Luar Biasa FK Undip

Ketua Kelompok Studi !eri "#$D%SS& Semaran'Ketua Kelompok Studi !eri "#$D%SS& Semaran'

(akil ketua &katan $ematolo'i &ndonesia Semaran'(akil ketua &katan $ematolo'i &ndonesia Semaran'

)n''ota &nternational )ssociation for Stud! of "ain)n''ota &nternational )ssociation for Stud! of "ain

Dr* $B* (ira+an Sp*S,K-Dr* $B* (ira+an Sp*S,K-


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TATE OF THE ART INTATE OF THE ART IN

NEUROPATHIC PAIN

EUROPATHIC PAIN

MANAGEMEN W I HANAGEMEN W I H

PREGABALIN

REGABALIN

Dr. RB Wirawan, Sp.S(K)


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DEFINISIDEFINISI

NYERINYERI

DEFINISIDEFINISI

NYERINYERI

Pengalaman sensorik dan emosional gPengalaman sensorik dan emosional g!dk menenangkan aki"a! ker#sakan $aringan,!dk menenangkan aki"a! ker#sakan $aringan,

"aik ak!#al ma#p#n po!ensial, a!a# g"aik ak!#al ma#p#n po!ensial, a!a# g

digam"arkan dalam "en!#k ker#sakandigam"arkan dalam "en!#k ker#sakan

!erse"#!.!erse"#!.

International association for the study ofpain

(IASP)


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Langkah-langkah

1* .entukan macam n!erin!a

/* Suda0 erapa lama2

3* Ba'aimana intensitas n!erin!a2

4* )pa pen!ean!a2

5* #dukasi pasien

Menghadapi NYERI


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N.N%SISEP&IK

N.N%SISEP&IK

'. aam NYERI'. aam NYERI

NYER

I

NYER

I

N.

NE*R%P+&IK

N.

NE*R%P+&IK

N. PSIK%ENIK

N. PSIK%ENIK N.Soma!ik

N.-iseral

ReerredPain

N.Soma!ik

N.-iseral

ReerredPain Perier

Sen!ral

Perier

Sen!ral,!eri &nflamasi-,!eri Fun'sional-


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NeriNosisep!ik

NeriNe#ropa!i

k

Penyebab Stimuli sarafnosiseptik Disfungsisistim saraf

Cirinya Sakit ringansampai berat

Hiperpati,allodinia,

disestesia erapi Analgetik !

"SAIDAntikon#ulsanAntidepresan


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NeriNosisep!ik

NeriNe#ropa!i

k

Penyebab Stimuli sarafnosiseptik Disfungsi!lesisistim saraf

Cirinya Sakit ringansampai berat

Hiperpati,allodinia,

disestesia erapi Analgetik !

"SAIDAntikon#ulsanAntidepresan

MI!E" PAIN


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#$ N%e&i Ak'( )* +&,nik

"en!ea

Durasi

Biasan!adiketa0ui

Durasi

sin'kat

Serin'kali tidakdiketa0ui*

Berlan'sun' minimal

36 ulan

Karakteristik !eri )kut !eri Kronik


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Eek Neri Kronik /Eek Neri Kronik /$ %emampuan &sik ' hambatan

AD

$ Psikologik ' ansietas, depresi

$ Sosial ' isolasi sosial,keluarga, teman

$ Sosioekonomi ' kehilangan harikera


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-$ In(en.i(a. n%e&i

1* umeric "ain &ntensit! Scale ,"&S-

1 – 3 Nyeri ringan

4 – 6 Nyeri sedang

7 – 10 Nyeri berat

/* isual )nalo' Scale ,)S-

3* Faces "ain $atin' Scale ,untuk anak-

"en'ukuran skala n!eri


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S+ALA INTENSITAS NYERI

Visual Analogue Scale (VAS)

Numeric Pain Rating Scale (NPRS)

Faces Pain Rating Scale (anak)


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/$ Apa Pen%e0a0n%a1

• !eri merupakan 'eala

• Cari etiolo'in!a

,radan'8 trauma8 tumor8 ds-


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2$ Ed'ka.i Pa.ien

• Berila0 keteran'an dan peneran'an

• .erapi apa !an' dapat dierikan2• Ba'aimana 0arapan kesemu0an2

• "en'ertian dan kera sama pasien

san'at pentin'


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%onsep *anaemen "yeri

+ *acam "yeri - Deraat "yeri

. /ingan

0 Sifat nyeri . Sedang

. Akut . 1erat . %ronik

2 Penyebab "yeri

. "on *aligna

. *aligna . Psikogenik

3 4dukasi Pasien


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&* "en!ean!a

&&* eala : .anda

&&&* ;ekanisme

&* Dia'nosis

* .erapi

N%e&i Ne'&,pa(ik


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&* "en!ea !eri europatik

,)ttal 8et al /


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,)ttal 8et al /


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,)ttal 8et al /


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II$ Tanda 3 Ge4ala

N%e&i Ne'&,pa(ik

• A#$& #U$%").&K

A#$& S"%.) A#$& "&CU ,#%K#D-

K%.&U ")$%KS&S;)L )L%D&&) ?&"#$)L#S&)


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&* ;ekanisme "erifer

1* )ktivitas ektopik

/* Sensitisasi perifer

3* &nteraksi anormal antar seraut saraf 4* Sensitisasi ter0adap katekolamin

&&* ;ekanisme Sentral

1* Sensitisasi sentral/* Disin0iisi

3* $eor'anisasi struktural

&&&* ;#K)&S;# A#$& #U$%").&K


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"a.a& Mekani.5e N%e&i

Ne'&,pa(ik

;ekanisme"erifer

?ipereksitasi

neuron perifer

Ke0ilan'an

kontrol

pen'0amatan

;ekanisme

sentral

?ipereksitasi

neuron sentral

)normal

disc0ar'es

!eri

neuropatik


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"#$S#"S& NYERI

Spinot0alamicSpinot0alamictracttract

"erip0eral"erip0eral

nervenerve

Dorsal ?ornDorsal ?orn

Dorsal rootDorsal root

'an'lion'an'lion

"ain"ain

;odulation;odulation

.ransduction.ransduction

)scendin')scendin'

inputinput

Descendin'Descendin'

modulationmodulation

"erip0eral"erip0eral

nociceptorsnociceptors

.rauma.rauma

Adapted from Gottschalk A et al Am Fam Physician !001"63#1$%1& and 'ehlet ( et al Anesth Analg 1$$3"77#104$

"erception"erception

transmissiontransmission


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ociceptive afferent fier

EK+NISE NYERI N%R+0EK+NISE NYERI N%R+0

oious

stimuli

Descendin'

modulation

)scendin'

input

Spinal cord

"erceived pain


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+K&I-I&+S EK&%PIK +K&I-I&+S EK&%PIK (E!opi Dis1arges)(E!opi Dis1arges)erve lesion induces 0!peractivit! due to c0an'es in ion c0annel function

)ctopic discharges)ctopic discharges

erve lesion

Spinal cord


Descendin'

modulation

)scendin'

input

"erceived pain

Na*

ion channels


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DISIN2IBISIDISIN2IBISI(0oss o in1i"i!or on!rols)(0oss o in1i"i!or on!rols)Loss of descendin' modulation causes ea''erated pain due to an imalance

et+een ascendin' and descendin' si'nals


oious

stimuli

)scendin'

input

Spinal cord

Loss of

descendin'

modulation

#a''erated pain

perception

Ne+rotransmiter ,erotonin - Norepinefrin


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I6$ "IAGNOSIS

1* $i+a!at n!eri lokasi8 kualitas8 a+itan8 etc*

/* ;acamn!a n!eri3* Durasi n!eri

4* &ntensitas n!eri

5* Komorid insomnia8 cemas8 depresi

ANAMNESIS


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PEMERI+SAAN


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PEMERI+SAAN NEUROLOGI


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NEUROPATI "IABETI+A

• Nyeri seperti terbakar& kesetr+m& sensasi dit+s+k.t+s+k& parestesi• /asa nyeri intermiten& lebih terasa malam hari• ,ering terasa baal - mati pada kaki disestesia

2# . Gangg+an motorik # kelemahan& refle men+r+n

. Gangg+an sensorik # nyeri& tekanan& s+h+& ibrasi

. 5isf+ngsi otonom # . 'ardioask+ler # takikardi& hipotensi ortostatik

. Gastrointestinal# mencret& obstipasi

. rogenital # disf+ngsi seks+al

# . Anti 'on+lsan

. Anti 5epresan . Anti Aritmik - opikal

)# )d+kasi - 2engendalian Gl+kosa


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NEURALGIA PASCA HERPES

• Nyeri di tempat r+am setelah menderita (erpes 8oster

• /asa nyeri seperti panas& kesetr+m& menyentak

• Ada Alodinia dan (iperalgesia

2emeriksaan# . 9ekas r+am di k+lit daerah nyeri . Anestesia di daerah bekas r+am anestesia dolorosa

. Alodinia *

erapi # . Anti 5epresan - Anti 'on+lsan . :eiletine& 'lonidin& erapi 2sikologik

2reensi # Acycloir& paling lambat 3 hari dari a;itan


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• ,erangan nyeri paroksismal seperti tekanan& panas kesetr+m

• Nyeri dirasakan di daerah inerasi N >

• Alodinia * makan& sikat gigi& kena angin

• 5i l+ar serangan normal

" . idak ada kelainan ne+rologi

. :/?=@ ,can# +nt+k deteksi lesi primer

kompresi ask+ler& t+mor& infark

.# . Anti 'on+lsan

. 9aclofen

. perasi

NEURALGIA TRIGEMINAL


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-. Prinsip ana$emenNeri /

I. &erapi armakologik

. Analgesik non opioid

. Analgesik opioid

. Analgesik au#an

. Analgesik topikal

II. &erapi non armakologik

. erapi &sik

. erapi pikiran

. erapi enersi

III. &erapi in3asi non "ed

. 1lok saraf

. 1lok spinal

. "eurolitik

. Suntikan 1oto5

I-. &erapi "eda1

. halamotomi

. /hi6otomi

. 7steotomi

(Wirawan, !NAS N"eri #ana$o, %&&')


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+nalgesik +$#3an+nalgesik +$#3an

7

An(ik,n8'l.an

n(ik,n8'l.an

7

An(idep&e.an

n(idep&e.an

4 Relaksan o!o!Relaksan o!o!

4 Kor!ikos!eroidKor!ikos!eroid

4+nes!esi lokal (an!i5ari!mia)+nes!esi lokal (an!i5ari!mia)


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G,l,ngan An(ik,n8'l.an

'66 5 '666 P#sing, ne#!ropeni47ar"ama8epinDosis

(mg91r)Eek samping

'66 5 :66 +!a;ia, 1iper!ro<g#si

4Feni!oin

:66 5 '=66 Somnolen, a!a;ia4a"apen!in

'=6 5 =66 Diplopia,mengan!#k

40amo!rigin

>66 5 '?66 0ela1, ngan!#k 4%;ar"a8epin

@= 5 @66 0ela1, anore;ia4&opirama!

'=6 5 '666 &remor, m#al4-alproa!

7

P&ega0alin

'=6 A 66 Somnolen,

p#sing


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G,l,ngan An(idep&e.anDosis

(mg91r)+n!i

kolinergik 2ipo!ensi Sedasi

Duloetin 65'@6 (na#sea)

4Paro;e!in @6 5 C6 5

4aprop!ilin @= 5 '=6

4+mi!rip!ilin '6 5 '=6

4Ser!ralin =6 5

4Fl#o;e!in @6 5 C6 5 5

4Imipramin @= 5 =

enlafain 15< ,'astrointestinal-


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TERAPI NYERI NEUROPATI+TERAPI NYERI NEUROPATI+9EFNS GUI"ELINE #::;<

1*1* !eri europatik "erifer !eri europatik "erifer • G92=2regabalinG92=2regabalin

==• @A@A

==• pioid& ,N/?pioid& ,N/?

/*/* eural'ia .ri'eminaleural'ia .ri'eminal• @9B=C@@9B=C@

==

• perasiperasi3*3* !eri Sentral ,Stroke=SC&-!eri Sentral ,Stroke=SC&-

• @A& DG@A& DG• G92= 2regabalinG92= 2regabalin

#FS #uropean Federation of eurolo'ical Societies


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Te&api N%e&i Ne'&,pa(ik "ia0e(ika

9G'ideline Ma%, Clini> #::;-#::? <

B++I+N+ DEN+N PRE+B+0INB++I+N+ DEN+N PRE+B+0IN


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E5oes not affect @a** infl+ in normal ne+rons

B++I+N+ DEN+N PRE+B+0INB++I+N+ DEN+N PRE+B+0INDasar ekanisme +n!i5Kon3#lsanDasar ekanisme +n!i5Kon3#lsan (Pregabalin(Pregabalin


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"ASAR ME+ANISME PREGABALIN

• "re'aalin terikat pada suunit /

saluran kalsium

• "re'aalin men'uran'i influks kalsium

pada neuron 0ipereksitasi ,presinaps-

• )kiat ikatan / 8 pre'aalin men'uran'i

pelepasan neurotransmitter eksitatoris

,'lutamat8 norepinefrin8 etc-

,ee et al 19968 Fink et al /


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PROFIL FARMA+O+INETI+

ROFIL FARMA+O+INETI+

PREGABALIN

REGABALIN

E )ffectie plasma concentration maintained& clinically effectie ;ith t;ice or three times daily dosing5ata on file& 2fi8er ?nc ,+mmary of 2rod+ct @haracteristics

-aria"le Proper!ies 7linial rele3ane

+"sorp!ion ma5 ≤ + h/apid attainment of plasma

le#els

Bioa3aila"ili! ≥ 89:

"o food e;ect

Consistent across dose range

Administration


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TI"A+ A"A INTERA+ I

I"A+ A"A INTERA+ I

PREGABALIN OBAT

REGABALIN OBAT

#

Insulin

7ral hypoglycemics

Diuretics

7ral contracepti#e

75ycodone

Alcohol

ora6epam

9rockbrader at el A), !001 5ata on file& 2fi8er ?ncE9ased on pop+lation pharmacokinetic analysis

+n!i5epilep!i dr#gs(+EDs)

Carbama6epine

abapentin

amotriginePhenytoin

Ealproic acid

Phenobarbital@

iagabine@

opiramate@


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EFE+ AMPING PREGABALIN

FE+ AMPING PREGABALIN

Plae"o (nGC) Prega"alin (nG'==)

InideneDison!in#e

dInidene

Dison!in#ed

Di88iness ?2 9- 0+F@ -+

Somnolene -B 9+ +-B@ 0?

Perip1eraledema

+B 9+ 83@ 9B

Ine!ion 2B 9+ ?0 9+

Dr mo#!1 +B 9+ 38@ 9-

"E


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"re'aalin #fektif pada europati Diaetika"re'aalin #fektif pada europati Diaetika

/osenstock et al 2ain!004"110#6!%.3%

"E


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S!#di Prega"alin padaS!#di Prega"alin padaNeri Ne#ralgia Pasa 2erpesNeri Ne#ralgia Pasa 2erpes

"E


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Prega"alin Eek!i padaPrega"alin Eek!i padaNeri Spinal 7ord In$#r (S7I)Neri Spinal 7ord In$#r (S7I)

Prega"alin pada Neri Ne#ropa!iPrega"alin pada Neri Ne#ropa!i


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Prega"alin pada Neri Ne#ropa!iPrega"alin pada Neri Ne#ropa!i

Dia"e!ika (angg#an &id#r)Dia"e!ika (angg#an &id#r)

"E


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Prega"alin H -enlaa;ine pada

Generalized Anxiety Disorder

#"

"E


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N (hi P i T i d


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Ne'&,pa(hi> Pain T&iad

Functionalimpairment

P+IN

%%D S0EEP

4 An5iety4 Depression

4 Depri#ation

4 Insomnia4 Poor

#ali! o 0ie

9PREGABALIN<


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workshop nyeri 22-11-2008 print

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