Clinical practice guideline for cancer pain

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(Clinical Practice Guideline for Cancer Pain)

ISBN 978-616-91654-0-8

¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬Thai Association for the Study of Pain

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§”π‘¬¡ III

√“¬π“¡§≥–ºŸâ®—¥∑” IV

¢âÕ·π–π”°“√„™â CPG VII

∫∑π” 1

1. μ“√“ß∑’Ë 1 √ÿªπÈ”Àπ—°§”·π–π”°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß 3

2. ·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ß°“√ª√–‡¡‘π§«“¡ª«¥ ·≈–Õ“°“√√à«¡μà“ßÊ „πºŸâªÉ«¬¡–‡√Áß 4

3. ·ºπ¿Ÿ¡‘∑’Ë 2 ·π«∑“ß°“√∫”∫—¥§«“¡ª«¥®“°¡–‡√Áß 5

4. μ“√“ß∑’Ë 2 √–¥—∫°“√μÕ∫ πÕß¢Õß§«“¡ª«¥·∫∫μà“ßÊ ∑’Ëæ∫‰¥â„πºŸâªÉ«¬¡–‡√Áß 6μàÕ¬“·°âª«¥°≈ÿà¡μà“ßÊ

Check list: Comprehensive pain assessment 7

1. °“√ª√–‡¡‘πª√– ∫°“√≥å§«“¡ª«¥ 8

2. °“√ª√–‡¡‘π∑“ß¥â“π®‘μ„® Õ“√¡≥å ·≈– —ß§¡ 9

3. °“√ª√–‡¡‘π ¿“«– ÿ¢¿“æ 9

4. °“√μ√«®√à“ß°“¬·≈–°“√μ√«®∑“ß√–∫∫ª√– “∑ 9

5. °“√„Àâ°“√«‘π‘®©—¬§«“¡ª«¥ 10

6. °“√ àßμ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√·≈–¿“æ∂à“¬√—ß ’ 10

¿“§ºπ«° 1 Õ“°“√‡©æ“–Õ◊ËπÊ 14

1.1 Dyspnea 14

1.2 Lymphedema 15

1.3 Constipation 16

1.4 Deconditioning and fatigue 18

VI

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¿“§ºπ«° 2 ¿“«–∑“ß®‘μ‡«™ 19

2.1 Distress 19

2.2 Anxiety 19

2.3 Depression 21

2.4 Delirium 25

¿“§ºπ«° 3 °“√ ◊ËÕ “√·≈–°“√„Àâ§«“¡√Ÿâ 28

3.1 ∫∑∫“∑·≈–Àπâ“∑’Ë¢ÕßºŸâªÉ«¬·≈–≠“μ‘ 28

3.2 §«“¡‡¢â“„®§≈“¥‡§≈◊ËÕπ‡°’Ë¬«°—∫°“√„™â¬“°≈ÿà¡ opioids 28

¿“§ºπ«° 4 °“√√—°…“‡©æ“–¢Õß§«“¡ª«¥®“°¡–‡√Áß∑’Ë‡°‘¥®“° “‡Àμÿμà“ßÊ 31

4.1 Neuropathic cancer pain (NCP) 31

4.2 Cancer-induced bone pain (CIBP) 32

4.3 Tumor-induced headache (TIH) 33

4.4 Visceral pain and malignant bowel obstruction (MBO) 35

¿“§ºπ«° 5 Opioids 38

5.1 ‡¿ —™«‘∑¬“§≈‘π‘°¢Õß¬“„π°≈ÿà¡ opioids 38

5.2 Equianalgesic dose ¢Õß¬“„π°≈ÿà¡ opioids ·≈–°“√§”π«≥ 39

5.3 À≈—°°“√„™â¬“„π°≈ÿà¡ opioids 43

5.4 °“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“„π°≈ÿà¡ opioids 46

¿“§ºπ«° 6 Non-opioids 48

¿“§ºπ«° 7 Adjuvants 51

¿“§ºπ«° 8 Complementary and alternative medicine 54

¿“§ºπ«° 9 Pain at the end of life 55

∫√√≥“πÿ°√¡·≈–‡Õ° “√·π–π”‡æ‘Ë¡‡μ‘¡ 56

VII

·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

Clinical Practice Guideline (CPG) ‡À¡◊Õπ·ºπ∑’Ë À√◊Õ§Ÿà¡◊Õ°“√‡¥‘π∑“ß ‡ªÑ“À¡“¬À≈—°¢Õß CPG

§◊Õ °“√«‘π‘®©—¬∑’Ë∂Ÿ°μâÕß·≈–°“√¥Ÿ·≈√—°…“¿“«–ª«¥®“°¡–‡√Áß °“√„™â CPG ‡À¡◊Õπ°—∫°“√„™â·ºπ∑’Ë ‡¡◊ËÕÀ≈ß∑“ß

À√◊Õμ‘¥¢—¥ ≥ ®ÿ¥„¥°Á‡ªî¥¥Ÿ√“¬≈–‡Õ’¬¥·≈–»÷°…“¢âÕ¡Ÿ≈ ≥ ®ÿ¥π—Èπ ´÷ËßÕ“®‡ªìπμ“√“ß À√◊Õ√“¬≈–‡Õ’¬¥„π¿“§

ºπ«°∑â“¬‡≈à¡

πÈ”Àπ—°§”·π–π” (Strength of Recommendation)πÈ”Àπ—° ++ À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«¡’

ª√–‚¬™πåÕ¬à“ß¬‘ËßμàÕºŸâªÉ«¬·≈–§ÿâ¡§à“ (cost effective) ç§«√∑”é

πÈ”Àπ—° + À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√

¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–Õ“®§ÿâ¡§à“„π¿“«–®”‡æ“– çπà“∑”é

πÈ”Àπ—° +/- À¡“¬∂÷ß §«“¡¡—Ëπ„®¬—ß‰¡à‡æ’¬ßæÕ„π°“√„Àâ§”·π–π” ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«

¬—ß¡’À≈—°∞“π‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π«à“ Õ“®¡’À√◊ÕÕ“®‰¡à ¡’

ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà‰¡à°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ß

π—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬Õ◊ËπÊ çÕ“®∑”À√◊Õ‰¡à∑”é

πÈ”Àπ—° - À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√

¥—ß°≈à“«‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ À“°‰¡à®”‡ªìπ ç‰¡àπà“∑”é

πÈ”Àπ—° - - À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«

Õ“®‡°‘¥‚∑…À√◊Õ°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ ç‰¡à§«√∑”é

§ÿ≥¿“æ¢ÕßÀ≈—°∞“π∑“ß«‘™“°“√ (Classification of References)Level of evidence A À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥â®“° systematic review ¢Õß randomized, controlled

clinical trials À√◊ÕÀ≈—°∞“π∑’Ë‰¥â®“° randomized, controlled clinical trials ∑’Ë

¥”‡π‘π°“√Õ¬à“ß‡À¡“– ¡

Level of evidence B À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥â®“° systematic review ¢Õß controlled clinical study

À√◊Õ À≈—°∞“π∑’Ë ‰¥â®“° controlled clinical study (‡™àπ nonrandomized,

controlled trial, cohort study, case-control study, cross sectional study) ∑’Ë

¢âÕ·π–π”°“√„™â CPG

VIII

¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¥”‡π‘π°“√Õ¬à“ß‡À¡“– ¡ À√◊ÕÀ≈—°∞“π∑’Ë‰¥â®“°°“√«‘®—¬∑“ß§≈‘π‘°∑’Ë„™â√Ÿª·∫∫

°“√«‘®—¬Õ◊Ëπ·≈–º≈°“√«‘®—¬æ∫ª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘√—°…“∑’Ë‡¥àπ™—¥¡“°

À√◊Õ‡√◊ËÕß¥—ß°≈à“«‰¡à¡’º≈ß“π«‘®—¬ª√–‡¿∑ randomized, controlled clinical trials

·μà‰¥âπ”‡Õ“À≈—°∞“π∑’Ë ‰¥â®“° randomized, controlled clinical trials „π

ª√–™“°√°≈ÿà¡Õ◊ËπÀ√◊Õ‡√◊ËÕßÕ◊Ëπ∑’Ë§≈â“¬§≈÷ß°—π¡“„™â‡ªìπÀ≈—°∞“π À√◊ÕÀ≈—°∞“π∑’Ë‰¥â®“°

systematic review ¢Õß randomized, controlled clinical trials À√◊Õ randomized,

controlled clinical trials ∑’Ë¥”‡π‘π°“√‰¡à‡À¡“– ¡

Level of evidence C À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥â®“° systematic review ¢Õß descriptive study À√◊Õ

À≈—°∞“π∑’Ë‰¥â®“° descriptive study ÷ËßÀ¡“¬∂÷ß√“¬ß“πºŸâªÉ«¬Àπ÷Ëß√“¬À√◊Õ¡“°

°«à“ À√◊ÕÀ≈—°∞“π∑’Ë‰¥â®“° systematic review ¢Õß controlled clinical study

À√◊Õ controlled clinical study ∑’Ë¥”‡π‘π°“√‰¡à‡À¡“– ¡ À√◊ÕÀ≈—°∞“π∑’Ë‰¥â®“°

controlled clinical trials „πª√–™“°√°≈ÿà¡Õ◊ËπÀ√◊Õ‡√◊ËÕßÕ◊Ëπ∑’Ë§≈â“¬§≈÷ß°—π

Level of evidence D À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥â®“°§«“¡‡ÀÁπÀ√◊Õ©—π∑“¡μ‘ (consensus) ¢Õß§≥–ºŸâ‡™’Ë¬«™“≠

‡π◊ËÕß®“°‰¡à¡’À≈—°∞“π®“°º≈ß“π«‘®—¬∑“ß§≈‘π‘° À√◊Õº≈ß“π«‘®—¬∑“ß§≈‘π‘°∑’Ë¡’Õ¬Ÿà

‰¡à Õ¥§≈âÕßÀ√◊Õ‡À¡“– ¡°—∫ ∂“π°“√≥å·≈– ∂“π¿“æ¢Õß°“√ª√–°Õ∫«‘™“™’æ

„πª√–‡∑»‰∑¬ À√◊Õ¡’‡æ’¬ßÀ≈—°∞“π∑“ßÀâÕßªØ‘∫—μ‘°“√À¡“¬‡Àμÿ: Level of evidence ( “√√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààßª√–‡∑»‰∑¬ ªï∑’Ë 18 ©∫—∫∑’Ë 6 æ.¬.- ∏.§. 2544)

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ß‡«™ªØ‘∫—μ‘π’È‰¡à„™à¢âÕ∫—ß§—∫¢Õß°“√ªØ‘∫—μ‘ *** 1

·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

∫∑π”

¡–‡√Áß‡ªìπ‚√§∑’Ëæ∫∫àÕ¬‚¥¬¡’Õ—μ√“°“√ªÉ«¬·≈–μ“¬∑—Ë«‚≈°„π≈”¥—∫μâπÊ ·≈–®“° ∂‘μ‘ “∏“√≥ ÿ¢„πªï

æ.». 2553 æ∫«à“‡ªìπ‚√§∑’Ë¡’Õ—μ√“°“√μ“¬ Ÿß‡ªìπÕ—π¥—∫·√°¢Õßª√–‡∑»‰∑¬ §◊Õ 91.2 μàÕª√–™“°√ 100,000

§π °“√¥Ÿ·≈√—°…“„π√–¬–μà“ßÊ ¢Õß‚√§¡–‡√Áß °≈ÿà¡Õ“°“√∑’ËºŸâªÉ«¬μâÕß∑ÿ°¢å∑√¡“π®“°¡–‡√Áß·≈–®“°°“√

√—°…“∑—Èß„π√–¬–μâπμ≈Õ¥∂÷ß√–¬–μàÕ¡“¡’§«“¡·μ°μà“ß°—π„π·μà≈–™à«ß‡«≈“¢Õß°“√¥”‡π‘π‚√§

§«“¡ª«¥®“°¡–‡√Áß∑”„Àâ¡’§«“¡∑ÿ°¢å∑√¡“π„πºŸâªÉ«¬∑ÿ°√–¬–¢Õß‚√§∂÷ß√âÕ¬≈– 53 „πºŸâªÉ«¬√–¬–∑â“¬

∑’Ë¡’°“√≈ÿ°≈“¡¢Õß‚√§æ∫§«“¡ª«¥‡°‘¥¢÷Èπ√âÕ¬≈– 64 ·≈–ºŸâªÉ«¬¡“°°«à“ 1 „π 3 ¡’§«“¡ª«¥ª“π°≈“ß∂÷ß

√ÿπ·√ß¡“°

Õß§å°“√Õπ“¡—¬‚≈°‰¥â‡º¬·æ√à·π«∑“ßªØ‘∫—μ‘‡°’Ë¬«°—∫°“√√—°…“§«“¡ª«¥„πºŸâªÉ«¬¡–‡√Áß·≈–¡’°“√π”

‰ª„™â°—πÕ¬à“ß·æ√àÀ≈“¬ πÕ°®“°π’È¬—ß¡’·π«∑“ß‡«™ªØ‘∫—μ‘„π°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß¢Õßª√–‡∑»μà“ßÊ

À≈“¬ª√–‡∑»„π™à«ß‡«≈“°«à“ 20 ªï∑’Ëºà“π¡“ ·μà°Á¬—ßæ∫ªí≠À“°“√¥Ÿ·≈√—°…“∑’Ë‰¡à¡’ª√– ‘∑∏‘¿“æ æ∫«à“§«“¡

ª«¥®“°¡–‡√Áß∑’Ë·¬à≈ß¡’§«“¡ —¡æ—π∏å°—∫§ÿ≥¿“æ™’«‘μ∑’Ë‰¡à¥’¢ÕßºŸâªÉ«¬¡–‡√Áß ·≈–‡ªìπªí≠À“∑“ß “∏“√≥ ÿ¢∑—Ë«‚≈°

°“√ª√–‡¡‘πºŸâªÉ«¬®”‡ªìπμâÕß∑”Õ¬à“ß§√Õ∫§≈ÿ¡ ∑—Èß„π·ßà¢Õß§«“¡ª«¥·≈–¥â“πÕ◊ËπÊ ÷Ëß®–∑”„Àâ°“√

√—°…“Õ“°“√ª«¥„πºŸâªÉ«¬¡–‡√Áß‰¥âº≈¥’ ‡¡◊ËÕ„™â√à«¡°—∫°“√„™â¬“·°âª«¥·≈–°“√√—°…“¡–‡√Áß∑’Ë‡À¡“– ¡

μ“√“ß∑’Ë 1 √ÿªπÈ”Àπ—°§”·π–π”∑’Ë ”§—≠„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥®“°¡–‡√Áß

≈”¥—∫¢—Èπ„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥®“°¡–‡√Áß¡’¥—ßπ’È

1. ª√–‡¡‘πºŸâªÉ«¬μ“¡·ºπ¿Ÿ¡‘∑’Ë 1 ´÷Ëß· ¥ß°“√ª√–‡¡‘πºŸâªÉ«¬¡–‡√Áß‚¥¬·∫àß°“√ª√–‡¡‘π‡ªìπ 3 ¥â“π

ë ª√–‡¡‘π§«“¡ª«¥ ‚¥¬„™â Check list: comprehensive pain assessment ‡æ◊ËÕ„Àâ∑√“∫ “‡Àμÿ

™π‘¥ ·≈–§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥

ë ª√–‡¡‘πÕ“°“√‡©æ“–Õ◊ËπÊ ´÷Ëß‡ªìπ “‡Àμÿ∑’Ë ”§—≠¢Õß§«“¡ª«¥ ÷ËßμâÕß‰¥â√—∫°“√√—°…“‡©æ“–

μ“¡¿“§ºπ«° 1 Õ“°“√‡©æ“–Õ◊ËπÊ

ë ª√–‡¡‘π¿“«–∑“ß®‘μ‡«™∑’Ë ”§—≠ ´÷Ëß¡’º≈μàÕ°“√¥Ÿ·≈√—°…“§«“¡ª«¥μ“¡¿“§ºπ«° 2 ¿“«–

∑“ß®‘μ‡«™

2. À≈—ß®“°„Àâ°“√«‘π‘®©—¬§«“¡ª«¥·≈â« À“°ºŸâªÉ«¬¡’§«“¡ª«¥®“°¡–‡√Áß (cancer-related pain) ®–

„Àâ°“√∫”∫—¥§«“¡ª«¥μ“¡Õ“°“√μàÕ‰ª‚¥¬Õ“»—¬À≈—°°“√ 2 ª√–°“√„π°“√æ‘®“√≥“‡≈◊Õ°„™â¬“ ‰¥â·°à

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ß‡«™ªØ‘∫—μ‘π’È‰¡à„™à¢âÕ∫—ß§—∫¢Õß°“√ªØ‘∫—μ‘ ***2

¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

ë √–¥—∫§«“¡√ÿπ·√ßμ“¡·ºπ¿Ÿ¡‘∑’Ë 2 ‚¥¬ª√—∫√Ÿª·∫∫¬“·°âª«¥μ“¡§«“¡√ÿπ·√ßμ—Èß·μàπâÕ¬

ª“π°≈“ß ·≈–√ÿπ·√ß μ“¡ WHO analgesic ladder ¡’À≈—°°“√„™â¬“μ“¡¿“§ºπ«° 5 Opioids ¿“§ºπ«° 6

Non-opioids ·≈–¿“§ºπ«° 7 Adjuvants °“√„™â¬“·°âª«¥°≈ÿà¡ opioids ®”‡ªìπμâÕß¡’°“√∑”§«“¡‡¢â“„®

√–À«à“ß∫ÿ§≈“°√∑“ß°“√·æ∑¬å ºŸâªÉ«¬ ·≈–≠“μ‘ ‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥‰¥âº≈¥’´÷Ëß¡’ª√–‡¥Áπ ”§—≠μ“¡

¿“§ºπ«° 3 °“√ ◊ËÕ “√·≈–°“√„Àâ§«“¡√Ÿâ

ë “‡Àμÿ¢Õß§«“¡ª«¥∑’Ëæ∫‰¥â „πºŸâªÉ«¬¡–‡√Áß ∫“ß “‡ÀμÿμâÕß‰¥â√—∫°“√√—°…“‡©æ“–μ“¡

¿“§ºπ«° 4 °“√√—°…“‡©æ“–¢Õß§«“¡ª«¥®“°¡–‡√Áß∑’Ë‡°‘¥®“° “‡Àμÿμà“ßÊ ‚¥¬§«“¡ª«¥·μà≈– “‡ÀμÿÀ√◊Õ

·μà≈–™π‘¥¡’√–¥—∫°“√μÕ∫ πÕß¢Õß¬“·°âª«¥·μ°μà“ß°—π¥—ßμ“√“ß∑’Ë 2

3. Õ“®æ‘®“√≥“„™â°“√√—°…“§«“¡ª«¥‚¥¬„™â°“√·æ∑¬å·∫∫º ¡º “π·≈–°“√·æ∑¬å∑“ß‡≈◊Õ°√à«¡

¥â«¬‰¥âμ“¡§«“¡‡À¡“– ¡ ¥Ÿ„π¿“§ºπ«° 8 Complementary and alternative medicine

4. ‡¡◊ËÕºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥®“°¡–‡√Áß‡¢â“ Ÿà√–¬– ÿ¥∑â“¬¢Õß°“√‡®Á∫‰¢â¡’À≈—°„π°“√¥Ÿ·≈√—°…“μ“¡

¿“§ºπ«° 9 Pain at the end of life


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

§”·π–π” πÈ”Àπ—°

§”·π–π”∑—Ë«‰ª

ª√–‡¡‘π§«“¡ª«¥·∫∫§√Õ∫§≈ÿ¡∑—Èß∑“ß√à“ß°“¬ ®‘μ„® ·≈– —ß§¡ ++

ë ª√–‡¡‘π “‡Àμÿ ™π‘¥ ·≈–§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥ ++

ë °“√μ√«®‡æ‘Ë¡‡μ‘¡Õ◊ËπÊ (additional investigation) ‡æ◊ËÕ°“√∫”∫—¥Õ“°“√ª«¥ +

„Àâ°“√√—°…“∑’Ë®”‡æ“–°—∫Õ“°“√‡©æ“–Õ◊ËπÊ ∑’Ë‡°‘¥√à«¡ ‡™àπ neuropathic pain,

cancer-induced bone pain +

ë °“√„™â adjuvant analgesics ∑’Ë‡À¡“– ¡ +

ë æ‘®“√≥“°“√√—°…“∑’Ë‰¡à„™â¬“„π°√≥’∑’Ë‡À¡“– ¡ ‡™àπ √—ß ’√—°…“ ‡«™»“ μ√åøóôπøŸ +

À—μ∂°“√∑“ß«‘ —≠≠’«‘∑¬“ œ≈œ

„Àâ§”·π–π”·≈– ◊ËÕ “√°—∫ºŸâªÉ«¬·≈–≠“μ‘‡°’Ë¬«°—∫‚√§·≈–°“√¥Ÿ·≈√—°…“‡ªìπ√–¬–Ê ++

°“√«“ß·ºπ¥Ÿ·≈√—°…“≈à«ßÀπâ“ (advance care plan) +

μ‘¥μ“¡°“√‡ª≈’Ë¬π·ª≈ß¢Õß‚√§¡–‡√Áß·≈–¿“«–∑“ß®‘μ‡«™ ‡™àπ ∑ÿ°¢å «‘μ°°—ß«≈ ´÷¡‡»√â“ °“√ª√—∫μ—« +

°“√√—°…“§«“¡ª«¥¥â«¬°“√„™â°“√·æ∑¬å·∫∫º ¡º “π·≈–°“√·æ∑¬å∑“ß‡≈◊Õ° +/-

°“√√—°…“§«“¡ª«¥¥â«¬¬“

°“√„™âÀ≈—°°“√ multimodal analgesia „π°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß ++

°“√ª√—∫¬“·°âª«¥μ“¡√–¥—∫§«“¡ª«¥μ“¡ WHO analgesic ladder ++

°“√„Àâ¬“·°âª«¥·∫∫ non-invasive route „πºŸâªÉ«¬∑’ËμâÕß„™â¬“√–¬–¬“« ++

°“√ —Ëß„™â opioids ·∫∫ around-the-clock „π°“√√—°…“ºŸâªÉ«¬ cancer pain ´÷Ëß¡’ continuous pain ++

°“√¡’ rescue analgesics ”À√—∫ breakthrough pain ·≈–ª√–‡¡‘π§«“¡ª«¥´È”∑ÿ° 48-72 ™—Ë«‚¡ß ++

°“√„™â¡“μ√°“√‡æ◊ËÕªÑÕß°—πÕ“°“√∑âÕßºŸ°≈à«ßÀπâ“„πºŸâªÉ«¬ cancer pain ∑’Ë‰¥â√—∫ opioids „π√–¬–¬“« ++

μ‘¥μ“¡°“√∑”ß“π¢Õßμ—∫·≈–‰μ¢ÕßºŸâªÉ«¬‡ªìπ√–¬–Ê +

°“√„™â pethidine „πºŸâªÉ«¬ chronic cancer pain - -

°“√„Àâ¬“À√◊Õ “√Õ◊ËπÊ ‡æ◊ËÕÀ«—ß placebo effect - -

μ“√“ß∑’Ë 1 √ÿªπÈ”Àπ—°§”·π–π”°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ß°“√ª√–‡¡‘π§«“¡ª«¥ ·≈–Õ“°“√√à«¡μà“ßÊ „πºŸâªÉ«¬¡–‡√Áß

* Cancer-related pain À¡“¬∂÷ß§«“¡ª«¥∑’Ë‡°‘¥®“°¡–‡√Áß °“√≈ÿ°≈“¡¢Õß¡–‡√Áß À√◊Õ‡ªìπº≈®“°°“√√—°…“¡–‡√Áß‰¡à«à“®–‡ªìπ®“°°“√ºà“μ—¥ ©“¬√—ß ’ À√◊Õ ‡§¡’∫”∫—¥

** Non cancer-related pain À¡“¬∂÷ßÕ“°“√ª«¥∑’Ë‡°‘¥„πºŸâªÉ«¬¡–‡√Áß ·μà “‡Àμÿ¢ÕßÕ“°“√ª«¥‰¡à‰¥â‡°‘¥®“°¡–‡√ÁßÀ√◊Õº≈æ«ß¢Õß¡–‡√Áß ‡™àπ Õ“°“√ª«¥®“°ßŸ «—¥ Õ“°“√ª«¥À—«‰¡‡°√π ‡ªìπμâπ


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

·ºπ¿Ÿ¡‘∑’Ë 2 ·π«∑“ß°“√∫”∫—¥§«“¡ª«¥®“°¡–‡√Áß

* À¡“¬∂÷ß §«“¡ª«¥¡’§«“¡√ÿπ·√ßÕ¬Ÿà„π√–¥—∫∑’ËºŸâªÉ«¬¬Õ¡√—∫‰¥â·≈–ºŸâªÉ«¬ “¡“√∂∑πÕ“°“√‰¡àæ÷ßª√– ß§å¢Õß¬“·°âª«¥‰¥â∂â“ºŸâªÉ«¬„™â opioids „Àâ¥Ÿ‡æ‘Ë¡‡μ‘¡„π¿“§ºπ«° 5.4 °“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“„π°≈ÿà¡ opioids

§”¬àÕ: NRS = Numerical rating scale §–·ππ 0-10


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

Nociceptive pain* NCP** CIBP** TIH** Vis/MBO**

Opioids ¥’¡“° ª“π°≈“ß ¥’¡“° ¥’ ¥’¡“°

”À√—∫Õ“°“√ª«¥

μ≈Õ¥‡«≈“

ª“π°≈“ß

”À√—∫Õ“°“√ª«¥∫‘¥

‡ªìπæ—°Ê

NSAIDs/Coxibs ¥’¡“° ‰¡à¥’ ¥’¡“° ¥’ ‰¡à·π–π”

Antidepressants πâÕ¬ ¥’¡“° ª“π°≈“ß ‰¡à·π–π” ‰¡à·π–π”

TCAs ·≈– SNRIs

Gabapentinoids πâÕ¬ ¥’¡“° ¥’ ‰¡à·π–π” ¥’

”À√—∫ visceral

hyperalgesia

Carbamazepine ‰¡à¥’ ¥’ πâÕ¬ πâÕ¬ ‰¡à¥’

”À√—∫ ¬°‡«âπ„™â‡ªìπ

paroxysmal ¬“°—π™—°

sharp shooting

pain

Bisphosphonates ‰¡à¥’ ‰¡à¥’ ¥’ ‰¡à¥’ ‰¡à¥’

‡¡◊ËÕ„Àâ¬“„π

√–¬–¬“«

Corticosteroids ‰¡à·π–π” ¥’¡“° ª“π°≈“ß ¥’¡“° ¥’

”À√—∫ nerve/spinal ”À√—∫ liver

cord compression capsule distension

μ“√“ß∑’Ë 2 √–¥—∫°“√μÕ∫ πÕß¢Õß§«“¡ª«¥·∫∫μà“ßÊ ∑’Ëæ∫‰¥â„πºŸâªÉ«¬¡–‡√ÁßμàÕ¬“·°âª«¥°≈ÿà¡μà“ßÊ

* Nociceptive pain ‡™àπ §«“¡ª«¥®“°°âÕπ¡–‡√Áß∑’Ë°¥‡∫’¬¥‡π◊ÈÕ‡¬◊ËÕ à«π°“¬ ‡™àπ °≈â“¡‡π◊ÈÕ °√–¥Ÿ° À√◊Õ‡π◊ÈÕ‡¬◊ËÕÕàÕπÕ◊ËπÊÀ√◊Õ visceral organ ‡™àπ μ—∫ °√–‡æ“–Õ“À“√

** ¡’°“√√—°…“‡©æ“– „Àâ¥Ÿ„π¿“§ºπ«° 4 °“√√—°…“‡©æ“–¢Õß§«“¡ª«¥®“°¡–‡√Áß∑’Ë‡°‘¥®“° “‡Àμÿμà“ßÊ§”¬àÕ: NCP = Neuropathic cancer pain, CIBP = Cancer-induced bone pain, TIH = Tumor-induced headache,Vis/MBO = Visceral pain ·≈– malignant bowel obstruction, NSAIDs = Non-steroidal anti-inflammatory drugs,TCAs = Tricyclic antidepressants, SNRIs = Serotonin norepinephrine reuptake inhibitors


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

√Ÿª∑’Ë 1 Õß§åª√–°Õ∫¢Õß°“√ª√–‡¡‘π§«“¡ª«¥Õ¬à“ß§√Õ∫§≈ÿ¡

Check listComprehensive pain assessment

°“√ª√–‡¡‘π§«“¡ª«¥∑’Ë‡ªìπ¡“μ√∞“π§◊Õ°“√√“¬ß“π§«“¡ª«¥‚¥¬μ—«ºŸâªÉ«¬‡Õß (patientûs self report)

°“√ª√–‡¡‘π§«“¡ª«¥Õ¬à“ß§√Õ∫§≈ÿ¡ (comprehensive pain assessment) ª√–°Õ∫¥â«¬ °“√´—°ª√–«—μ‘

°“√μ√«®√à“ß°“¬ °“√ª√–‡¡‘π∑“ß¥â“π®‘μ„® Õ“√¡≥å ·≈– —ß§¡ √«¡∑—Èß°“√ àßμ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√·≈–

¿“æ∂à“¬√—ß ’ μ“¡√Ÿª∑’Ë 1


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°“√ª√–‡¡‘πª√– ∫°“√≥å§«“¡ª«¥

‡¡◊ËÕ„¥∑’Ë§«“¡ª«¥‡√‘Ë¡‡°‘¥¢÷Èπ (onset) ª«¥Õ¬à“ßμàÕ‡π◊ËÕßÀ√◊Õ‡ªìπ§√—Èß§√“« (temporal pattern) ª«¥

·μà≈–§√—Èßπ“π·§à‰Àπ

μ”·Àπàß∑’Ëª«¥ (¡“°°«à“ 1 μ”·ÀπàßÀ√◊Õ‰¡à) ·≈–°“√°√–®“¬¢Õß§«“¡ª«¥ (referral pattern, radia-

tion of pain)

≈—°…≥–¢Õß§«“¡ª«¥ ‡™àπ μ◊ÈÕÊ μÿä∫Ê ∑‘Ë¡μ” ∫’∫√—¥ ·À≈¡Ê ª«¥√â“« ‡ªìπμâπ

§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥ (‡™àπ ®“°§–·ππ 0-10, 0 À¡“¬∂÷ß ‰¡àª«¥‡≈¬ ·≈– 10 À¡“¬∂÷ßª«¥¡“°

∑’Ë ÿ¥∑’Ë‡ªìπ‰ª‰¥â ºŸâªÉ«¬ª«¥°’Ë§–·ππ) ‚¥¬ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥¢≥–π—Èπ (right now)

¢≥–æ—° ¢≥–‡§≈◊ËÕπ‰À« √–¥—∫∑’Ë√ÿπ·√ß¡“°∑’Ë ÿ¥·≈–πâÕ¬∑’Ë ÿ¥„π√–¬–‡«≈“ 24 ™—Ë«‚¡ß∑’Ëºà“π¡“

„π°√≥’∑’ËºŸâªÉ«¬‰¡à “¡“√∂ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥‡ªìπμ—«‡≈¢ Õ“®„ÀâºŸâªÉ«¬‡≈◊Õ°„∫Àπâ“

· ¥ß§«“¡ª«¥‚¥¬„™â faces pain rating scale À√◊Õ„™â§”§ÿ≥»—æ∑å· ¥ß§«“¡ª«¥ ‡™àπ ª«¥πâÕ¬

ª“π°≈“ß ¡“° ¡“°∑’Ë ÿ¥ ‡ªìπμâπ

·æ∑¬åÀ√◊Õæ¬“∫“≈Õ“®μâÕßª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥®“°°“√ —ß‡°μæƒμ‘°√√¡¢ÕßºŸâªÉ«¬„π

°√≥’∑’ËºŸâªÉ«¬‰¡à “¡“√∂ª√–‡¡‘π√–¥—∫§«“¡ª«¥‰¥â¥â«¬μπ‡Õß‡π◊ËÕß®“° “‡Àμÿ∑“ß°“¬À√◊Õ°“√√—∫√Ÿâ∫°æ√àÕß

(cognitive impairment) ·μàμâÕßμ√–Àπ—°«à“ “‡ÀμÿÕ◊ËπÊ ‡™àπ §«“¡∑√¡“π∑“ß¥â“π®‘μ„® °Á àßº≈„Àâ¡’

æƒμ‘°√√¡π—ÈπÊ ‰¥â‡™àπ°—π

ªí®®—¬∑’Ë∑”„Àâª«¥¡“°¢÷Èπ·≈–ªí®®—¬∑’Ë∑”„Àâª«¥≈¥≈ß

º≈°√–∑∫¢Õß§«“¡ª«¥μàÕ°“√¥”‡π‘π™’«‘μ ‡™àπ °“√∑”°‘®«—μ√ª√–®”«—π °“√∑”ß“π °“√æ—°ºàÕππÕπ

À≈—∫ ·≈–Õ“√¡≥å ‡ªìπμâπ

Õ“°“√Õ◊ËπÊ ∑’Ë‡ªìπ√à«¡ ‡™àπ §≈◊Ëπ‰ â Õ“‡®’¬π ‡ªìπμâπ

°“√√–ß—∫ª«¥∑’Ë‰¥â√—∫¢≥–π’È (current pain management) ∑—Èß°“√„™â¬“·≈–«‘∏’°“√Õ◊ËπÊ ∑’Ë‰¡à„™â¬“

„π°√≥’∑’Ë‡ªìπ°“√√—°…“·∫∫„™â¬“ „Àâ´—°ª√–«—μ‘√“¬≈–‡Õ’¬¥‡À≈à“π’È¥â«¬ ‰¥â·°à

„™â¬“Õ–‰√∫â“ß

¢π“¥∑’Ë„™â

§«“¡∂’Ë∑’Ë„™â

º≈°“√√–ß—∫ª«¥∑’Ë‰¥â√—∫ (®“°¬“·μà≈–™π‘¥)

Õ“°“√‰¡àæ÷ßª√– ß§å (®“°¬“·μà≈–™π‘¥) ‡™àπ ∑âÕßºŸ° §≈◊Ëπ‰ â ßà«ß´÷¡ ‡ªìπμâπ

°“√√–ß—∫ª«¥∑’Ë‡§¬‰¥â√—∫ ∑—Èß°“√„™â¬“·≈–«‘∏’°“√Õ◊ËπÊ ∑’Ë‰¡à„™â¬“ ‚¥¬ —°√“¬≈–‡Õ’¬¥‡°’Ë¬«°—∫‡Àμÿº≈∑’Ë„™â

√–¬–‡«≈“∑’Ë„™â °“√μÕ∫ πÕßμàÕ°“√√—°…“ Õ“°“√‰¡àæ÷ßª√– ß§å ·≈–‡Àμÿº≈∑’ËÀ¬ÿ¥„™â¬“·μà≈–μ—«À√◊Õ

À¬ÿ¥°“√√—°…“·μà≈–™π‘¥


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

°“√ª√–‡¡‘π∑“ß¥â“π®‘μ„® Õ“√¡≥å ·≈– —ß§¡

§«“¡‡¢â“„®·≈–º≈°√–∑∫¢Õß¡–‡√Áß·≈–°“√√—°…“¡–‡√ÁßμàÕºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈

§«“¡À¡“¬·≈–º≈°√–∑∫¢Õß§«“¡ª«¥μàÕºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈

æƒμ‘°√√¡„π°“√μÕ∫ πÕßμàÕ§«“¡‡§√’¬¥À√◊Õ§«“¡ª«¥¢ÕßºŸâªÉ«¬

§«“¡√Ÿâ §«“¡ ß —¬ §«“¡μâÕß°“√ ·≈–§«“¡§“¥À«—ß¢ÕßºŸâªÉ«¬μàÕ°“√√–ß—∫ª«¥

§«“¡°—ß«≈¢ÕßºŸâªÉ«¬μàÕ°“√„™â¬“√–ß—∫ª«¥ ‡™àπ ¬“°≈ÿà¡ opioids ¬“πÕπÀ≈—∫ ‡ªìπμâπ

º≈¢Õß»“ π“ «—≤π∏√√¡ μàÕ§«“¡ª«¥·≈–°“√· ¥ßÕÕ°¢Õß§«“¡ª«¥ (pain expression)

º≈°√–∑∫¢Õß§«“¡ª«¥·≈–°“√√–ß—∫ª«¥μàÕ‡»√…∞“π–¢ÕßºŸâªÉ«¬

º≈°√–∑∫¢Õß§«“¡ª«¥μàÕÕ“√¡≥å¢ÕßºŸâªÉ«¬ ‡™àπ ∑”„ÀâÀ¥ÀŸà ´÷¡‡»√â“ ‡ªìπμâπ

§«“¡™à«¬‡À≈◊Õ®“°§√Õ∫§√—«·≈– —ß§¡

°“√ª√–‡¡‘π ¿“«– ÿ¢¿“æ

‚√§Õ◊ËπÊ ∑’ËºŸâªÉ«¬‡ªìπ

¬“√—°…“‚√§Õ◊ËπÊ ∑’ËºŸâªÉ«¬„™â

°“√√—°…“¡–‡√Áß∑’Ë‰¥â√—∫ ‡™àπ °“√ºà“μ—¥ °“√©“¬· ß ‡§¡’∫”∫—¥ ‡ªìπμâπ

§«“¡ª«¥‡√◊ÈÕ√—ßÕ◊ËπÊ ∑’Ë‡ªìπ¡“°àÕπ

°“√μ√«®√à“ß°“¬·≈–°“√μ√«®∑“ß√–∫∫ª√– “∑

μ√«®∫√‘‡«≥∑’Ë¡’§«“¡ª«¥·≈–∫√‘‡«≥∑’Ë¡—°¡’°“√°√–®“¬¢Õß§«“¡ª«¥

μ√«®∑“ß√–∫∫ª√– “∑

μ√«®‡ âπª√– “∑ ¡Õß·≈–®Õª√– “∑μ“ (fundoscopic evaluation) „πºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥

∫√‘‡«≥»’√…–·≈–≈”§Õ

μ√«®°“√√—∫§«“¡√Ÿâ ÷° °“√∑”ß“π¢Õß°≈â“¡‡π◊ÈÕ¢Õß√–¬“ß§å °“√∑”ß“π¢ÕßÀŸ√Ÿ¥¢Õß∑àÕªí “«–

·≈–∑«“√Àπ—° „πºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥∑’Ë§ÕÀ√◊ÕÀ≈—ß


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°“√„Àâ°“√«‘π‘®©—¬§«“¡ª«¥ (pain diagnosis)

μ“¡ “‡Àμÿ (etiology)

¡–‡√Áß

°“√√—°…“¡–‡√Áß

“‡ÀμÿÕ◊ËπÊ ∑’Ë‰¡à‡°’Ë¬«¢âÕß°—∫¡–‡√Áß

μ“¡æ¬“∏‘ √’√«‘∑¬“ (pathophysiology)

Nociceptive pain ‡™àπ §«“¡ª«¥®“°°âÕπ¡–‡√Áß∑’Ë°¥‡∫’¬¥‡π◊ÈÕ‡¬◊ËÕ à«π°“¬ ‡™àπ °≈â“¡‡π◊ÈÕ °√–¥Ÿ°

À√◊Õ‡π◊ËÕ‡¬◊ËÕÕàÕπÕ◊ËπÊ À√◊Õ visceral organ ‡™àπ μ—∫ °√–‡æ“–Õ“À“√

Neuropathic pain ‡™àπ §«“¡ª«¥®“°¡–‡√Áß∑’Ë°√–®“¬‰ª∑’Ë somatosensory system ‡™àπ ‡ âπ

ª√– “∑ à«πª≈“¬ ·≈–‰¢ —πÀ≈—ß

μ“√“ß∑’Ë 3 μ—«Õ¬à“ß·∫∫ª√–‡¡‘π§«“¡ª«¥Õ¬à“ß§√Õ∫§≈ÿ¡„πºŸâªÉ«¬¡–‡√Áß‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ë™à«¬„π°“√

ª√–‡¡‘πºŸâªÉ«¬‚¥¬‡©æ“–„π°“√μ√«®√—°…“§√—Èß·√° ·≈–μ“√“ß∑’Ë 4 · ¥ßμ—«Õ¬à“ß·∫∫μ‘¥μ“¡§«“¡ª«¥„π

ºŸâªÉ«¬¡–‡√Áß ÷Ëß„™â„π°“√μ‘¥μ“¡ºŸâªÉ«¬

°“√ àßμ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√·≈–¿“æ∂à“¬√—ß ’

„Àâæ‘®“√≥“μ“¡§«“¡®”‡ªìπ

∂◊Õ‡ªìπ°“√„™â‡æ◊ËÕμ√«®‡æ‘Ë¡‡μ‘¡ μ“¡μ“√“ß∑’Ë 5


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áßμ“

√“ß∑

’Ë 3 μ—«

Õ¬à“ß

·∫∫ª

√–‡¡

‘π§«“

¡ª«¥

Õ¬à“ß

§√Õ∫

§≈ÿ¡„

πºŸâªÉ«

¬¡–‡

√Áß


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬μ“

√“ß∑

’Ë 4 μ—«

Õ¬à“ß

·∫∫μ

‘¥μ“¡

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πºŸâªÉ«

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·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

‚¥¬∑—Ë«‰ª®–μ√«®‡æ‘Ë¡‡μ‘¡‡¡◊ËÕ

1. ß —¬À√◊Õ‰¡à·πà„®„π “‡ÀμÿÀ√◊Õ∑’Ë¡“¢ÕßÕ“°“√ª«¥ ÷Ëß®–¡’º≈μàÕ°“√μ—¥ ‘π„®„π°“√√—°…“ à«π„À≠à

®–‡ªìπ°“√μ√«®∑“ß√—ß ’

2. μ√«® Õ∫ª√– ‘∑∏‘¿“æ°“√∑”ß“π¢Õß√à“ß°“¬ μ√«®À“‚√§∑’Ë‡ªìπ√à«¡ ‡æ◊ËÕ™à«¬„π°“√μ—¥ ‘π„®‡≈◊Õ°¬“

ª√—∫¬“ À√◊Õ«‘∏’°“√√—°…“„Àâª≈Õ¥¿—¬°—∫ºŸâªÉ«¬¡“°∑’Ë ÿ¥

°“√μ√«®‡æ◊ËÕ™à«¬À“ “‡Àμÿ¢ÕßÕ“°“√ª«¥

Plain film: chest X-ray (CXR) ¥Ÿ°“√·æ√à°√–®“¬¢Õß¡–‡√Áß‰ª∑’ËªÕ¥ ™àÕß‡¬◊ËÕÀÿâ¡ªÕ¥ À√◊Õ™àÕß‡¬◊ËÕÀÿâ¡À—«„®

Plain abdomen Õ“°“√ª«¥„π™àÕß∑âÕß∑’ËÕ“®‡°‘¥®“°≈”‰ âÕÿ¥μ—π ¿“«–≈”‰ âÀ√◊Õ

°√–‡æ“–Õ“À“√∑–≈ÿ

Bone scan Õ“°“√ª«¥∑’Ë ß —¬«à“Õ“®‡°‘¥®“°°“√·æ√à°√–®“¬¢Õß¡–‡√Áß‰ª¬—ß°√–¥Ÿ°

Computed tomography (CT) ¥Ÿ°“√·æ√à°√–®“¬¢Õß¡–‡√Áß‰ª¬—ßÕ«—¬«–μà“ßÊ ∑’Ë —¡æ—π∏å°—∫Õ“°“√ª«¥

π—ÈπÊ ¥Ÿ≈”‰ âÕÿ¥μ—π ¿“«–≈”‰ âÀ√◊Õ°√–‡æ“–Õ“À“√∑–≈ÿ °“√°√–®“¬‰ª∑’Ë ¡Õß

Magnetic resonance ¥Ÿ°“√·æ√à°√–®“¬¢Õß¡–‡√Áß‰ª¬—ß‡ âπª√– “∑À√◊Õ‰¢ —πÀ≈—ß

imaging (MRI) √«¡∂÷ß°“√°¥∑—∫‡ âπª√– “∑

°“√μ√«® Õ∫ª√– ‘∑∏‘¿“æ°“√∑”ß“π¢Õß√à“ß°“¬ ‡æ◊ËÕ™à«¬„π°“√μ—¥ ‘π„®‡≈◊Õ°¬“À√◊Õª√—∫¢π“¥¬“

Complete blood count (CBC) μ√«®¥Ÿ¿“«– anemia ∑’ËÕ“®‡°‘¥®“°¬“∫“ß°≈ÿà¡ ‡™àπ NSAIDs ∑’Ë∑”„Àâ‡°‘¥

‡≈◊Õ¥ÕÕ°„π∑“ß‡¥‘πÕ“À“√

Blood urea nitrogen (BUN) °“√‰¥â¬“√–ß—∫ª«¥À≈“¬μ—« Õ“®∑”„Àâ‡°‘¥Õ“°“√ßà«ß´÷¡ „π¢≥–‡¥’¬«°—π

·≈– electrolyte ¿“«– electrolyte imbalance ·≈–°“√‡æ‘Ë¡¢÷Èπ¢Õß§à“ BUN °Á¡’º≈∑”„Àâ

ºŸâªÉ«¬ßà«ß´÷¡¥â«¬‡™àπ°—π

Liver function test °“√∑”≈“¬¬“·°âª«¥ à«π„À≠à®–‡°‘¥¢÷Èπ∑’Ëμ—∫‚¥¬Õ“»—¬‡Õπ‰´¡å¢Õßμ—∫

À“°Àπâ“∑’Ë¢Õßμ—∫º‘¥ª°μ‘ Õ“®®–∑”≈“¬¬“‰¥â™â“≈ß àßº≈„Àâ¬“ÕÕ°ƒ∑∏‘Ï‰¥â

π“π¢÷Èπ

Creatinine clearance · ¥ß∂÷ßª√– ‘∑∏‘¿“æ¢Õß‰μ °“√≈¥≈ß¢Õß§à“ creatinine clearance

À¡“¬∂÷ß°“√∑”ß“π¢Õß‰μ·¬à≈ß °“√¢—∫¬“·°âª«¥∫“ß™π‘¥ÕÕ°®“°√à“ß°“¬

Õ“®≈¥≈ß¥â«¬ ∑”„ÀâμâÕß≈¥¢π“¥¬“≈ß À√◊Õ‡æ‘Ë¡√–¬–Àà“ß¢Õß°“√„Àâ¬“

μ“√“ß∑’Ë 5 °“√μ√«®‡æ‘Ë¡‡μ‘¡Õ◊ËπÊ (additional investigation) ‡æ◊ËÕ™à«¬„π°“√∫”∫—¥§«“¡ª«¥


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 1Õ“°“√‡©æ“–Õ◊ËπÊ

1.1 DyspneaDyspnea ‡ªìπÕ“°“√ (symptom) ∑’ËºŸâªÉ«¬√Ÿâ ÷°·≈–¡—°∫Õ°°—∫·æ∑¬å«à“¡’Õ“°“√À“¬„®≈”∫“° ·πàπÀπâ“Õ°

À“¬„®‰¡àÕ‘Ë¡ ‡ªìπμâπ ´÷ËßÕ“°“√¥—ß°≈à“«‰¡à®”‡ªìπμâÕß —¡æ—π∏å°—∫Õ“°“√· ¥ß (sign) ∑’Ë·æ∑¬åμ√«®æ∫ ‰¡à«à“®–‡ªìπ°“√„™â accessory muscle ™à«¬„π°“√À“¬„® °“√‡ª≈’Ë¬π·ª≈ß¢ÕßÕ—μ√“°“√À“¬„® À√◊Õ§à“ oxygensaturation „π‡≈◊Õ¥∑’ËμË”≈ß ∑—Èßπ’È‡π◊ËÕß®“° dyspnea ‡ªìπÕ“°“√∑’Ë¡’ªí®®—¬‡°’Ë¬«¢âÕßÀ≈“¬¥â“π ∑—Èß∑“ß¥â“π√à“ß°“¬®‘μ„® —ß§¡·≈–®‘μ«‘≠≠“≥ ºŸâªÉ«¬∑’Ë¡’Õ“°“√π’È®–¡’§«“¡«‘μ°°—ß«≈·≈–À«“¥°≈—«‰¥âÕ¬à“ß¡“° ∑”„Àâ§ÿ≥¿“æ™’«‘μ·¬à≈ß ‚¥¬ºŸâªÉ«¬®–¡’°“√‡æ‘Ë¡§«“¡æ¬“¬“¡„π°“√À“¬„® Õ“°“√¥—ß°≈à“« √â“ß§«“¡‰¡à ∫“¬„®„Àâ°—∫∑—Èßμ—«ºŸâªÉ«¬ §√Õ∫§√—« ·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’Ë„Àâ°“√¥Ÿ·≈

√–∫“¥«‘∑¬“æ∫‰¥â√âÕ¬≈– 21-76.8 ¢ÕßºŸâªÉ«¬¡–‡√Áß√–¬–≈ÿ°≈“¡ ‚¥¬√âÕ¬≈– 10-63 ¢ÕßºŸâªÉ«¬¡’Õ“°“√„π√–¥—∫

ª“π°≈“ß∂÷ß√ÿπ·√ß „π 24 ™—Ë«‚¡ß ÿ¥∑â“¬¢ÕßºŸâªÉ«¬¡–‡√Áß√–¬–≈ÿ°≈“¡®–æ∫Õ“°“√π’È ‰¥â Ÿß∂÷ß√âÕ¬≈– 80

“‡Àμÿë ®“°μ—«‚√§¡–‡√Áß‚¥¬μ√ß ‡™àπ lung cancer, head & neck cancer, pulmonary metastasis,

lymphangitis carcinomatosis, pleural effusion, phrenic nerve paralysis ‡ªìπμâπë ®“°¿“«–·∑√°´âÕπ¢Õß°“√√—°…“¡–‡√Áß ‡™àπ pneumonectomy, radiation pneumonitis, chemo-

therapy induced pulmonary toxicity/cardiomyopathy ‡ªìπμâπë ®“°¿“«–·∑√°´âÕπ∑’Ë‰¡à‰¥â‡°‘¥®“°¡–‡√Áß‚¥¬μ√ß ‡™àπ cachexia, anemia, pulmonary emboli

‡ªìπμâπë ®“°‚√§∑“ßÕ“¬ÿ√°√√¡∑’ËºŸâªÉ«¬‡ªìπ√à«¡ ‚¥¬‰¡à‡°’Ë¬«°—∫¡–‡√Áß ‡™àπ chronic obstructive lung

disease (COPD), congestive heart failure, asthma, non malignant pleural effusion ‡ªìπμâπ

°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë¡’ dyspnea¡’‡ªÑ“À¡“¬À≈—°§◊Õ√—°…“Õ“°“√ ‡æ◊ËÕ„ÀâºŸâªÉ«¬¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’¢÷Èπ ‚¥¬°“√´—°ª√–«—μ‘‡°’Ë¬«°—∫ onset,

pattern, associated symptom, chest pain, cough, fever, factors exacerbating/relieving, role of

anxiety in precipitating attacks, impact on social life ·≈–‚√§∑’Ë‡ªìπ√à«¡Õ◊ËπÊ ‡™àπ COPD, ischemic

heart disease (IHD) §«√μ√«®√à“ß°“¬‚¥¬≈–‡Õ’¬¥ ·≈– àßμ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√∑’Ë®”‡ªìπ‡æ◊ËÕ§âπÀ“ “‡Àμÿ

∑’Ë‡°’Ë¬«¢âÕß·≈–√—°…“μ“¡ “‡Àμÿ‚¥¬μ√ß À“°¬—ß “¡“√∂∑”‰¥âÕ“®„™â°“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ß¥â«¬ visualanalogue scale À√◊Õ modified Borg scale ∑’Ë¡’§–·ππ√–À«à“ß 0-10 (0 = ‰¡à¡’Õ“°“√ 10 = ¡’Õ“°“√

¡“°∑’Ë ÿ¥) ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√μ‘¥μ“¡º≈°“√√—°…“


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

°“√√—°…“ª√–°Õ∫¥â«¬°“√√—°…“μ“¡ “‡Àμÿ‚¥¬μ√ß ‡™àπ √—ß ’√—°…“ °“√„Àâ¬“ªØ‘™’«π– °“√‡®“–πÈ”„π™àÕß‡¬◊ËÕ

Àÿâ¡ªÕ¥ÕÕ° ·≈–°“√√—°…“Õ“°“√‚¥¬√«¡ ÷ËßÕ“»—¬«‘∏’°“√„™â¬“·≈–‰¡à„™â¬“

ë Opioids ‡ªìπ¬“∑’Ë„™â ‰¥âº≈¥’ ‰¥â·°à morphine 2-5 ¡°. ©’¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥”À√◊Õ„μâº‘«Àπ—ß∑ÿ°

4 ™—Ë«‚¡ß À√◊Õ√—∫ª√–∑“π„π¢π“¥ 10-30 ¡°./«—π À√◊Õ hydromorphone 2-5 ¡°. ∑ÿ° 6 ™—Ë«‚¡ß

(hydromorphone ¬—ß‰¡à¡’„™â„πª√–‡∑»‰∑¬) ‰¡à·π–π”„Àâæàπ¬“ opioids ºà“π nebulizer

ë ¬“°≈ÿà¡ benzodiazepines ·≈– phenothaizines ¡’ª√–‚¬™πå‡©æ“–°—∫ºŸâªÉ«¬∑’Ë¡’Õ“°“√°—ß«≈À√◊Õ

°≈—«¡“°‡∑à“π—Èπ

ë Oxygen therapy ·π–π”„Àâ„™â°—∫ºŸâªÉ«¬∑’Ë¡’ hypoxemia ‡∑à“π—Èπ

ë Non pharmacological treatment ∑’Ë¡’°“√»÷°…“«à“‰¥âº≈¥’ ‰¥â·°à °“√Ωñ°À“¬„® „™âÕÿª°√≥å™à«¬‡¥‘π

chest wall vibration ·≈–°“√„™âæ—¥≈¡‡ªÉ“‡∫“Ê ∑’ËÀπâ“ºŸâªÉ«¬‚¥¬μ√ß

1.2 Lymphedema‡ªìπ§«“¡º‘¥ª°μ‘¢Õß°“√‰À≈°≈—∫¢ÕßπÈ”‡À≈◊Õß (lymph) ÷Ëßª√–°Õ∫¥â«¬‚ª√μ’π®”π«π¡“° ‚¥¬πÈ”‡À≈◊Õß

´÷¡ÕÕ°®“°∑àÕπÈ”‡À≈◊Õß‡¢â“¡“Õ¬Ÿà„π™àÕß«à“ß√–À«à“ß‡´≈≈å ‡ªìπº≈„Àâ∫«¡ ¡’°“√Õ—°‡ ∫‡√◊ÈÕ√—ß ‡π◊ÈÕ‡¬◊ËÕ‰¢¡—π‡°‘¥¿“«– hypertrophy ·≈–‡°‘¥æ—ßº◊¥ ‡°‘¥°—∫ à«π„¥¢Õß√à“ß°“¬°Á‰¥â æ∫¡“°∑’Ë¢“ ·¢π ∑”„Àâ°√–∑∫μàÕ°“√

„™âß“π·≈–§«“¡ «¬ß“¡¢ÕßÕ«—¬«–π—ÈπÊ „πºŸâªÉ«¬¡–‡√Áß¡—°‡ªìπ®“°°“√Õÿ¥°—Èπ¢Õß∑àÕπÈ”‡À≈◊Õß·≈–μàÕ¡πÈ”‡À≈◊Õß

À√◊Õ®“°°“√‰¥â√—∫√—ß ’√—°…“ À√◊Õºà“μ—¥

°“√μ√«®√à“ß°“¬®–æ∫∫«¡°¥∫ÿã¡„π√–¬–·√° À“°‡ªìπ¡“π“π®–·¢Áß‡π◊ËÕß®“°‡√‘Ë¡¡’æ—ßº◊¥ §«√«—¥‡ âπ

√Õ∫«ß¢Õß·¢πÀ√◊Õ¢“∑’Ë∫«¡‡æ◊ËÕ‡ªìπ¢âÕ¡Ÿ≈μ‘¥μ“¡º≈°“√√—°…“„π°√≥’∑’Ëª√–«—μ‘·≈–°“√μ√«®√à“ß°“¬‰¡à™—¥‡®π Õ“®μ√«®‡æ‘Ë¡‡μ‘¡¥â«¬¿“æ∑“ß√—ß ’

°“√«‘π‘®©—¬·¬°‚√§ ‰¥â·°à deep vein thrombosis, chronic venous insufficiency ·≈– myxedema

°“√√—°…“ë ‡æ◊ËÕ≈¥¿“«–·∑√°´âÕπ·≈–§«∫§ÿ¡√–¬–¬“«π“π ‚¥¬°“√Õ∏‘∫“¬ ¿“«–‚√§ „Àâ°”≈—ß„® ∑”°“√¥Ÿ·≈

º‘«Àπ—ß °“√¥Ÿ·≈§«“¡ –Õ“¥º‘« À≈’°‡≈’Ë¬ß°“√‡®“–‡≈◊Õ¥∫√‘‡«≥π—ÈπÊ ‡æ◊ËÕ≈¥°“√μ‘¥‡™◊ÈÕë °“√π«¥‡æ◊ËÕ°√–μÿâπ°“√‰À≈°≈—∫¢ÕßπÈ”‡À≈◊Õß ∑’Ëπ‘¬¡§◊Õ°“√π«¥Õ¬à“ß‡∫“Ê „ÀâπÈ”‡À≈◊Õß‰À≈‡«’¬π

®“°¥â“πª≈“¬¢Õß·¢π¢“∑’Ë∫«¡‡¢â“À“≈”μ—«

ë «‘∏’Õ◊ËπÊ ‰¥â·°à °“√„™â compression stockings À√◊Õ sleeves ∑’Ë„Àâ·√ß°¥ 20-30 ¡‘≈≈‘‡¡μ√ª√Õ∑

∑’Ë·¢πÀ√◊Õ¢“‡æ◊ËÕª√–§Õß‰¡à„ÀâπÈ” – ¡ ÷Ëß “¡“√∂∑”„ÀâºŸâªÉ«¬¥’¢÷Èπ‰¥â„π 24-48 ™—Ë«‚¡ß §Õ¬ª√—∫≈¥¢π“¥

‡¡◊ËÕÕ“°“√∫«¡¥’¢÷Èπ

ë Compression pump ·≈– intensive low compression bandaging ™à«¬≈¥°“√∫«¡Õ¬à“ß™â“Ê

´÷Ëß¡’¢âÕÀâ“¡‡¡◊ËÕ¡’°“√°√–®“¬¢Õß¡–‡√Áß∑’Ëº‘« ∫«¡∑’Ë≈”μ—« °“√μ‘¥‡™◊ÈÕ À√◊Õ¡’ venous thrombosis

ë ‡¡◊ËÕ‡ªìπ‡√◊ÈÕ√—ß §«√∑“§√’¡„Àâº‘«™ÿà¡™◊Èπ·≈–√–«—ß°“√μ‘¥‡™◊ÈÕ

ë °“√„™â¬“¢—∫ªí “«–‰¡à¡’ª√–‚¬™πå ¬°‡«âπ‡¡◊ËÕ¡’°“√„™â NSAIDs À√◊Õ steroids À√◊Õ¡’‚√§À—«„®√à«¡


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

1.3 ConstipationConstipation (∑âÕßºŸ°) ‡ªìπÕ“°“√∑’Ëæ∫¡“°„πºŸâªÉ«¬¡–‡√Áß‚¥¬Õ“®¡’ “‡Àμÿ®“°°“√√—∫ª√–∑“πÕ“À“√

∑’Ë„¬Õ“À“√‰¡à‡æ’¬ßæÕ ¥◊Ë¡πÈ”πâÕ¬ ¡’°‘®°√√¡∑“ß°“¬πâÕ¬ (πÕπμ‘¥‡μ’¬ßÀ√◊ÕÕ—¡æ“μ) À√◊Õ‰¥â√—∫¬“∫“ß™π‘¥ ‡™àπ

opioids À√◊Õ antidepressants ‡ªìπμâπ ‚¥¬¬“ opioids ∑”„ÀâºŸâªÉ«¬∑âÕßºŸ°æ∫‰¥â√âÕ¬≈– 40-95 Õ“°“√∑âÕßºŸ°

‡ªìπÕ“°“√∑’Ë¡’ªí®®—¬‡°’Ë¬«¢âÕßÀ≈“¬¥â“π·≈–∑”„Àâ§ÿ≥¿“æ™’«‘μ·¬à≈ß‰¥â

√–∫“¥«‘∑¬“ºŸâªÉ«¬¡–‡√Áßæ∫‰¥â√âÕ¬≈– 70-100 ‚¥¬‡©æ“–„πºŸâ ŸßÕ“¬ÿ ºŸâªÉ«¬Õ—¡æ“μÀ√◊Õ‰¥â√—∫¬“∫“ß™π‘¥ ‡™àπ opioids

“‡Àμÿë ¬“ opioids ‡π◊ËÕß®“°¡’ƒ∑∏‘Ï„π°“√‡æ‘Ë¡°“√¥Ÿ¥´÷¡πÈ”°≈—∫ ≈¥ “√§—¥À≈—Ëß„π ”‰ â ·≈–≈¥°“√‡§≈◊ËÕπ‰À«

¢Õß≈”‰ â

ë ¬“Õ◊ËπÊ ‡™àπ antacids, anticholinergics, antihistamines, calcium channel blockers, 5-HT3

antagonists, iron supplements, monoamine oxidase inhibitors, psychotherapeutic drugs, tricyclic

antidepressants ‡ªìπμâπ

ë √—∫ª√–∑“πÕ“À“√∑’Ë¡’°“°„¬πâÕ¬ ¥◊Ë¡πÈ”πâÕ¬

ë “‡Àμÿ√Õß‰¥â·°à ≈”‰ âÕÿ¥°—Èπ®“°‚√§μà“ßÊ ‡™àπ ¡–‡√Áß≈”‰ â„À≠à, volvulus, adhesion, stroke,

hypercalcemia, hypokalemia, hyperparathyroidism, inflammatory bowel disease, diverticulosis,

spinal cord compression, multiple sclerosis, hypothyroidism, chronic renal failure, Parkinsonûs

disease À√◊Õ scleroderma

°“√√—°…“√—°…“μ“¡ “‡Àμÿ·≈–Õ“°“√‚¥¬§«√‡≈◊Õ°„™â¬“∂à“¬À√◊Õ¬“√–∫“¬μ“¡°≈‰°°“√‡°‘¥Õ“°“√∑âÕßºŸ°

·π–π”°“√ªØ‘∫—μ‘μ—« ‡™àπ „Àâ¥◊Ë¡πÈ”‡æ‘Ë¡¢÷Èπ √—∫ª√–∑“πÕ“À“√∑’Ë¡’°“°„¬ ‡æ‘Ë¡°‘®°√√¡∑“ß°“¬·≈–„Àâ‡«≈“

·≈– √â“ß∫√√¬“°“»∑’Ë¥’„π°“√¢—∫∂à“¬ ·≈â«®÷ßæ‘®“√≥“„™â¬“√–∫“¬ Õ“®∑”°“√≈â«ßÕÿ®®“√–„π°√≥’∑’Ë¡’°“√

Õÿ¥μ—πμ‘¥μàÕ°—π‡ªìπ√–¬–‡«≈“π“π à«πÀ“°‡°‘¥≈”‰ âÕÿ¥μ—π„Àâ∑”°“√√—°…“μ“¡·π«∑“ß∑“ß»—≈¬°√√¡ ÷ËßÕ“®

®”‡ªìπμâÕß‰¥â√—∫°“√ºà“μ—¥

°“√√—°…“¥â«¬¬“‡≈◊Õ°„™â¬“ ÷Ëß¡’∑—Èß™π‘¥√—∫ª√–∑“π ‡ÀπÁ∫∑«“√Àπ—° À√◊Õ «πÕÿ®®“√– ·μà„π°√≥’∑’Ë„Àâ¬“√–∫“¬‡æ◊ËÕ

ªÑÕß°—πÕ“°“√∑âÕßºŸ°®“°°“√„™â opioids ‰¡à·π–π”„Àâ„™â¬“°≈ÿà¡ bulk forming laxatives ‡π◊ËÕß®“°Õ“®

∑”„Àâ‡°‘¥¿“«–≈”‰ âÕÿ¥μ—π‰¥â (μ“√“ß∑’Ë 6)


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

™π‘¥ μ—«Õ¬à“ß °≈‰°°“√ÕÕ°ƒ∑∏‘Ï §”·π–π”

Stool Softeners

Surfactant Docusate ∑”„ÀâÕÿ®®“√–πÿà¡‚¥¬ ë „™â√à«¡°—∫ stimulant

≈¥·√ßμ÷ßº‘« ‡æ‘Ë¡§«“¡ laxatives

‡¢â“°—π°—∫πÈ”

Osmotic Lactulose, magnesium ¥÷ßπÈ”‡¢â“ Ÿà lumen ¢Õß ë º≈°“√√—°…“¢÷Èπ°—∫™π‘¥∑’Ë

hydroxide, polyethylene ≈”‰ â„À≠à ∑”„ÀâÕÿ®®“√– ‡≈◊Õ°„™â Õ“®∑”„Àâ¡’

glycol, sodium phosphate πÿà¡¢÷Èπ electrolyte imbalance

ë À“°„™â magnesium

hydroxide μâÕßμ‘¥μ“¡°“√

∑”ß“π¢Õß‰μ‡ªìπ√–¬–Ê

·≈–‰¡à§«√„™â„πºŸâªÉ«¬∑’Ë¡’

¿“«–‰μ∫°æ√àÕß

Lubricant Mineral oil À≈àÕ≈◊Ëπ ”‰ â ™–≈Õ°“√ ë „™â√à«¡°—∫ laxatives Õ◊ËπÊ

¥Ÿ¥´÷¡πÈ”®“°Õÿ®®“√–°≈—∫ ‡¡◊ËÕÕÿ®®“√–·¢Áß·≈–·Àâß

∑’Ë≈”‰ â„À≠à ·≈–∑”„Àâ

Õÿ®®“√–πÿà¡¢÷Èπ

Stimulants Bisacodyl, senna °√–μÿâπª≈“¬ª√– “∑ ë μâ“πº≈°“√≈¥ propulsive

‡æ‘Ë¡°“√∫’∫μ—«¢Õß≈”‰ â activity ®“° opioids

·≈–≈¥°“√¥Ÿ¥´÷¡πÈ”°≈—∫ „™â√à«¡°—∫ stool softeners

°“√„™â¬“√–∫“¬ Docusate + senna ¥Ÿ¥â“π∫π ë ¥Ÿ¥â“π∫π

√à«¡°—π Docusate + mineral oil - ‰¡à§«√„™â‡æ√“–Õ“®∑”„Àâ‡°‘¥

oil emboli

Peripheral opioid Methylnaltrexone, μâ“πº≈¢Õß opioids ë ¬—ß‰¡à¡’„™â„πª√–‡∑»‰∑¬

receptor blockers alvimopan „π≈”‰ â‡æ◊ËÕ≈¥Õ“°“√

∑âÕßºŸ°®“° opioids

Bulk forming Methylcellulose, æÕßμ—«®“°°“√¥÷ßπÈ” ‰¡à§«√„™â

laxatives psyllium

μ“√“ß∑’Ë 6 ¬“√–∫“¬ ”À√—∫Õ“°“√∑âÕßºŸ°∑’Ë‡°‘¥®“°„™â¬“„π°≈ÿà¡ opioids


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

1.4 Deconditioning and fatigueºŸâªÉ«¬¡–‡√Áß à«π„À≠à‡¡◊ËÕ‰¥â√—∫°“√√—°…“¥â«¬‡§¡’∫”∫—¥·≈–√—ß ’√—°…“·≈â«®–‰¥â√—∫°“√μ√«®μ‘¥μ“¡

º≈Õ¬à“ßÀà“ßÊ ‚¥¬‡ªìπ°“√μ‘¥μ“¡¥Ÿº≈‡≈◊Õ¥À√◊Õ°“√μ√«®∑“ß√—ß ’ ºŸâªÉ«¬¡—°®–‰¡à‰¥â√—∫°“√μ‘¥μ“¡„π¥â“π

§ÿ≥¿“æ™’«‘μ ºŸâªÉ«¬¡–‡√Áß à«π¡“°®–μâÕßμàÕ Ÿâ°—∫ªí≠À“μà“ßÊ ∑’Ëμ“¡¡“À≈—ß°“√√—°…“‡ √Á® ‘ÈπμàÕ‰ª¥â«¬μπ‡Õß

‡™àπ Õ“°“√‰¡àæ÷ßª√– ß§å¢Õß¬“‡§¡’∫”∫—¥ Õ“°“√ª«¥ ¿“«– deconditioning and fatigue ∑”„Àâ physical

fitness ·≈–°“√‡§≈◊ËÕπ‰À«¢Õß¢âÕ≈¥≈ß àßº≈„ÀâºŸâªÉ«¬‰¡à “¡“√∂°≈—∫‰ª„™â™’«‘μ‡™àπ‡¥‘¡‰¥â

¡’ªí≠À“À≈“¬Õ¬à“ß∑’Ëæ∫‰¥â„πºŸâªÉ«¬¡–‡√ÁßÀ≈—ß°“√√—°…“∑’Ëπ”¡“ ÷Ëß°“√‡ª≈’Ë¬π·ª≈ß∑—Èß∑“ß¥â“π√Ÿª√à“ß

¿“æ≈—°…≥å ·≈–°“√„™âß“π ∂â“‰¡àμ√–Àπ—°·≈–„Àâ§«“¡ ”§—≠μàÕ°“√øóôπøŸ ¡√√∂¿“æ ®– àßº≈„ÀâºŸâªÉ«¬ Ÿ≠‡ ’¬

Àπâ“∑’Ë·≈–°“√„™âß“π¢ÕßÕ«—¬«– à«ππ—ÈπÊ

¿“«–∂¥∂Õ¬¢Õß√à“ß°“¬ (deconditioning) ·≈–°“√≈¥§«“¡∑π∑“π¢Õß√à“ß°“¬ (endurancedeficits)

ºŸâªÉ«¬¡–‡√Áß¡—°¡’§«“¡ “¡“√∂¢Õß√à“ß°“¬„π°“√ÕÕ°°”≈—ß°“¬·≈– ¡√√∂¿“æ¢Õß√–∫∫À—«„®·≈–

ªÕ¥≈¥≈ß®“°°“√√—°…“ ‡™àπ °“√ºà“μ—¥ªÕ¥∫“ß à«πÕÕ°∑”„Àâ‡Àπ◊ËÕ¬ßà“¬ ºŸâªÉ«¬∑’ËπÕπμ‘¥‡μ’¬ßπ“πÊ ‡æ√“–

‡æ≈’¬®“°°“√„Àâ‡§¡’∫”∫—¥À√◊Õ√—ß ’√—°…“ ¬“∫“ß™π‘¥ ‡™àπ anthracycline, doxorubicin ÷Ëß¡’Õ“°“√‰¡àæ÷ß

ª√– ß§åμàÕÀ—«„® ·≈–°“√„Àâ√—ß ’√—°…“‚¥¬μ√ßμàÕºπ—ß∑√«ßÕ°·≈–À—«„®∑’ËÕ“®∑”„Àâ‡°‘¥æ—ßº◊¥μ“¡¡“

§«“¡≈â“ (fatigue)‡°‘¥¢÷Èπ°—∫ºŸâªÉ«¬√âÕ¬≈– 80 „π™à«ß√—∫°“√√—°…“¡–‡√Áß ·≈– à«πÀπ÷ËßÕ“°“√π’È®–§ßÕ¬Ÿà·¡â«à“°“√√—°…“

®∫‰ª·≈â«°Áμ“¡ cancer-related fatigue ¡’º≈μàÕ§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬ ·μà “¡“√∂‡¬’¬«¬“‰¥â¥â«¬°“√øóôπøŸ

¡√√∂¿“æ∑“ß°“¬ ¡’°“√»÷°…“´÷Ëß¡’§«“¡πà“‡™◊ËÕ∂◊Õ∑’Ëæ∫«à“°“√ÕÕ°°”≈—ß°“¬¡’º≈¥’μàÕ cancer-related

fatigue

°“√∑√ßμ—«·≈–‚Õ°“ ≈â¡ ¿“«–∂¥∂Õ¬¢Õß√à“ß°“¬∑”„Àâ°≈â“¡‡π◊ÈÕ¢“ÕàÕπ·√ß πÕ°®“°π’ÈºŸâªÉ«¬Õ“®¡’°“√√—∫§«“¡√Ÿâ ÷°·≈–

√’‡ø≈Á°´å≈¥≈ßÀ√◊Õ¡’¿“«–‡ ’¬°“√∑√ßμ—«∑—Èß¢≥–Õ¬Ÿàπ‘Ëß·≈–‡§≈◊ËÕπ‰À«®“° chemotherapy-induced peri-

pheral neuropathy ÷Ëß°“√¡’ªí≠À“°“√∑√ßμ—«Õ“®π”‰ª Ÿà°“√≈â¡·≈–°√–¥Ÿ°À—°‰¥â

¡“μ√°“√øóôπøŸ ¡√√∂¿“æ ‘Ëß ”§—≠∑’Ë ÿ¥„π°“√·°âªí≠À“¢â“ßμâπ§◊ÕºŸâ„Àâ°“√√—°…“μâÕß¡’§«“¡μ√–Àπ—°∑’Ë®–∂“¡À√◊Õ¡ÕßÀ“ªí≠À“

‡À≈à“π’È ·≈–ª√—∫‡ª≈’Ë¬π§«“¡‡™◊ËÕ∑’Ë«à“ºŸâªÉ«¬¡–‡√ÁßμâÕß çπÕπ·πàπ‘Ëßé ‡∑à“π—Èπ ¡“μ√°“√∑“ß‡«™»“ μ√åøóôπøŸ∑’Ë

§«√∑”§◊Õ graded conditioning exercise, low-resistance weight training, balance training, activities

of daily living (ADL) training ÷Ëß “¡“√∂∑”‚¥¬π—°°“¬¿“æ∫”∫—¥ π—°°‘®°√√¡∫”∫—¥ À√◊Õ„Àâ§”·π–π”‰ª

ªØ‘∫—μ‘∑’Ë∫â“π Õ¬à“ß‰√°Áμ“¡§«“¡≈â“·≈– ¿“«–∂¥∂Õ¬¢Õß√à“ß°“¬‡ªìπÕÿª √√§ ”§—≠μàÕ°“√ÕÕ°°”≈—ß°“¬´÷Ëß

“¡“√∂·°â ‰¢‰¥â¥â«¬°“√ √â“ß·√ß®Ÿß„®®“°ª√–‚¬™πå¢Õß°“√ÕÕ°°”≈—ß°“¬ ·≈–„Àâ‡√‘Ë¡μ“¡§«“¡‡À¡“– ¡

‡ªìπ√“¬Ê ‰ªμ—Èß·μàºŸâªÉ«¬¬—ßÕ¬Ÿà„π√–À«à“ß°“√√—°…“


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

2.1 Distress¿“«–∑ÿ°¢å (distress) ‡ªìπ»—æ∑å„À¡à∑“ß°“√·æ∑¬å∑’Ë National Comprehensive Cancer Network

(NCCN) ‰¥â‡ πÕ„Àâ‡ª≈’Ë¬π°“√ª√–‡¡‘π‡√◊ËÕß§«“¡«‘μ°°—ß«≈À√◊Õªí≠À“∑“ß®‘μμà“ßÊ ‡ªìπ°“√ª√–‡¡‘π‡√◊ËÕß

distress ·∑π ‡æ◊ËÕ≈¥§«“¡≈”∫“°„® ”À√—∫ºŸâªÉ«¬¡–‡√Áß‡√◊ËÕß∂Ÿ°¡Õß«à“¡’ªí≠À“ ÿ¢¿“æ®‘μÀ√◊Õ¡’‚√§∑“ß®‘μ

NCCN ‰¥â √â“ß‡§√◊ËÕß¡◊Õ∑’Ë‡√’¬°«à“ Distress Thermometer ‡æ◊ËÕ„Àâ∑’¡ºŸâ√—°…“ºŸâªÉ«¬¡–‡√Áß„™â„π°“√ª√–‡¡‘π

·≈–«‘‡§√“–Àåªí≠À“¥â“πμà“ßÊ ¢ÕßºŸâªÉ«¬Õ¬à“ß‡ªìπÕß§å√«¡ ·≈–æ¬“¬“¡ àß‡ √‘¡„Àâ‡§√◊ËÕß¡◊Õπ’È‡ªìπ —≠≠“≥™’æ∑’Ë

6 (the 6th vital sign) ”À√—∫ºŸâªÉ«¬¡–‡√Áß §”«à“∑ÿ°¢åπ’È √«¡§«“¡μ—Èß·μà §«“¡«‘μ°°—ß«≈„πª√–‡¥Áπμà“ßÊ §«“¡

º‘¥À«—ß‡ ’¬„® ®π∂÷ßªí≠À“∑’Ë‚√§¡–‡√Áß°√–∑∫∂÷ß‡√◊ËÕß∑“ß®‘μ«‘≠≠“≥¢ÕßºŸâªÉ«¬ ‡æ√“–°“√®—¥°“√‡√◊ËÕßμà“ßÊ

‡À≈à“π’È≈â«π·μàμâÕß¥Ÿ·≈‡ªìπÕß§å√«¡·≈–μâÕßÕ“»—¬°“√ ◊ËÕ “√∑”ß“π‡ªìπ∑’¡ À “¢“

°“√ª√–‡¡‘π¿“«–∑ÿ°¢å¡’‡§√◊ËÕß¡◊Õ∑’Ë™◊ËÕ«à“ ª√Õ∑«—¥∑ÿ°¢å (Distress Thermometer ©∫—∫¿“…“‰∑¬) (√Ÿª

∑’Ë 2) ´÷Ëß‡ªìπ°√–∫«π°“√ª√–‡¡‘π∑’Ë„™â‡«≈“‰¡àπ“π ¡’‡π◊ÈÕÀ“∑’Ë§√Õ∫§≈ÿ¡ Õ’°∑—Èß¬—ß‡ªî¥æ◊Èπ∑’Ë„π°“√ ◊ËÕ “√

√–À«à“ßºŸâªÉ«¬°—∫∑’¡ºŸâ√—°…“„πªí≠À“¥â“πμà“ßÊ ¢ÕßºŸâªÉ«¬¥â«¬

«‘∏’°“√„™â‡§√◊ËÕß¡◊Õª√Õ∑«—¥∑ÿ°¢å§–·ππ¢Õßª√Õ∑«—¥∑ÿ°¢å‡ªìπ§–·ππ§«“¡√Ÿâ ÷°‡™‘ßπ“¡∏√√¡§≈â“¬ pain score ‚¥¬ºŸâªÉ«¬‡ªìπºŸâ‡≈◊Õ°«à“

¢≥–π’È√Ÿâ ÷°∑ÿ°¢å¡“°πâÕ¬‡æ’¬ß„¥ ®“°§–·ππ 0-10 „π™àÕß∑’Ë‡ªìπ√Ÿªª√Õ∑¥â“π â“¬ ®“°π—Èπª√–‡¡‘πªí≠À“¥â“πμà“ßÊ

¢Õßμπ‡Õß«à“¡’À√◊Õ‰¡à„πÀ—«¢âÕμà“ßÊ ∑“ß¥â“π¢«“ ∂â“§–·ππ„π™àÕßª√Õ∑¡“°°«à“ 4 ·μâ¡ §«√„Àâ°“√™à«¬‡À≈◊Õ

¥Ÿ·≈·∫∫Õß§å√«¡‡æ‘Ë¡‡μ‘¡∑—π∑’ ºŸâªÉ«¬Õ“®∑ÿ°¢å„®‡æ√“–¡’ªí≠À“¥â“π„¥¥â“πÀπ÷Ëß ÷Ëß∂â“‡ªìπªí≠À“ ÿ¢¿“æ®‘μ·≈â«

Õ“®®–¡’¿“«–«‘μ°°—ß«≈À√◊Õ¿“«–´÷¡‡»√â“Õ¬Ÿà

2.2 Anxiety‡¡◊ËÕºŸâªÉ«¬¡–‡√Áß¡’¿“«–«‘μ°°—ß«≈ (anxiety) Õ“®‡ªìπ‰ª‰¥â®“°À≈“¬ “‡Àμÿ ‰¥â·°à

1. °“√ª√—∫μ—«°—∫ªí≠À“™’«‘μÕ—π‡°‘¥®“°‚√§¡–‡√Áß·≈–°√–∫«π°“√√—°…“ (adjustment disorder with

anxiety)

2. ¿“«–«‘μ°°—ß«≈‡ªìπÕ“°“√· ¥ßÕÕ°∑“ß°“¬¢Õßªí≠À“ ÿ¢¿“æÕ◊ËπÊ ‡™àπ §«“¡ª«¥∑’Ë§«∫§ÿ¡‰¡à‰¥â

breathlessness, hyperthyriodism, hypoglycemia œ≈œ À√◊Õ‡°‘¥®“°º≈¢Õß¬“·≈–®“°°“√À¬ÿ¥¬“∫“ß™π‘¥

3. ºŸâªÉ«¬¡’‚√§«‘μ°°—ß«≈ phobia À√◊Õ panic À√◊Õ∫ÿ§≈‘°¿“æ∑’Ë«‘μ°°—ß«≈ßà“¬Õ¬Ÿà°àÕπ‡ªìπ¡–‡√Áß ·≈–∂Ÿ°

°√–μÿâπ¥â«¬ªí≠À“®“°‚√§¡–‡√Áß·≈–°√–∫«π°“√√—°…“

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‡√‘Ë¡μâπ¥â«¬°“√„Àâ§”ª√÷°…“„π‡√◊ËÕß∑’ËºŸâªÉ«¬°≈—«À√◊Õ°—ß«≈ ‡™àπ

ë „π¥â“πμ—«‚√§¡–‡√Áß ·π«∑“ß°“√√—°…“∑’Ë∑’¡®–®—¥°“√ ·≈–°“√æ¬“°√≥å‚√§

ë ºŸâªÉ«¬∫“ß√“¬¡’ªí≠À“°“√μ—¥ ‘π„® Õ“®μâÕß™à«¬™’È·®ß¢âÕ¥’¢âÕ‡ ’¬√«¡∂÷ß∂“¡„π ‘Ëß∑’ËºŸâªÉ«¬·≈–

≠“μ‘‡§¬®‘πμπ“°“√À√◊Õ§“¥À«—ß‰«â

ë Õ“°“√μà“ßÊ ‡™àπ §«“¡ª«¥ Õ“°“√§≈◊Ëπ‰ â À“¬„®ÀÕ∫‡Àπ◊ËÕ¬®—¥°“√‰¥âÕ¬à“ß‰√∫â“ß

ë °“√√—°…“¥â«¬¬“À√◊Õ«‘∏’°“√μà“ßÊ ¡’º≈Õ¬à“ß‰√ ¡’Õ“°“√‰¡àæ÷ßª√– ß§åÕ¬à“ß‰√

ë Õ“°“√Õ◊ËπÊ ∑’ËÕ“®®–æ∫„π¿“«–«‘μ°°—ß«≈ ‡™àπ πÕπ‰¡àÀ≈—∫ ÷¡‡»√â“ ∑âÕ·∑â „®À«‘« °√–«π°√–«“¬

2. „™â¬“„π°≈ÿà¡ anxiolytics ‡æ◊ËÕ™à«¬‡À≈◊ÕÕ“°“√μà“ßÊ ∑’Ë√∫°«π§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬ ‡™àπ

°√–«π°√–«“¬ πÕπ‰¡àÀ≈—∫ ·≈–√—°…“Õ“°“√∑“ß°“¬Õ◊ËπÊ ∑’Ëæ∫√à«¡¥â«¬

μ—«Õ¬à“ß¬“ anxiolytics ∑’Ë·π–π”§◊Õ¬“„π°≈ÿà¡ benzodiazepines ÷Ëß§«√„™â√–¬– —Èπ

ë Diazepam 2-10 ¡°. „π°√≥’∑’ËπÕπ‰¡àÀ≈—∫ À√◊Õ„Àâ‡ªìπ¬“©’¥ 5-10 ¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥”„π

°√≥’©ÿ°‡©‘π

ë Lorazepam 0.5-2 ¡°. „π°√≥’∑’ËπÕπ‰¡àÀ≈—∫À√◊ÕμâÕß°“√‡«≈“ÕÕ°ƒ∑∏‘Ï∑’Ë —Èπ°«à“ diazepam

À√◊Õ„™â lorazepam 0.5-1 ¡°. «—π≈– 2 §√—Èß„π™à«ß°≈“ß«—π∂â“¡’Õ“°“√«‘μ°°—ß«≈∑—Èß«—π

2.3 Depression°“√ªÉ«¬·≈–°“√∑√¡“π®“°‚√§¡–‡√Áß¬àÕ¡ àßº≈μàÕ ÿ¢¿“æ®‘μ¢ÕßºŸâªÉ«¬ ·μàÕ“®¡’ºŸâ§‘¥«à“¿“«–´÷¡‡»√â“

(depression) ‡ªìπ∏√√¡¥“ ”À√—∫ºŸâªÉ«¬¡–‡√Áß ‰¡à∂◊Õ«à“‡ªìπ§«“¡º‘¥ª°μ‘ ÷Ëß∑”„ÀâºŸâªÉ«¬‰¡à‰¥â√—∫°“√™à«¬‡À≈◊Õ

¥Ÿ·≈ ∑—Èß∑’Ë°“√√—°…“¿“«–´÷¡‡»√â“‡ªìπ‡√◊ËÕß∑’Ë‡æ‘Ë¡§ÿ≥¿“æ™’«‘μºŸâªÉ«¬‰¥â¡“° ·≈–‡ªìπªí®®—¬∑’Ë™à«¬„ÀâÕ“°“√ª«¥

¥’¢÷Èπ À“°ª≈àÕ¬„ÀâºŸâªÉ«¬´÷¡‡»√â“μàÕ‰ª®– àßº≈‡ ’¬μàÕ§«“¡√à«¡¡◊Õ„π°“√√—°…“ §«∫§ÿ¡Õ“°“√ª«¥‰¥â ‰¡à¥’

·≈–¡’°“√æ¬“°√≥å‚√§∑’Ë·¬à≈ß

Õ“°“√¢Õß¿“«– ÷¡‡»√â“À≈“¬Õ“°“√∑’Ë· ¥ßÕÕ°∑“ß√à“ß°“¬ ‡™àπ ‡∫◊ËÕÕ“À“√ πÕπ‰¡àÀ≈—∫ ÕàÕπ‡æ≈’¬

®–´âÕπ∑—∫°—∫Õ“°“√¢Õß‚√§¡–‡√Áß °“√ª√–‡¡‘π«à“ºŸâªÉ«¬¡–‡√Áß‡ªìπ‚√§´÷¡‡»√â“À√◊Õ‰¡à ®÷ß¡ÿàßæ‘®“√≥“„π‡√◊ËÕß

Õ“√¡≥å·≈–°“√· ¥ßÕÕ°¢ÕßÕ“√¡≥å ‡™àπ √Ÿâ ÷°‡»√â“ ‘ÈπÀ«—ß √âÕß‰Àâ∫àÕ¬ À√◊ÕÀßÿ¥Àß‘¥„®¡“°¢÷Èπ ‰¡à “¡“√∂

¡’§«“¡ ÿ¢‡æ≈‘¥‡æ≈‘π°—∫‡√◊ËÕß„¥‰¥â ¢“¥ ¡“∏‘„π°“√∑”°‘®°√√¡μà“ßÊ §‘¥«°«π‰ª¡“°—∫‡√◊ËÕß∑’Ë∑”„Àâ√Ÿâ ÷°º‘¥

‰√â§ÿ≥§à“À√◊Õ√Ÿâ ÷°·¬à ∫“ß§√—ÈßÕ“®æ∫¿“«–´÷¡‡»√â“√à«¡°—∫¿“«–«‘μ°°—ß«≈ À√◊Õ√à«¡°—∫Õ“°“√À≈ßº‘¥·≈–

ª√– “∑À≈Õπ‰¥â (depression with psychotic feature)

”À√—∫ºŸâªÉ«¬¡–‡√Áß πÕ°®“°‡√◊ËÕß®‘μ„®·≈â« ¬—ß¡’ªí®®—¬∑“ß™’«¿“æÀ≈“¬Õ¬à“ß∑’ËÕ“®°√–μÿâπ„ÀâºŸâªÉ«¬

‡°‘¥¿“«–´÷¡‡»√â“ ‰¥â·°à °“√„™â¬“„π°≈ÿà¡ corticosteriods °“√„™â¬“‡§¡’∫”∫—¥∫“ß™π‘¥ (vincristine,

vinblastine, asparaginase, intrathecal metrotrexate, interferon, interleukin) ¿“«–·∑√°´âÕπ¢Õß

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tress)

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Anti- ¢π“¥¬“ Õ“°“√‰¡àæ÷ßª√– ß§å/ ¢âÕ¥’depressants ¢âÕ§«√√–«—ß

Amitriptyline, ¢π“¥ Ÿß 100-150 ¡°. ¡’ƒ∑∏‘Ï anticholinergic ‡™àπ ™à«¬‰¥â¥’‡√◊ËÕßÕ“°“√πÕπnortriptyline °àÕππÕπ ª“°§Õ·Àâß ªí “«–‰¡àÕÕ° «‘μ°°—ß«≈·≈–‡∫◊ËÕÕ“À“√ ·≈–

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Fluoxetine 20-40 ¡°. «—π≈– Õ“°“√‰¡àæ÷ßª√– ß§å ‡™àπ Õ“°“√‰¡àæ÷ßª√– ß§åπâÕ¬°«à“1 §√—ÈßμÕπ‡™â“ §«√ §≈◊Ëπ‰ âÕ“‡®’¬π §«√√–¡—¥√–«—ß ¬“„π°≈ÿà¡ TCAs‡√‘Ë¡∑’Ë 10 ¡°. ‡æ◊ËÕ≈¥ ‡¡◊ËÕ„™â√à«¡°—∫¬“Õ◊Ëπ‡æ√“–Õ“°“√‰¡àæ÷ßª√– ß§å fluoxetine “¡“√∂¬—∫¬—Èß

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Escitalopram 5-10 ¡°. «—π≈– 1 §√—Èß ‡À¡◊Õπ fluoxetine Õ“°“√‰¡àæ÷ßª√– ß§åπâÕ¬°«à“¬“μÕπ‡™â“ ∂â“√Ÿâ ÷°ßà«ß¡“° „π°≈ÿà¡ TCAs “¡“√∂¬â“¬¡“‡ªìπ Õ—πμ√°‘√‘¬“°—∫¬“Õ◊ËππâÕ¬°«à“¡◊ÈÕ°àÕππÕπ fluoxetine

Mirtazapine 15-30 ¡°. °àÕππÕπ ¬“π’È¡’ƒ∑∏‘Ïßà«ß¡“° ™à«¬„ÀâπÕπÀ≈—∫ ·≈–‡æ‘Ë¡§«“¡Õ¬“°Õ“À“√

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πâÕ¬°«à“ TCAs

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§«√∑”°“√ª√–‡¡‘π ¿“æ∑“ß®‘μ ª√–‡¡‘π§«“¡∑ÿ°¢å∑√¡“π®“°Õ“°“√∑“ß°“¬ ‡™àπ Õ“°“√ª«¥¥â«¬ À“°∑”

°“√√—°…“Õ“°“√∑“ß°“¬‰¥â¥’·≈–„Àâ°“√ ◊ËÕ “√μà“ßÊ ‡μÁ¡∑’Ë·≈â« ºŸâªÉ«¬¬—ß¡’§«“¡§‘¥Õ¬“°¶à“μ—«μ“¬Õ¬à“ß™—¥‡®π

§«√ àßª√÷°…“®‘μ·æ∑¬åÀ√◊Õ∑’¡ ÿ¢¿“æ®‘μ √«¡∑—Èß®—¥°“√≈¥§«“¡‡ ’Ë¬ß ‡™àπ ‡ΩÑ“√–«—ß„°≈â™‘¥¢÷Èπ ‡°Á∫¢â“«¢Õß

∑’ËºŸâªÉ«¬Õ“®π”‰ª‡ªìπÕÿª°√≥å¶à“μ—«μ“¬ ¬â“¬μ”·Àπàß¢Õß‡μ’¬ßºŸâªÉ«¬„ÀâÕ¬Ÿà„π®ÿ¥∑’Ë¥Ÿ·≈‰¥âª≈Õ¥¿—¬¢÷Èπ

2.4 Delirium¿“«– —∫ π (delirium) ‡ªìπ¿“«–∑’Ë°“√∑”ß“π¢Õß ¡Õß‡ ’¬‰ª‚¥¬· ¥ßÕÕ°‡ªìπ§«“¡º‘¥ª°μ‘À≈“¬·∫∫

‡™àπ «ß®√°“√πÕπ°“√μ◊Ëπ °“√√—∫√Ÿâ μ‘ ¡“∏‘®¥®àÕ°—∫ ‘Ëß‡√â“ √Ÿª·∫∫§«“¡§‘¥ °“√√—∫√Ÿâμ“¡®√‘ß §«“¡∑√ß®”

Õ“√¡≥å ·≈–æƒμ‘°√√¡ ‚¥¬Õ“°“√∑’Ë¡—°μ√«®æ∫‰¥â™—¥‡®π§◊Õ §«“¡ —∫ π„π‡√◊ËÕß«—π‡«≈“ ∂“π∑’Ë·≈–μ—«∫ÿ§§≈

(disorientation) ·≈–¡’§«“¡·ª√ª√«π¢Õß°“√√—∫√Ÿâ„π√–À«à“ß«—π (fluctuation of consciousness) ‡™àπ

Õ“°“√‡ªìπ¡“°μÕπ°≈“ß§◊π·μàμÕπ‡™â“ª°μ‘ ¿“«–π’Èæ∫‰¥âª√–¡“≥√âÕ¬≈– 15-20 ¢ÕßºŸâªÉ«¬¡–‡√Áß∑’Ë√—°…“

μ—«„π‚√ßæ¬“∫“≈ ·≈–æ∫‰¥â Ÿß¢÷Èπ‡√◊ËÕ¬Ê ®π∂÷ß√âÕ¬≈– 85 „πºŸâªÉ«¬¡–‡√Áß√–¬– ÿ¥∑â“¬

“‡Àμÿ∑’Ë ¡Õß∑”ß“π‡ ’¬‰ªπ—Èπ‡°‘¥‰¥â®“°ªí≠À“¿“¬„π√–∫∫ª√– “∑ à«π°≈“ß‚¥¬μ√ß ‡™àπ ¡’‡´≈≈å

¡–‡√Áß·∑√°´÷¡ ‰¥â√—∫°“√©“¬√—ß ’‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß À√◊Õ®“°ªí®®—¬πÕ°√–∫∫ª√– “∑ à«π°≈“ß∑’Ë‰ª√∫°«π

°“√∑”ß“π¢Õß√–∫∫ à«π°≈“ß ‡™àπ ¬“∑’Ë„™â√—°…“‚¥¬‡©æ“–¬“·°âª«¥ªí≠À“¢Õß√–∫∫Õ◊ËπÊ ¢Õß√à“ß°“¬ °“√

μ‘¥‡™◊ÈÕ À√◊Õ¿“«– ¡Õß‡ ◊ËÕ¡∑’Ë¡’Õ¬Ÿà°àÕπ

“‡Àμÿ∑’Ëæ∫∫àÕ¬ ‰¥â·°à

ë Hypercalcemia ë Drug-related causes

ë Hypoglycemia - Opioids

ë Hyponatremia - Corticosteroids and withdrawal

ë Renal failure - Alcohol and withdrawal

ë Liver failure - Benzodiazepines and withdrawal

ë Cerebral tumor, primary or secondary - Antidepressants

ë Cerebrovascular disease or transient - ¬“Õ◊ËπÊ ‡™àπ digoxin, lithium À√◊Õ¬“Õ◊ËπÊ

ischemic attack (TIA) ∑’ËÕ“®¡’º≈μàÕ ¡Õß

ë Infection

ë Hypoxia


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°“√ª√–‡¡‘π¿“«– —∫ π1. ª√–«—μ‘ºŸâªÉ«¬°àÕπÀπâ“®–¡’Õ“°“√ —∫ π (baseline/pre-morbid cognitive impairment) ª√–«—μ‘

sensory impairment ·≈–°“√√—°…“∑’Ë‡°’Ë¬«¢âÕß ‡™àπ ·«àπμ“À√◊Õ‡§√◊ËÕß™à«¬øíß

2. ¬“À√◊Õ°“√√—°…“∑’Ë‰¥â√—∫Õ¬Ÿà ¡’§«“¡ —¡æ—π∏å°—∫‡«≈“¢ÕßÕ“°“√Õ¬à“ß‰√

3. Õ“°“√μà“ßÊ ‡™àπ Õ“°“√ª«¥ Õ“°“√‡Àπ◊ËÕ¬ Õ“°“√‰¢â À√◊Õ¢“¥πÈ”

4. °“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√æ◊Èπ∞“π„π¿“«–∑’Ë ß —¬

°“√ª√–‡¡‘πÕ“°“√¥â“πμà“ßÊë Orientation: ºŸâªÉ«¬ —∫ π‡√◊ËÕß‡«≈“ (‡™â“ ∫à“¬ ‡¬Áπ °≈“ß«—π °≈“ß§◊π) ∂“π∑’Ë ·≈–∫ÿ§§≈

®”∫ÿ§§≈º‘¥

ë Psychomotor activity: Õ“®–‡ªìπ‰¥â∑—Èß ¥Ÿ°√–«π°√–«“¬ (hyperactive) À√◊Õ¥Ÿ´÷¡ (hypoactive)

À√◊Õ ≈—∫‡ª≈’Ë¬πÕ“°“√‰ª¡“„π√–À«à“ß«—π (fluctuation)

ë Attention: ºŸâªÉ«¬¥Ÿ«Õ°·«° À—π¡Õß‰ª¡“ ‰¡à “¡“√∂®¥®àÕ°—∫°“√ π∑π“‰¥â ‰¡àμ‘¥μ“¡‡√◊ËÕß√“«„π

°“√ π∑π“ Õ“√¡≥å¢÷ÈπÊ ≈ßÊ ¥Ÿ·ª√ª√«π ‡ª≈’Ë¬π·ª≈ß‡√Á«¡“°°«à“ª°μ‘

ë Perception: ‡°‘¥Õ“°“√ª√– “∑À≈Õπ‰¥âÀ≈“¬√Ÿª·∫∫ ‡™àπ ‰¥â¬‘π‡ ’¬ßÀŸ·«à« (auditory hallucina-

tion) À√◊Õ ¡Õß‡ÀÁπ¿“æÀ≈Õπ (visual hallucination) À√◊Õ√Ÿâ ÷°¡’Õ–‰√‰μàμ“¡μ—« (tactile hallucination)

ë Thinking: §«“¡§‘¥∑’Ë —ß‡°μ®“°°“√ π∑π“ ®–‰¡à‡ªìπ√–∫∫‡À¡◊Õπª°μ‘ æŸ¥®“«°«π ‰¡à‡™◊ËÕ¡‚¬ß

°—∫‡√◊ËÕß∑’Ë°”≈—ß π∑π“ ¡’«‘∏’§‘¥·≈–°“√„™â‡Àμÿº≈·ª≈°Ê Õ“®‰¡à “¡“√∂∫Õ°§«“¡μâÕß°“√À√◊Õ§«“¡§‘¥

§«“¡√Ÿâ ÷°¢Õßμπ‡Õß‰¥â ∫“ß§√—Èßμ’§«“¡‡√◊ËÕß√“«μà“ßÊ º‘¥‰ª®“°§«“¡®√‘ß ‡™àπ À«“¥√–·«ß ‚¥¬Õ“®¡’Õ“°“√

À≈Õπ√à«¡¥â«¬À√◊Õ‰¡à°Á‰¥â

ë Memory: ®”‡Àμÿ°“√≥å√–¬–„°≈âÊ ‰¡à‰¥â ‡™àπ Õ¬Ÿà ‚√ßæ¬“∫“≈¡“°’Ë«—π μâÕß¡“‚√ßæ¬“∫“≈‡æ√“–

Õ–‰√ ‡¡◊ËÕ«“π‡°‘¥Õ–‰√¢÷Èπ ®”‡√◊ËÕß∑’ËæŸ¥‰ª°àÕπÀπâ“π’È ‰¡à‰¥â ·μà§«“¡®”„πÕ¥’μ√–¬–¬“«Õ“®‰¡à‡ ’¬

°“√¥Ÿ·≈√—°…“°“√¥Ÿ·≈√—°…“¿“«–π’È¢÷Èπ°—∫°“√À“ “‡Àμÿμà“ßÊ ∑’Ë‡ªìπ‰ª‰¥â „πºŸâªÉ«¬¡–‡√ÁßÕ“®æ∫‰¥âÀ≈“¬ “‡ÀμÿÀ√◊Õ

Õ“®‡ªìπ “‡Àμÿ∑’Ë‰¡à “¡“√∂·°â ‰¢‰¥â®“°μ—«‚√§ ®÷ß§«√§àÕ¬Ê ª√—∫‰ª∑’≈–ªí®®—¬§◊Õ

ë À¬ÿ¥¬“∑ÿ°μ—«∑’ËÕ“®‡ªìπ “‡Àμÿ §ß‰«â·μà¬“∑’Ë®”‡ªìπ ‡™àπ ¬“·°âª«¥‡π◊ËÕß®“°Õ“°“√®“°§«“¡ª«¥

·¬°‰¥â¬“°®“°¿“«– —∫ π

ë √—°…“·≈–ªÑÕß°—π¿“«–¢“¥πÈ” ·≈–Õ‘‡≈Á§‚μ√‰≈μåº‘¥ª°μ‘

ë À“ “‡Àμÿ°“√μ‘¥‡™◊ÈÕ„π√–∫∫μà“ßÊ ·≈–„Àâ°“√√—°…“

ë ºŸâªÉ«¬§«√¡’√–¥—∫°“√‰À≈‡«’¬π‚≈À‘μ·≈–°“√À“¬„®∑’Ë‡æ’¬ßæÕ

ë √—°…“Õ“°“√μà“ßÊ ‡™àπ Õ“°“√ª«¥

ë ¥Ÿ·≈°“√„™â™’«‘μª√–®”«—π ‡«≈“πÕπ À√◊Õ°“√¢—∫∂à“¬ªí “«–·≈–Õÿ®®“√–

ë ª√–‡¡‘π·≈–ª√—∫ª√ÿß¿“«–‚¿™π“°“√


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

ë ª√—∫ ‘Ëß·«¥≈âÕ¡„Àâ‡À¡“– ¡ ‰¡à¡’°‘®°√√¡À√◊Õ‡ ’¬ß√∫°«π ¡’· ß «à“ßμ“¡‡«≈“∏√√¡™“μ‘ (À√◊Õ

«à“ß¡“°æÕ„π√“¬∑’ËºŸâªÉ«¬√–·«ßÀ√◊Õ‡ÀÁπ¿“æÀ≈Õπ) ¡’≠“μ‘À√◊Õ§π∑’ËºŸâªÉ«¬√Ÿâ®—°‡ΩÑ“ ¡’π“Ãî°“À√◊ÕªØ‘∑‘π‡æ◊ËÕ

„ÀâºŸâªÉ«¬¥Ÿ ¡’¢â“«¢Õß∑’ËºŸâªÉ«¬§ÿâπ‡§¬„™âª√–®” ‰¡à„™â physical restraint ∂â“‰¡à®”‡ªìπ

ë ªÑÕß°—πæƒμ‘°√√¡∑’Ë¡’§«“¡‡ ’Ë¬ß ‡™àπ ≈ß®“°‡μ’¬ß‡Õß ¥÷ß “¬μà“ßÊ ‡°Á∫«—μ∂ÿ∑’ËÕ“®‡°‘¥Õ—πμ√“¬„Àâ

æâπ¡◊Õ ‡ΩÑ“√–«—ßºŸâªÉ«¬Àπ’ÕÕ°®“°∑’Ëæ—°¢≥– —∫ π

°“√„™â¬“‡æ◊ËÕ·°âÕ“°“√ —∫ π§◊Õ ¬“°≈ÿà¡ antipsychotics ∑’Ë·π–π” ‰¥â·°à

1. Haloperidol ª√–¡“≥ 0.5-5 ¡°./«—π ‚¥¬°“√√—∫ª√–∑“π À√◊Õ 0.5-2 ¡°. ∑ÿ° 6 ™—Ë«‚¡ß ©’¥‡¢â“∑“ß

°≈â“¡‡π◊ÈÕ ∂◊Õ‡ªìπ¬“Õ—π¥—∫·√° Õ“°“√‰¡àæ÷ßª√– ß§å∑’ËμâÕß√–«—ß§◊Õ extrapyramidal symptoms μà“ßÊ ·≈–

μâÕßª√–‡¡‘π QTc prolongation „πºŸâªÉ«¬‚√§À—«„®

2. Risperidone ¢π“¥ 0.25-1 ¡°. √—∫ª√–∑“π«—π≈– 1-2 §√—Èß

3. Quetiapine ª√–¡“≥ 12.5-50 ¡°./«—π ‚¥¬°“√√—∫ª√–∑“π ¡’ƒ∑∏‘Ïßà«ß°«à“ haloperidol ·≈–‰¡à¡’

„π√Ÿª¬“©’¥

4. Olanzapine ¢π“¥ 2.5-5 ¡°. √—∫ª√–∑“π«—π≈– 1 §√—Èß°àÕππÕπ

πÕ°®“°π’È°“√ ◊ËÕ “√°—∫≠“μ‘·≈– ◊ËÕ “√„π∑’¡ºŸâ√—°…“‡ªìπ‡√◊ËÕß®”‡ªìπ ‡æ√“–ºŸâªÉ«¬∑’Ë‡°‘¥¿“«–π’È®–¡’

æƒμ‘°√√¡·ª≈°‰ª®“°‡¥‘¡ ¥Ÿπà“‡ªìπÀà«ß·≈–§≈â“¬‚√§∑“ß®‘μÀ≈“¬™π‘¥ (μà“ß°—πμ√ß∑’Ë¡’§«“¡¢÷Èπ≈ß¢Õß

Õ“°“√Õ¬à“ß·ª√ª√«π·≈–‡ªìπÕ¬à“ß°√–∑—πÀ—π) ®÷ß§«√„Àâ¢âÕ¡Ÿ≈‡æ◊ËÕ≈¥§«“¡°—ß«≈«à“ ¢≥–π’ÈºŸâªÉ«¬‡æ’¬ß·μà°”≈—ß

—∫ π “¡“√∂√—°…“¿“«–π’È„Àâ¥’¢÷Èπ‰¥â®“°°“√·°â “‡Àμÿ·≈–„Àâ¬“§«∫§ÿ¡Õ“°“√

À“°ºŸâªÉ«¬¡’æƒμ‘°√√¡∑’Ë¥Ÿ«ÿàπ«“¬¢÷Èπ¡“° ·ª√ª√«π¡“°À√◊Õ‰¡à·πà„®‡√◊ËÕß°“√ª√–‡¡‘π·≈–°“√„™â¬“

antipsychotics „π°“√√—°…“ ·æ∑¬å‡®â“¢Õß‰¢â “¡“√∂ª√÷°…“®‘μ·æ∑¬å‡æ◊ËÕ√à«¡√—°…“‰¥â


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 3°“√ ◊ËÕ “√·≈–°“√„Àâ§«“¡√Ÿâ

°“√ ◊ËÕ “√∑’Ë¥’ ·≈–°“√„Àâ§«“¡√Ÿâ‡ªìπ ‘Ëß®”‡ªìπ∑’Ë§«√„Àâ°—∫ºŸâªÉ«¬∑ÿ°√“¬ °“√„Àâ§”ª√÷°…“„π‡√◊ËÕß∑’ËºŸâªÉ«¬

«‘μ°°—ß«≈ Õ“®™à«¬≈¥¿“«–«‘μ°°—ß«≈„π‡∫◊ÈÕßμâπ‰¥â

3.1 ∫∑∫“∑·≈–Àπâ“∑’Ë¢ÕßºŸâªÉ«¬·≈–≠“μ‘∫∑∫“∑·≈–Àπâ“∑’Ë¢ÕßºŸâªÉ«¬·≈–≠“μ‘∑’Ë ”§—≠∑’Ë§«√·®âß¡’¥—ßπ’È

1. „™â¬“·°âª«¥μ“¡∑’Ë√–∫ÿ‰«âμ“¡Àπâ“´Õß¬“Õ¬à“ß‡§√àß§√—¥

2. ®¥∫—π∑÷°°“√„™â¬“·°âª«¥ ‡™àπ ‡«≈“·≈–¢π“¥∑’Ë„™â¬“μ“¡‡«≈“ (around the clock) ‡«≈“·≈–

¢π“¥∑’Ë„™â¬“·°âª«¥∑’Ë„™â‡æ‘Ë¡ (rescue dose)

3. ®¥∫—π∑÷°Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ë‡°‘¥¢÷Èπ·≈–«‘∏’·°â ‰¢∑’ËºŸâªÉ«¬„™â ‡™àπ Õ“‡®’¬π ºŸâªÉ«¬®÷ß√—∫ª√–∑“π¬“

ondansetron

4. π—∫®”π«π¬“·°âª«¥·≈–¬“∑ÿ°™π‘¥∑’Ë„™â ·≈–π”¡“æ∫·æ∑¬å¥â«¬∑ÿ°§√—Èß ´÷Ëß¡’ª√–‚¬™πå§◊Õ

ë ∑”„Àâª√–‡¡‘π°“√„™â¬“¢ÕßºŸâªÉ«¬‰¥â ‡™àπ ‡À≈◊Õ¡“°°«à“∑’Ë§«√‡ªìπ Õ“®‡°‘¥®“°ºŸâªÉ«¬°‘π¬“‰¡à

§√∫μ“¡‡«≈“ À√◊Õ¬“À¡¥°àÕπ°”Àπ¥ Õ“®‡°‘¥®“°ºŸâªÉ«¬‡æ‘Ë¡¢π“¥¬“μ“¡‡«≈“¥â«¬μπ‡Õß‡π◊ËÕß®“°¢π“¥∑’Ë

·æ∑¬å —ËßÕ“®‰¡à‡æ’¬ßæÕ À√◊ÕºŸâªÉ«¬√—∫ª√–∑“π rescue dose ¡“°°«à“∑’Ë·æ∑¬å§“¥§–‡π

ë °“√π—∫¬“∑’Ë‡À≈◊Õ®–™à«¬„Àâ —Ëß¬“‡æ‘Ë¡‡∑à“∑’Ë ¡§«√ ‰¡à —Ëß´È”Ê ®πºŸâªÉ«¬‰¥â¬“®”π«π¡“°‡°‘π‰ª

¬“∑’Ë‰¥â√—∫¡“°‡°‘π§«√Õ“®‰¡à‰¥â„™â®πÀ¡¥Õ“¬ÿ‰¥â´÷Ëß‡ªìπ°“√ ‘Èπ‡ª≈◊Õß

5. ‰¡à§«√π”¬“ÕÕ°®“°´Õß∑’Ë¡’™◊ËÕ¬“À√◊Õπ”¬“À≈“¬™π‘¥¡“‰«â„π´Õß‡¥’¬«°—π

3.2 §«“¡‡¢â“„®§≈“¥‡§≈◊ËÕπ‡°’Ë¬«°—∫°“√„™â¬“„π°≈ÿà¡ opioids¡’§«“¡‡™◊ËÕ∑’Ë§≈“¥‡§≈◊ËÕπÀ≈“¬¢âÕ‡°’Ë¬«°—∫°“√„™â opioids √—°…“Õ“°“√ª«¥„πºŸâªÉ«¬¡–‡√Áß ‡™àπ ∫ÿ§≈“°√

∑“ß°“√·æ∑¬å¡—°‡™◊ËÕ°—π«à“ °“√ —Ëß¬“ opioids ‡ªìπ°“√∑”„ÀâºŸâªÉ«¬μ‘¥¬“‡ æμ‘¥ à«π∑“ßºŸâªÉ«¬·≈–≠“μ‘°Á

°—ß«≈„®‡¡◊ËÕμâÕß„™â¬“„π°≈ÿà¡π’È ¥—ßπ—Èπ®÷ß§«√‰¥â√—∫°“√ª√—∫§«“¡‡¢â“„®μ—Èß·μà‡¡◊ËÕ‡√‘Ë¡√—°…“„πª√–‡¥ÁπμàÕ‰ªπ’È

1. ¬“°≈ÿà¡π’È∂Ÿ°¡Õß∑“ß≈∫«à“‡ªìπ¬“‡ æμ‘¥π‚¬∫“¬∑“ß¿“§√—∞μâÕß°“√·°â‰¢ªí≠À“¬“‡ æμ‘¥ ®÷ß‡°‘¥°“√√≥√ß§å·≈–¡’°“√§«∫§ÿ¡°“√ —Ëß¬“„π°≈ÿà¡

opioids ‰ª¥â«¬ ·μà∑’Ë®√‘ß·≈â« opioids ‰¡à„™à¬“‡ æμ‘¥‡À¡◊ÕπΩîòπ·≈–‡Œ‚√Õ’π ‡ªìπ‡æ’¬ß¬“„π°≈ÿà¡§«∫§ÿ¡ æ‘‡»…

‡æ√“–Õ“®¡’ºŸâπ”‰ª„™â„π∑“ß∑’Ëº‘¥πÕ°‡Àπ◊Õ®“°°“√ —Ëß®à“¬¢Õß·æ∑¬å ®“° ∂‘μ‘∑’Ëºà“π¡“∑—Ë«‚≈° ¡’‚Õ°“ μË”¡“°

∑’ËºŸâªÉ«¬¡–‡√Áß®–‰¥â√—∫«‘π‘®©—¬«à“‡ æμ‘¥¬“·°âª«¥ opioids §«“¡°≈—« opioids ‚¥¬¢“¥‡Àμÿº≈ (opiophobia)


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

®÷ß‡ªìπÕÿª √√§ ”§—≠„π°“√æ—≤π“°“√¥Ÿ·≈√—°…“Õ“°“√ª«¥®“°‚√§¡–‡√Áß ªí®®ÿ∫—πæ∫«à“§«“¡ –¥«°„π°“√

‡¢â“∂÷ß¬“ opioids ”À√—∫ºŸâªÉ«¬¡–‡√Áß·≈–ª√‘¡“≥°“√ —Ëß„™â¬“ opioids „π°“√∫”∫—¥§«“¡ª«¥∑’Ë Ÿß¢÷Èπ°≈—∫

‡ªìπμ—«™’È«—¥§ÿ≥¿“æ·≈–§«“¡°â“«Àπâ“„π°“√¥Ÿ·≈ºŸâªÉ«¬¡–‡√Áß√–¬– ÿ¥∑â“¬„π√–¥—∫π“π“™“μ‘

2. “‡Àμÿ∑’Ë∑”„Àâ∫ÿ§≈“°√∑“ß°“√·æ∑¬å§‘¥«à“ºŸâªÉ«¬μ‘¥¬“ë ºŸâªÉ«¬√âÕß¢Õ¬“„πª√‘¡“≥∑’Ë∫ÿ§≈“°√∑“ß°“√·æ∑¬å‡ÀÁπ«à“¡“°‡°‘π‰ª À√◊Õ¢Õ∫àÕ¬‡°‘π‰ª

√–¥—∫¬“∑’Ë‡À¡“– ¡π—Èπ¢÷Èπ°—∫À≈“¬ªí®®—¬ ∑—Èß™π‘¥¢Õß§«“¡ª«¥ √–¥—∫§«“¡√ÿπ·√ß¢Õßæ¬“∏‘ ¿“æ

√«¡∑—Èß§«“¡·μ°μà“ß¢ÕßºŸâªÉ«¬·μà≈–√“¬„π‡™‘ß pharmacokinetics ·≈– pharmacodynamics °“√ —Ëß¬“

®÷ß‰¡à “¡“√∂¡’√–¥—∫¬“∑’Ëμ“¬μ—«‰¥â μâÕßª√—∫√–¥—∫¬“‚¥¬¥Ÿ®“°º≈°“√μÕ∫ πÕß¢ÕßºŸâªÉ«¬ ‡¡◊ËÕºŸâªÉ«¬¢Õ¬“‡æ‘Ë¡

®÷ß‰¡à„™à‡æ√“–‡ æμ‘¥¬“ ·μà‡ªìπ‡æ√“–√–¥—∫¬“∑’Ë‰¥â¬—ß‰¡à‡æ’¬ßæÕμàÕ°“√√–ß—∫ª«¥ (inadequate treatment)

‰¡à¡’§«“¡®”‡ªìπμâÕß„ÀâºŸâªÉ«¬∑πª«¥ À√◊Õ¡’§«“¡ª«¥√–¥—∫√ÿπ·√ß®÷ß§àÕ¬„™â‡æ◊ËÕ®–‰¥â ‰¡à°≈“¬‡ªìπ ç§πμ‘¥¬“é

Õ¬à“ß∑’Ë‡§¬‡™◊ËÕ°—π

ë ‰¡à “¡“√∂≈¥¢π“¥°“√„™â¬“≈ß‰¥â À¬ÿ¥„™â·≈â«°√–«π°√–«“¬‡À¡◊Õπ≈ß·¥ß μâÕß„™â‰ª‡√◊ËÕ¬Ê ·≈–

‡æ‘Ë¡¢π“¥¬“¢÷Èπ

¬“∑’ËÕÕ°ƒ∑∏‘Ï°—∫√–∫∫ª√– “∑∑ÿ°™π‘¥ “¡“√∂‡°‘¥ physical dependence §◊Õ¡’ tolerance ·≈–

withdrawal symptoms ‰¥â‡¡◊ËÕÀ¬ÿ¥¬“Õ¬à“ß∑—π∑’ physical dependence ‰¡à„™àπ‘¬“¡¢Õß¿“«–‡ æμ‘¥¬“

·μà‡ªìπ°≈‰°μ“¡ª°μ‘„πºŸâ∑’Ë„™â¬“∑ÿ°√“¬ √«¡∑—Èßμâπ‡Àμÿ¢ÕßÕ“°“√ª«¥¢ÕßºŸâªÉ«¬‚√§¡–‡√Áß‚¥¬¡“°¡—°‰¡à∑ÿ‡≈“

À“°¬—ß∑«’§«“¡√ÿπ·√ß¡“°¢÷Èπ®÷ßÕ“®®”‡ªìπ∑’Ë®–μâÕß„™â¬“·°âª«¥‡æ‘Ë¡¢÷Èπ¥â«¬ ·≈–æ∫«à“„π°≈ÿà¡ºŸâªÉ«¬¡–‡√Áß

®–¡’‚Õ°“ ‡°‘¥ physical tolerance ·≈– psychological dependence °—∫¬“°≈ÿà¡π’ÈμË”

ë ¬“¡’º≈μàÕ ÿ¢¿“æ®‘μºŸâªÉ«¬ ¥Ÿ‡À¡◊Õπ‡§≈‘È¡Ê ¡’§«“¡ ÿ¢

Opioids ·μà≈–μ—«¡’º≈μàÕ§«“¡√Ÿâ ÷°¥’·≈–ºàÕπ§≈“¬μà“ß°—π‰ª √à«¡°—∫°“√∑’ËºŸâªÉ«¬À“¬ª«¥¬àÕ¡

¡’§«“¡ ÿ¢¡“°¬‘Ëß¢÷Èπ ‰¡à§«√ √ÿª«à“ºŸâªÉ«¬„™â¬“‡æ√“–Õ¬“°¡’§«“¡ ÿ¢‡æ√“–®ÿ¥¡ÿàßÀ¡“¬„π°“√ —Ëß¬“§◊Õ √—°…“

Õ“°“√ª«¥ ºŸâªÉ«¬¢Õ¬“‡æ√“–Õ¬“°À“¬ª«¥¡‘„™àÕ¬“°¬“

ë ºŸâªÉ«¬‡§¬¡’ª√–«—μ‘μ‘¥ “√‡ æμ‘¥¡“°àÕπ

„π°≈ÿà¡ºŸâªÉ«¬¡–‡√Áß∑’Ë‡§¬¡’ª√–«—μ‘μ‘¥ “√‡ æμ‘¥Õ◊ËπÊ ¡“°àÕπ ‡¡◊ËÕæ∫«à“‡ªìπ‚√§¡–‡√Áß·≈–¡’

Õ“°“√ª«¥·≈â« °“√√—°…“°Á¬—ß§ß‡ªìπ‰ªμ“¡À≈—°°“√ª°μ‘ ¡‘§«√„ÀâπâÕ¬°«à“ª°μ‘¥—ß∑’Ë‡¢â“„®°—π °“√„Àâ¬“μË”

°«à“¢π“¥ª°μ‘∑”„ÀâºŸâªÉ«¬‰¡àÀ“¬ª«¥·≈–¬—ß· ¥ßæƒμ‘°√√¡‰¡àæ÷ßª√– ß§å°—∫∑’¡ºŸâ√—°…“¡“°¢÷Èπ „π∑“ß°≈—∫°—π

ºŸâªÉ«¬Õ“®μâÕß„™âª√‘¡“≥¬“„π¢π“¥∑’Ë Ÿß°«à“ª°μ‘ ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß∂â“‡§¬μ‘¥‡Œ‚√Õ’π‡æ√“– ¡ÕßºŸâªÉ«¬Õ“®

™‘π°—∫√–¥—∫ opioids ∑’Ë Ÿß¡“°àÕπ‰¥â√—∫¬“·°âª«¥·≈–¡’·π«‚πâ¡∑πμàÕ§«“¡ª«¥‰¥âμË”

ë §«“¡‡™◊ËÕ∑’Ë«à“ opioids ®–°¥°“√À“¬„® ∑”„ÀâºŸâªÉ«¬μ“¬‡√Á«¢÷Èπ‰¥â

Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ë‡°‘¥¢÷Èπ®“°°“√„™â opioids “¡“√∂ªÑÕß°—π‰¥â‡¡◊ËÕ¡’°“√‡ΩÑ“√–«—ß∑’Ë¥’ ‚¥¬

∑—Ë«‰ª°àÕπ®–‡°‘¥°“√°¥°“√À“¬„®®–¡’Õ“°“√μà“ßÊ „Àâ —ß‡°μ°àÕπ ‡™àπ ßà«ß´÷¡À√◊Õ¡÷πßß ´÷ËßºŸâªÉ«¬°Á¡—°®–‰¡à

‰¥â√—∫¬“‡æ‘Ë¡Õ’° πÕ°®“°π’ÈÕ“®‡°‘¥®“°¿“«–Õ◊ËπÊ ‡™àπ ¢“¥πÈ” Õ«—¬«–∑”ß“π≈â¡‡À≈« μ‘¥‡™◊ÈÕ∑’Ë‡ √‘¡„ÀâÕ“°“√


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

‰¡àæ÷ßª√– ß§å¢Õß¬“¡“°¢÷Èπ®π°¥°“√À“¬„®‰¥â ∫“ß§√—Èß§«“¡‡™◊ËÕπ’ÈÕ“®®–‡°‘¥®“°°“√ —ß‡°μ«à“ºŸâªÉ«¬∑’Ë‰¥â

opioids ¡—°‡ ’¬™’«‘μÕ¬à“ß√«¥‡√Á«¿“¬„π‡«≈“‰¡à°’Ë«—π ·μà∑’Ë®√‘ß‡°‘¥®“°°“√∑’ËºŸâªÉ«¬¡–‡√Áß„π™à«ß«—π ÿ¥∑â“¬¢Õß

™’«‘μ¡—°¡’Õ“°“√ª«¥À√◊ÕÀ“¬„®‡Àπ◊ËÕ¬∑’Ë√ÿπ·√ß ‡≈¬®”‡ªìπμâÕß„™â opioids ‡æ◊ËÕ√—°…“¡“°°«à“·≈–‰¡à§«√ √ÿª

«à“‡ ’¬™’«‘μ‡æ√“–°“√„™â opioids

ë §«“¡‡™◊ËÕ∑’Ë«à“ºŸâªÉ«¬¡–‡√Áßμ‘¥¬“°Á‰¡à‡ªìπ‰√ ‡æ√“–‡«≈“„π™’«‘μ°Á‡À≈◊ÕπâÕ¬Õ¬Ÿà·≈â«

π‘¬“¡¢Õß°“√μ‘¥ “√‡ æμ‘¥ §◊Õ °“√· «ßÀ“ “√‡ æμ‘¥¡“‡ æ‚¥¬‰¡à “¡“√∂§«∫§ÿ¡°“√„™â ‰¥â

·¡â√Ÿâ«à“‡°‘¥‚∑… π”‰ª Ÿàªí≠À“„π°“√„™â™’«‘μ·≈–ΩÉ“Ωóπ°ÆÀ¡“¬¢Õß —ß§¡ ´÷Ëß‰¡àμ√ß°—∫ºŸâªÉ«¬¡–‡√Áß∑’Ë„™â¬“

opioids Õ¬à“ß¡’®ÿ¥¡ÿàßÀ¡“¬¿“¬„μâ°“√§«∫§ÿ¡¥Ÿ·≈¢Õß·æ∑¬å‡æ◊ËÕ√–ß—∫ª«¥ ·≈–™à«¬„ÀâºŸâªÉ«¬„™â‡«≈“„π™’«‘μ

Õ—π®”°—¥Õ¬à“ß¡’§«“¡À¡“¬μàÕ‰ª‰¥â ºŸâªÉ«¬®÷ß‰¡à∂◊Õ«à“‡ªìπºŸâμ‘¥¬“·μàÕ¬à“ß„¥

πÕ°®“°∑—»π§μ‘∑’Ë∂Ÿ°μâÕß¢Õß∑’¡ºŸâ√—°…“·≈â« §«√ª√–‡¡‘π∑—»π§μ‘∑’Ë¡’μàÕ opioids „πºŸâªÉ«¬·≈–≠“μ‘¥â«¬

‡æ◊ËÕ™’È·®ßª√—∫§«“¡‡¢â“„®„Àâμ√ß°—π‡æ◊ËÕª√–‚¬™πå Ÿß ÿ¥„π°“√√—°…“


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

4.1 Neuropathic cancer pain (NCP)¿“«–ª«¥‡Àμÿæ¬“∏‘ ¿“æª√– “∑„πºŸâªÉ«¬¡–‡√Áß (neuropathic cancer pain; NCP) ‡ªìπ¿“«–

”§—≠∑’Ë∑”„Àâ°“√∫”∫—¥√—°…“§«“¡ª«¥®“°¡–‡√Áß‰¥âº≈‰¡à¥’π—° æ∫‰¥â√“«√âÕ¬≈– 19-39 ‚¥¬Õ“®‡ªìπÕ“°“√

‡√‘Ë¡μâπ¢Õß¡–‡√ÁßÀ√◊Õ‡°‘¥¿“¬À≈—ß°Á‰¥â

“‡Àμÿ à«π„À≠à‡°‘¥®“°¡–‡√Áß°¥‡∫’¬¥ à«πμà“ßÊ ¢Õß√–∫∫ª√– “∑ ‡™àπ ‡ âπª√– “∑ ¢à“¬ª√– “∑

√“°ª√– “∑ ‰¢ —πÀ≈—ß ¡Õß ‚¥¬‡°‘¥‰¥â„π¡–‡√Áß√–¬–μà“ßÊ πÕ°®“°π’ÈÕ“®‡°‘¥μ“¡À≈—ßºà“μ—¥ √—ß ’√—°…“ À√◊Õ

‡§¡’∫”∫—¥ μ“¡√“¬≈–‡Õ’¬¥„πμ“√“ß∑’Ë 9

§«“¡ª«¥≈—°…≥–‡©æ“–¢Õß neuropathic pain ‰¥â·°à aching, burning, stabbing À√◊Õ lancinating

·≈–Õ“®æ∫ paraesthesia, dysaesthesia, hyperalgesia À√◊Õ allodynia

°“√ª√–‡¡‘πë ª√–‡¡‘π§«“¡ª«¥∑ÿ°Õß§åª√–°Õ∫ §◊Õ §«“¡√ÿπ·√ß ≈—°…≥– ∫√‘‡«≥∑’Ëª«¥ °“√ª«¥√â“« ‡«≈“¢Õß

°“√ª«¥ ªí®®—¬∑’Ë∑”„Àâ¡’°“√ª«¥ ·≈–°“√ àßº≈μàÕ°“√ªØ‘∫—μ‘μπ„π™’«‘μª√–®”«—π ∑—Èßπ’È‡æ◊ËÕ™à«¬„π°“√«‘π‘®©—¬

°≈ÿà¡Õ“°“√ª«¥‡©æ“– μ‘¥μ“¡Õ“°“√§«“¡ª«¥∑’Ë‡ªìπ¡“°¢÷Èπ·≈–°“√μÕ∫ πÕßμàÕ°“√√—°…“·≈–μâÕßª√–‡¡‘π

§«“¡ª«¥Õ¬à“ß ¡Ë”‡ ¡Õ ·≈–§«√‡¢’¬π∫—π∑÷°§«“¡ª«¥∑’Ë‡°‘¥¢÷Èπ„À¡à

Cancer-related neuropathic pain

ë Paraneoplastic neurological syndrome

ë Tumor metastasis infiltration or compression of the peripheral nervous system ‡™àπ nerves,

plexus, cranial nerve

ë Tumor metastasis infiltration or compression of the central nervous system ‡™àπ spinal cord

compression

ë Õ◊ËπÊ: metastatic cancer-induced bone pain, mixed pain

Cancer therapy-induced neuropathic pain

ë Chemotherapy-induced peripheral neuropathy ‡™àπ vincristine, oxaliplatin, taxane

ë Radiation treatment ‡™àπ ploxopathies, tissue fibrosis, mucositis

ë Surgery ‡™àπ postmastectomy pain, post thoracotomy pain, phantom limb pain

Cancer-associated pain

ë Postherpetic neuralgia

μ“√“ß∑’Ë 9 ¿“«–ª«¥ª√– “∑∑’Ë‡°’Ë¬«¢âÕß°—∫¡–‡√Áß∑’Ëæ∫∫àÕ¬

¿“§ºπ«° 4°“√√—°…“‡©æ“–¢Õß§«“¡ª«¥®“°¡–‡√Áß∑’Ë‡°‘¥®“° “‡Àμÿμà“ßÊ


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

ë À“ “‡Àμÿ«à“‡°‘¥®“°°“√°¥∑—∫‡ âπª√– “∑À√◊Õ√–∫∫ª√– “∑ à«π∑’Ë ”§—≠À√◊Õ‰¡à ÷ËßμâÕß√’∫·°â ‰¢∑—π∑’

°“√μ√«®«‘π‘®©—¬‡æ‘Ë¡‡μ‘¡ ‡™àπ CT scan, MRI, electromyography ®–™à«¬ª√–‡¡‘π§«“¡º‘¥ª°μ‘∑—Èß∑“ß

√–∫∫°“¬«‘¿“§·≈– √’√«‘∑¬“¢Õßª√– “∑∑’Ë‡°’Ë¬«¢âÕß ™à«¬„π°“√À“∫√‘‡«≥∑’Ë¡’°“√°¥∑—∫À√◊Õæ¬“∏‘ ¿“æ ·≈–

™à«¬«“ß·ºπ°“√√—°…“®”‡æ“– Õ¬à“ß‰√°Áμ“¡§«√‡√‘Ë¡„Àâ¬“·°âª«¥„Àâ‡√Á«∑’Ë ÿ¥ ·¡â«à“¬—ß‰¡à∑√“∫º≈°“√μ√«®

«‘π‘®©—¬∑’Ë ¡∫Ÿ√≥å

°“√√—°…“ë °“√√—°…“®”‡æ“–∑“ß¡–‡√Áß

‰¥â·°à °“√ºà“μ—¥ √—ß ’√—°…“ ·≈–‡§¡’∫”∫—¥ ‡™àπ √—ß ’√—°…“μ√ß∑’Ë°âÕπ‡π◊ÈÕ¡–‡√Áß°¥‡ âπª√– “∑À√◊Õ

√–§“¬‡§◊Õß‡ âπª√– “∑ °“√ºà“μ—¥À√◊Õ√—ß ’√—°…“√à«¡°—∫°“√„Àâ ‡μ’¬√Õ¬¥å„π°√≥’∑’Ë¡–‡√Áß°¥∑—∫‰¢ —πÀ≈—ß

À√◊Õ ¡Õß

ë °“√√—°…“μ“¡Õ“°“√

„™â·π«∑“ß‡«™ªØ‘∫—μ‘¢Õß neuropathic pain ∑’Ë‰¡à‰¥â‡°‘¥®“°¡–‡√Áß¡“ª√–¬ÿ°μå ´÷Ëß¬“∑’Ë„™â‡ªìπ°“√

√—°…“≈”¥—∫·√° §◊Õ °≈ÿà¡¬“°—π™—°·≈–¬“μâ“π‡»√â“ „π√“¬∑’Ë¡’™π‘¥¢Õß§«“¡ª«¥À≈“¬™π‘¥√à«¡°—π (mixed

pain) §«√æ‘®“√≥“¬“∑’Ë¡’ƒ∑∏‘Ïμà“ß°—π√à«¡°—π ‡™àπ antidepressants, antiepileptics, opioids, NSAIDs

ë ¬“μâ“π‡»√â“„™â ‰¥â¥’„π°“√‡ªìπ¬“‡ √‘¡ ‚¥¬‡©æ“–Õ“°“√ª«¥μàÕ‡π◊ËÕß ‰¥â·°à tricyclic antidepres-

sant (‡™àπ amytriptyline, nortriptyline) À√◊Õ°≈ÿà¡ serotonin norepinephrine reuptake inhibitors (‡™àπ

venlafaxine, duloxetine)

ë °≈ÿà¡¬“°—π™—°∑’Ë‰¥âº≈¥’ ‡™àπ gabapentin ·≈– pregabalin à«π phenytoin ·≈– carbamazepine

º≈‰¡à™—¥‡®π

ë ¬“Õ◊ËπÊ ‡™àπ lidocaine, mexiletine, ketamine ¡—°‰¡àπ‘¬¡„™â‡π◊ËÕß®“°¡’Õ“°“√‰¡àæ÷ßª√– ß§å Ÿß

À“°®”‡ªìπ§«√„™â‚¥¬ºŸâ‡™’Ë¬«™“≠‡∑à“π—Èπ

ë °“√„™â intervention therapy (‰¥â·°à neurostimulation, spical cord stimulation, neural

blockade, neurolysis) ¬“∑“‡©æ“–∑’Ë ‡™àπ §√’¡/‡®≈ Õ“®„™â„πÕ“°“√ª«¥‡©æ“–∑’ËÀ≈—ßºà“μ—¥ à«π intrathe-

cal opioids, clonidine „™â‡©æ“–√“¬∑’Ë°“√√—°…“¥â«¬¬“∑’Ë°≈à“«¡“°àÕπÀπâ“‰¡à‰¥âº≈ À√◊Õ‰¡à “¡“√∂∑πμàÕ¬“‰¥â

4.2 Cancer-induced bone pain (CIBP)°√–¥Ÿ°‡ªìπÕ«—¬«–∑’Ë‚√§¡–‡√Áß·æ√à°√–®“¬‰ª¡“°∑’Ë ÿ¥ §«“¡ª«¥°√–¥Ÿ°®“°¡–‡√Áß (cancer-induced

bone pain; CIBP) æ∫‰¥âª√–¡“≥√âÕ¬≈– 28-45 ¢ÕßºŸâªÉ«¬¡–‡√Áß∑’Ë·æ√à°√–®“¬‰ª°√–¥Ÿ°1 ‚¥¬¡’≈—°…≥–

‡©æ“–·μ°μà“ß®“°§«“¡ª«¥ª√–‡¿∑Õ◊Ëπ §◊Õ πÕ°®“°®–¡’ background pain ·≈â« ¬—ß¡’ breakthrough

pain ∫àÕ¬¡“° ∑—Èß·∫∫ spontaneous rest pain ·≈– incident pain ∑’Ë¡—°§“¥‡¥“‰¡à‰¥â«à“®–‡°‘¥‡¡◊ËÕ‰√ ®÷ß

√∫°«π§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬·≈–¥Ÿ·≈√—°…“¬“°°«à“

°“√√—°…“§«“¡ª«¥°√–¥Ÿ°®“°‚√§¡–‡√Áß„πª—®®ÿ∫—π ª√–°Õ∫¥â«¬ √—ß ’√—°…“ (external radiotherapy),

‰Õ‚´‚∑ª°—¡¡—πμ√—ß ’ (radioisotopes), ¬“·°âª«¥°≈ÿà¡ opioids, NSAIDs ·≈– bisphosphonates


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

√—ß ’√—°…“ (external radiotherapy) ‰¥âº≈∫√√‡∑“§«“¡ª«¥„π¿“æ√«¡ overall response √âÕ¬≈–

58-59 ·≈– complete response √âÕ¬≈– 23-242 ®÷ß‡ªìπ à«πÀπ÷Ëß¢Õß°“√∫”∫—¥§«“¡ª«¥®“° CIBP À√◊Õ

Õ“®æ‘®“√≥“ àßª√÷°…“·æ∑¬å√—ß ’√—°…“„π°√≥’∑’ËºŸâªÉ«¬ CIBP ¬—ß‰¡à “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â¥â«¬¬“3 ·≈–

‡π◊ËÕß®“°°“√‰¥â√—∫√—ß ’√—°…“‡æ’¬ß§√—Èß‡¥’¬« (single fraction) ‰¥âº≈‰¡àμà“ß®“°°“√©“¬À≈“¬§√—Èß (multiple

fraction)2,4 ºŸâªÉ«¬∑’Ë¡’√–¬–‡«≈“√Õ¥™’«‘μ —ÈπÀ√◊Õ‰¡à –¥«°„π°“√‡¥‘π∑“ß¡“√—∫°“√√—°…“ °Á¬—ß‰¥âª√–‚¬™πå®“°

√—ß ’√—°…“‡æ’¬ß§√—Èß‡¥’¬«

‰Õ‚´‚∑ª°—¡¡—πμ√—ß ’ (radioisotopes) ‰¥âº≈∫√√‡∑“§«“¡ª«¥ complete relief ‡ª√’¬∫‡∑’¬∫°—∫

placebo RR = 2.10 (95% CI =1.32-3.35) ‚¥¬μâÕß√–¡—¥√–«—ß‡¡Á¥‡≈◊Õ¥¢“«·≈–‡°≈Á¥‡≈◊Õ¥≈¥≈ß5 ®÷ß§«√

àßºŸâªÉ«¬∑’Ë¡’°“√°√–®“¬‰ª°√–¥Ÿ°À≈“¬·Ààß·≈–§«∫§ÿ¡§«“¡ª«¥¥â«¬¬“·≈â«‰¥âº≈‰¡à¥’ ª√÷°…“·æ∑¬å‡«™»“ μ√å

π‘«‡§≈’¬√å3

¬“√–ß—∫ª«¥°≈ÿà¡ opioids ‰¥âº≈¥’„π°“√∫√√‡∑“ background pain ·μà¬—ß¡’ªí≠À“„π°√≥’ break-

through pain ∑’Ë¡’ rapid onset ÷ËßÕ“®®”‡ªìπμâÕßæ÷Ëß parenteral form À√◊Õ rapid onset opioids

¬“°≈ÿà¡ NSAIDs ‰¥âº≈¥’°«à“¬“À≈Õ° ·≈–°“√„™â¬“°≈ÿà¡π’È√à«¡°—∫¬“°≈ÿà¡ opioids ¡’·π«‚πâ¡≈¥§«“¡

ª«¥®“°‚√§¡–‡√Áß‰¥â¥’°«à“¬“‡æ’¬ß°≈ÿà¡‡¥’¬«6 ·μàÀ≈—°∞“π‡™‘ßª√–®—°…å‡°’Ë¬«°—∫°“√„™â¬“°≈ÿà¡π’È„π√–¬–¬“« ·≈–

„π°“√ ∫√√‡∑“§«“¡ª«¥°√–¥Ÿ°¬—ß‰¡à™—¥‡®π ®÷ß§«√„™â¥â«¬§«“¡√–¡—¥√–«—ß ‚¥¬‡©æ“–Õ“°“√‰¡àæ÷ßª√– ß§å

®“°¬“1

¬“°≈ÿà¡ bisphosphonates ‰¥âº≈∫√√‡∑“§«“¡ª«¥ best pain response „π 12 —ª¥“Àå ‡ª√’¬∫‡∑’¬∫

°—∫°≈ÿà¡§«∫§ÿ¡ OR = 2.37 (95% CI =1.61-3.50) ·μàπâÕ¬°«à“°“√„™â¬“√–ß—∫ª«¥°≈ÿà¡ opioids À√◊Õ√—ß ’

√—°…“7 “¡“√∂„™âªÑÕß°—π°“√‡°‘¥ skeletal-related event „πÕπ“§μ ‡™àπ °√–¥Ÿ°À—° ‰¢ —πÀ≈—ß∂Ÿ°°¥∑—∫

‡ªìπμâπ ·≈–√—°…“¿“«–·§≈‡ ’¬¡„π‡≈◊Õ¥ Ÿß´÷Ëßæ∫‰¥â∂÷ß√âÕ¬≈– 10-30 „πºŸâªÉ«¬¡–‡√Áß8 ·μà‰¡à§«√„™â∑¥·∑π

¬“·°âª«¥ ·≈–ºŸâªÉ«¬®–μâÕß‰¥â√—∫°“√ª√–‡¡‘π ÿ¢¿“æ¢Õßøíπ°àÕπ3

¬—ß‰¡à¡’À≈—°∞“π‡™‘ßª√–®—°…å π—∫ πÿπ°“√„™â calcitonin9 ·≈–°“√Ωíß‡¢Á¡10 „π°“√∫√√‡∑“§«“¡ª«¥

°√–¥Ÿ°®“°‚√§¡–‡√Áß

„π°√≥’∑’Ë¡–‡√Áß·æ√à°√–®“¬‰ª∑’Ë°√–¥Ÿ° —πÀ≈—ß Õ“°“√‡√‘Ë¡·√°¢ÕßºŸâªÉ«¬°àÕπ®–¡’‰¢ —πÀ≈—ß∂Ÿ°°¥∑—∫

§◊ÕÕ“°“√ª«¥À≈—ßÕ¬à“ß√ÿπ·√ß ·≈–μ√«®æ∫°≈ÿà¡Õ“°“√®“°‰¢ —πÀ≈—ß∑’Ë∂Ÿ°°¥ §«√ª√–‡¡‘π·≈–À“ “‡Àμÿ

Õ¬à“ß‡√àß¥à«π ‡™àπ μ√«®∑“ß√–∫∫ª√– “∑ ·≈–μ√«® MRI ‡æ‘Ë¡‡μ‘¡´÷Ëß®–∑”„Àâ«“ß·ºπ°“√√—°…“μàÕ‰ª‰¥â

™—¥‡®π¢÷Èπ ‡™àπ °“√ºà“μ—¥À√◊Õ°“√„Àâ√—ß ’√—°…“ °“√ª√–‡¡‘π·≈–√—°…“‰¥âÕ¬à“ß∑—π∑à«ß∑’®– “¡“√∂≈¥¿“«–

∑ÿææ≈¿“æ¢Õß°≈â“¡‡π◊ÈÕ¢Õß√–¬“ß§å ·≈–ÀŸ√Ÿ¥¢Õß∑àÕªí “«–·≈–∑«“√Àπ—°

4.3 Tumor-induced headache (TIH)¿“«–ª«¥»’√…–„π°√≥’π’È¡—°‡°‘¥®“°§«“¡¥—π„π‚æ√ß°–‚À≈°»’√…– Ÿß ‡°‘¥‰¥â∑—Èß¡–‡√Áß¢Õß ¡ÕßÀ√◊Õ

√–∫∫ª√– “∑‡Õß ·≈–¡–‡√Áß∑’Ë°√–®“¬¡“®“°Õ«—¬«–Õ◊Ëπ Õ¬à“ß‰√°Áμ“¡°≈ÿà¡¡–‡√Áß∑’Ë°√–®“¬¡“æ∫∫àÕ¬°«à“

¡“°∂÷ß√“«√âÕ¬≈– 20-40 ¢ÕßºŸâªÉ«¬¡–‡√Áß·≈–√“« Õß„π “¡®–¡’Õ“°“√ ¡–‡√Áß∑’Ë°√–®“¬¡“∫àÕ¬ ‰¥â·°à ªÕ¥

‡μâ“π¡ º‘«Àπ—ß ≈”‰ â„À≠à ·≈–‰μ à«πÀπ÷Ëß®–‰¡àæ∫¡–‡√Áßª∞¡¿Ÿ¡‘∑’Ë°√–®“¬¡“ „π°√≥’∑’Ë§«“¡¥—π„π‚æ√ß


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°–‚À≈°»’√…–‰¡à Ÿß§«√§”π÷ß∂÷ß¿“«–Õ◊Ëπ∑’Ë‡°’Ë¬«¢âÕß ‡™àπ ¡–‡√Áß°√–®“¬‰ª∑’Ë‡¬◊ËÕÀÿâ¡ ¡Õß

Õ“°“√ª«¥»’√…–‡ªìπÕ“°“√∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥ „π¿“«–∑’Ë¡–‡√Áß°√–®“¬¡“∑’Ë ¡Õß μ“¡¥â«¬§«“¡º‘¥ª°μ‘

¢Õß√–∫∫ª√– “∑‡©æ“–∑’Ë ·≈–Õ“°“√™—°

Õ“°“√ª«¥»’√…– à«π„À≠à¡—°ª«¥∑—Ë«Ê μ◊ÈÕÊ ¡÷πÊ ∫“ß à«πÕ“®ª«¥μÿâ∫Ê À√◊Õª«¥·∑ß ¡—°¡’Õ“°“√√à«¡

‡™àπ §≈◊Ëπ‰ â/Õ“‡®’¬π ·≈–ª«¥¡“°¢÷Èπ‡¡◊ËÕ‡∫àß‰Õ ®“¡À√◊Õ∑”°‘®°√√¡∑—Ë«‰ª Õ“°“√ª«¥»’√…–®–°”‡√‘∫‡ªìπ§√—ÈßÊ

·≈–¡’§«“¡√ÿπ·√ß¡“°¢÷Èπ ª√–¡“≥Àπ÷Ëß„π ’Ë®–ª«¥‡«≈“°≈“ß§◊πÀ√◊Õμ◊ËππÕπ À“°‚√§≈ÿ°≈“¡®–¡’Õ“°“√

¡“°¢÷Èπ‡√◊ËÕ¬Ê μ”·Àπàß∑’Ëª«¥Õ“®∫Õ°∂÷ß√Õ¬‚√§‰¥â∫â“ß·μà‰¡à·πàπÕππ—° ºŸâªÉ«¬ à«π„À≠à¡—°μÕ∫ πÕß¥’μàÕ

°“√√—°…“∑’Ë„Àâ ‰¡à«à“®–‡ªìπ°“√√—°…“®”‡æ“–·≈–°“√√—°…“μ“¡Õ“°“√ À“°¡’°“√ª«¥´È” §«√√–«—ß«à“‚√§®–

≈ÿ°≈“¡À√◊Õ‡ªìπ´È”¿“¬À≈—ß

°“√«‘π‘®©—¬¿“«–π’È¡—°„™â CT À√◊Õ MRI ¡Õß∑’Ëæ∫°âÕπμ—Èß·μà 1 °âÕπ¢÷Èπ‰ª °âÕπ¡—°¡’≈—°…≥–°≈¡ ∫«¡

√Õ∫Ê ·≈–¡’°“√‡√◊Õß· ßÀ≈—ß©’¥ “√ª√—∫™—¥ ∫“ß√“¬¡’°“√°√–®“¬‰ª∑’Ë‡¬◊ËÕÀÿâ¡ ¡Õß√à«¡¥â«¬

°“√√—°…“ë °“√√—°…“®”‡æ“–

ë °“√ºà“μ—¥ ¡—°‡≈◊Õ°∑”„π√“¬∑’Ë¡’°âÕπ‡æ’¬ß 1-2 °âÕπ „πμ”·Àπàß∑’Ëºà“μ—¥‰¥â ‰¡à¬“° ¡’§«“¡ª≈Õ¥¿—¬

„πºŸâªÉ«¬∑’Ë¡’ ∂“π–¥’ ·≈–‰¡à¡’‚√§Õ◊Ëπ√à«¡¡“°π—°

ë √—ß ’√—°…“ ¡—°„™â„π√“¬∑’Ë°âÕπÀ≈“¬°âÕπ ºŸâªÉ«¬¡’ ∂“π–‰¡à¥’π—° ‚¥¬¡—°„Àâ√—ß ’√—°…“∑—Èß»’√…–

(whole brain radiation) ‚¥¬·∫àß„Àâ‡ªìπÀ≈“¬§√—Èß„π¢π“¥∑’ËμË”Ê

ë ‡§¡’∫”∫—¥ „™â„π√“¬∑’Ë¡–‡√Áßª∞¡¿Ÿ¡‘μÕ∫ πÕßμàÕ‡§¡’∫”∫—¥¡“°àÕπ ‡™àπ ¡–‡√ÁßμàÕ¡πÈ”‡À≈◊Õß

¡–‡√Áß‡μâ“π¡ ¡–‡√Áß‡´≈≈å ◊∫æ—π∏ÿå

ë °“√√—°…“ª√–§—∫ª√–§Õß

ë ‡μ’¬√Õ¬¥å: Dexamethasone ‡ªìπ¬“„π°≈ÿà¡π’È∑’Ë„™â∫àÕ¬∑’Ë ÿ¥ ¡—°„™â¢π“¥ Ÿß ‚¥¬„Àâ§√—Èß·√°„π

¢π“¥ 4-8 ¡°.©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” ·≈â«„ÀâμàÕ‡π◊ËÕß√“« 8 ¡°./«—π ‚¥¬·∫àß„Àâ 2-4 §√—Èß „π√“¬∑’Ë¡’Õ“°“√

√ÿπ·√ß ‡™àπ √–¥—∫ μ‘≈¥≈ß §«“¡¥—π„π‚æ√ß°–‚À≈°»’√…– Ÿß¡“° Õ“®„™â¬“„π¢π“¥ Ÿß√“« 16-24 ¡°./«—π

·≈â«≈¥¢π“¥≈ß‡√◊ËÕ¬Ê „π —ª¥“Àå·√°·≈â«À¬ÿ¥¬“¿“¬„π 2 —ª¥“Àå À“°‡ªìπ‰ª‰¥â √–À«à“ßπ—ÈπºŸâªÉ«¬§«√‰¥â

√—∫°“√√—°…“·≈–‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ∑’ËÕ“®‡°‘¥¢÷Èπ®“°¬“‰¥â

ë Õ◊ËπÊ

ë ¬“°—π™—°: „™â„π√“¬∑’Ë¡’Õ“°“√™—° ‡æ◊ËÕªÑÕß°—π‰¡à„Àâ§«“¡¥—π„π°–‚À≈° Ÿß¢÷ÈπÕ’°

ë Mannitol: „™â„π™à«ß —ÈπÊ ‡æ◊ËÕ„Àâ≈¥§«“¡¥—πÕ¬à“ß√«¥‡√Á«√à«¡°—∫ ‡μ’¬√Õ¬¥å

ë ¬“·°âª«¥: ¡—°„™â√à«¡°—∫°“√√—°…“μà“ßÊ ¢â“ßμâπ ‚¥¬‡©æ“– ‡μ’¬√Õ¬¥å ™π‘¥¢Õß¬“·°âª«¥π—Èπ

®–‡≈◊Õ°μ“¡§«“¡√ÿπ·√ß¢ÕßÕ“°“√ª«¥»’√…– ÷Ëß„™â ‰¥â∑—Èß¬“·°âª«¥∏√√¡¥“, NSAIDs, paracetamol À√◊Õ

opioids §«√√–«—ßÕ“°“√‰¡àæ÷ßª√– ß§å·≈–Õ—μ√°‘√‘¬“√–À«à“ß°—π¢Õß¬“¥â«¬


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

4.4 Visceral pain and malignant bowel obstruction (MBO)§«“¡ª«¥®“°Õ«—¬«–¿“¬„π·≈–¿“«–≈”‰ âÕÿ¥μ—π®“°¡–‡√Áß (Visceral pain and malignant bowel

obstruction; MBO) ‡ªìπ¿“«–·∑√° âÕπ∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬¡–‡√Áß„π™àÕß∑âÕß·≈–Õÿâß‡™‘ß°√“π√–¬–≈ÿ°≈“¡ ‚¥¬¡’

Õÿ∫—μ‘°“√≥å√âÕ¬≈– 10-28.4 „πºŸâªÉ«¬¡–‡√Áß≈”‰ â ·≈– Ÿß∂÷ß√âÕ¬≈– 5.5-51 „π¡–‡√Áß√—ß‰¢à1 ·≈–Õ“®‡°‘¥®“°

°“√·æ√à°√–®“¬¢Õß¡–‡√Áßμ”·ÀπàßÕ◊Ëπ¡“¬—ß™àÕß∑âÕß °“√«‘π‘®©—¬‰¥â®“°ª√–«—μ‘ °“√μ√«®√à“ß°“¬ ·≈–

¿“æ∂à“¬∑“ß√—ß ’

æ¬“∏‘ √’√«‘∑¬“2

μâÕß·¬°æ¬“∏‘ √’√«‘∑¬“¢Õß MBO «à“‡°‘¥®“° mechanical obstruction À√◊Õ functional obstruc-

tion ‚¥¬

ë Mechanical obstruction ‡°‘¥®“°°“√Õÿ¥μ—π®“°¿“¬πÕ°≈”‰ â®“°°âÕπ¡–‡√Áß‡ÕßÀ√◊Õæ—ßº◊¥„π

™àÕß∑âÕßÀ√◊Õ°“√Õÿ¥μ—π®“°¿“¬„π≈”‰ â

ë Functional obstruction (À√◊Õ adynamic ileus) ‡°‘¥®“°‡ âπª√– “∑ À√◊Õ coeliac plexus ‡°‘¥

¿“«– paraneoplastic neuropathy, autonomic neuropathy ¿“«–‰¢ —πÀ≈—ß∂Ÿ°°¥∑—∫, peritonitis, intra-

abdominal carcinomatosis

Õ“°“√· ¥ß3,4,5

Õ“°“√¡—°§àÕ¬‡ªìπ§àÕ¬‰ª ‡√‘Ë¡®“°ª«¥∑âÕß §≈◊Ëπ‰ â Õ“‡®’¬π ∑âÕß‚ªÉßæÕß ÷Ëß¡—°√ÿπ·√ß‡ªìπ√–¬–Ê ·≈–

À“¬‰¥â‡Õß §«“¡√ÿπ·√ß®–¢÷Èπ°—∫μ”·Àπàß¢Õß°“√Õÿ¥μ—π ‡¡◊ËÕÕ“°“√√ÿπ·√ß¡“°¢÷ÈπÕ“®ª«¥μ≈Õ¥‡«≈“ ‰¡à∂à“¬

Õÿ®®“√– ‰¡àº“¬≈¡ ‡∫◊ËÕÕ“À“√ Õ“®æ∫Õ“°“√∑âÕß‡ ’¬®“°°“√ – ¡¢Õß·∫§∑’‡√’¬„π≈”‰ â Õ“®æ∫Õ“°“√√à«¡Õ◊ËπÊ

‡™àπ ßà«ß ´÷¡ À“¬„®≈”∫“° ª“°·Àâß®“°¿“«–¢“¥πÈ” μ√«®æ∫∑âÕß‚ªÉßæÕß Õ“®¡Õß‡ÀÁπ°“√‡§≈◊ËÕπ‰À«¢Õß

≈”‰ â®“°ºπ—ßÀπâ“∑âÕß

Õ¬à“ß‰√°Áμ“¡§«√·¬°ªí≠À“∑âÕßºŸ°·≈–≈”‰ â ‰¡à∑”ß“π®“° “‡ÀμÿÕ◊ËπÊ ‡™àπ ¬“·°âª«¥°≈ÿà¡ opioids,

tricyclic antidepressants À√◊Õ¬“∑’Ë¡’ƒ∑∏‘Ï anticholinergic ‡ªìπμâπ

Õ“°“√· ¥ß Õÿ¥μ—π∑’Ë°√–‡æ“–Õ“À“√ À√◊Õ Õÿ¥μ—π∑’Ë≈”‰ â‡≈Á° à«πª≈“¬ À√◊Õ

≈”‰ â‡≈Á° à«πμâπ ≈”‰ â„À≠à

Õ“‡®’¬π πÈ”¥’ πÈ” ª√‘¡“≥¡“° ¡’°≈‘ËππâÕ¬ Õ“®®–¡’À√◊Õ‰¡à¡’Õ“°“√Õ“‡®’¬π ª√‘¡“≥πâÕ¬

·μà¡’°≈‘Ëπ·√ß

Õ“°“√ª«¥ æ∫‰¥â„π√–¬–·√°Ê ∫√‘‡«≥√Õ∫Ê –¥◊Õ æ∫‰¥â„π√–¬–∑â“¬Ê ª«¥≈÷°Ê

ª«¥∫‘¥‡ªìπ√–¬– —ÈπÊ ∫‘¥Ê ‡ªìπ√–¬–‡«≈“π“πÊ

∑âÕß‚ªÉßæÕß ¡’À√◊Õ‰¡à¡’°Á‰¥â ¡“°

‡∫◊ËÕÕ“À“√ √ÿπ·√ß ¡’À√◊Õ‰¡à¡’°Á‰¥â

μ“√“ß∑’Ë 10 °“√«‘π‘®©—¬·¬°μ”·Àπàß¢Õß≈”‰ âÕÿ¥μ—π ‚¥¬„™âª√–«—μ‘·≈–Õ“°“√· ¥ß2


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

·ºπ¿Ÿ¡‘∑’Ë 3 ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ MBO ¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ß 2

À≈—°°“√«‘π‘®©—¬·¬°μ”·Àπàß¢Õß≈”‰ âÕÿ¥μ—π®–„™âª√–«—μ‘·≈–Õ“°“√· ¥ß‡ªìπ ”§—≠¥—ß· ¥ß„πμ“√“ß∑’Ë

10 à«π·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ MBO ¥—ß·ºπ¿Ÿ¡‘∑’Ë 3 ·≈–°“√√—°…“Õ“°“√μà“ßÊ ¥—ßμ“√“ß∑’Ë 11

°“√μ√«®¿“æ∂à“¬∑“ß√—ß ’«‘∑¬“6

æ‘®“√≥“°“√μ√«®¿“æ∂à“¬∑“ß√—ß ’ plain abdominal radiography ·≈–„π°√≥’∑’Ë¡’‡§√◊ËÕß¡◊ÕÀ√◊Õ¡’

·æ∑¬åºŸâ‡™’Ë¬«™“≠Õ“®∑”°“√μ√«®æ‘‡»…Õ◊ËπÊ ‡™àπ computed tomography, ultrasonography, limited

pressure barium enema


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

1. “‡Àμÿ®“°°“√∫’∫μ—«≈â¡‡À≈« 2. ¡’°“√Õÿ¥μ—π∫“ß à«πÀ√◊Õ∫“ß§√—Èß 3. ¡’°“√Õÿ¥μ—πÕ¬à“ß ¡∫Ÿ√≥å

Õ“°“√ Õ“°“√ Õ“°“√

ë Õ“‡®’¬π‡ªìπÕ“À“√∑’Ë‰¡à¬àÕ¬ ë º“¬≈¡ À√◊Õ ∂à“¬Õÿ®®“√–∫â“ß ë ‰¡à∂à“¬Õÿ®®“√–

ë §≈◊Ëπ‰ â‡ªìπ√–¬–Ê ·≈– ë §≈◊Ëπ‰ â Õ“‡®’¬π ª«¥ªî¥ ë ∑âÕß‚ªÉß æÕß

Õ“°“√∫√√‡∑“‡¡◊ËÕÕ“‡®’¬π ë √ÿπ·√ß¡“° ≈—∫πâÕ¬ ë §≈◊Ëπ‰ â Õ“‡®’¬πæÿàß√ÿπ·√ß

ë ‰¡à¡’Õ“°“√ª«¥∫‘¥

ë º“¬≈¡‰¥â

ë πÈ”Àπ—°¢÷Èπ ∫«¡

ë ‡ ’¬ß‡§≈◊ËÕπ‰À«≈”‰ â≈¥≈ß

ë ¡’À√◊Õ‰¡à¡’Õ“°“√∑âÕßÕ◊¥

ë ¡’À√◊Õ‰¡à¡’Õ“‡®’¬πæÿàß·√ß

°“√√—°…“ °“√√—°…“ °“√√—°…“ - À¬ÿ¥¬“√–∫“¬∑ÿ°™π‘¥

ë À¬ÿ¥¬“°≈ÿà¡∑’Ë‡ªìπ “‡Àμÿ ‡™àπ ë À≈’°‡≈’Ë¬ßÕ“À“√∑’Ë¡’°“°„¬ Ÿß §≈◊Ëπ‰ âÕ“‡®’¬π

anticholinergics, tricycli- ë „Àâ¬“√–∫“¬ÕàÕπÊ ‡æ◊ËÕ„Àâ ë cyclizine 100-150 ¡°./«—π

cantidepressants Õÿ®®“√–π‘Ë¡ ë ∂â“¬—ß¡’Õ“°“√Õ“‡®’¬π„Àâ haloperidol

ë ≈¥¢π“¥¬“ opioids ë æ‘®“√≥“ dexamethasone 1.25-2.5 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑—π∑’

ë „Àâ¬“√–∫“¬ 8-10 ¡°. 2 §√—Èß/«—π ë dexamethasone 8-10 ¡°.

ë „Àâ¬“ prokinetic antiemetic ë ≈¥¢π“¥¬“ opioids 2 §√—Èß/«—π

‡™àπ metoclopramide §≈◊Ëπ‰ âÕ“‡®’¬π ë octreotide 300-600 ¡§°./«—π

30-120 ¡°./«—π ë ∂â“‰¡àª«¥∫‘¥ „Àâ metoclo- ª«¥∫‘¥

pramide 30-120 ¡°./«—π ë hyoscine-N-butylbromide

ë ∂â“ª«¥∫‘¥ „Àâ cyclizine 20 ¡°. ∑—π∑’ (30-120 ¡°./«—π)

100-150 ¡°./«—π ª«¥μàÕ‡π◊ËÕß®“°¡–‡√Áß „Àâ opioids

ª«¥μàÕ‡π◊ËÕß®“°¡–‡√Áß „Àâ opioids ¬—ß§ßÕ“‡®’¬π

ª«¥∫‘¥‡ªìπæ—°Ê „Àâ antispasmodic ë „Àâ anticholinergic √à«¡°—∫

¢π“¥μË” ‡™àπ hyoscine-N-butylbro- octreotide

mide 20 ¡°. ∑—π∑’ (20-60 ¡°./«—π) ë ∑” vent stomach-PEG

ë Stent

μ“√“ß∑’Ë 11 °“√√—°…“ MBO ¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ß 6

§”¬àÕ: PEG = Percutaneous endoscopic gastrostomy


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¬“·°âª«¥„π°≈ÿà¡ opioids ‡ªìπ¬“·°âª«¥À≈—°∑’Ëπ”¡“„™â∫”∫—¥§«“¡ª«¥„πºŸâªÉ«¬¡–‡√Áß °“√„™â¬“®”‡ªìπ

μâÕß∑√“∫¢âÕ¡Ÿ≈æ◊Èπ∞“π¥—ßπ’È

5.1 ‡¿ —™«‘∑¬“§≈‘π‘°¢Õß¬“„π°≈ÿà¡ opioids ·μà≈–¢π“π ·μà≈–‡¿ —™¿—≥±å ‡æ√“–¡’≈—°…≥–‡©æ“–

·μ°μà“ß°—π´÷Ëß‡ªìπªí®®—¬°”Àπ¥ª√– ‘∑∏‘¿“æ √Ÿª·∫∫°“√„Àâ¬“ ·≈–°“√μ‘¥μ“¡º≈°“√∫”∫—¥§«“¡ª«¥

√«¡∂÷ß equianalgesic dose ·≈–°“√§”π«≥‡¡◊ËÕ¡’§«“¡®”‡ªìπμâÕß‡ª≈’Ë¬π™π‘¥¢Õß¬“ opioids À√◊Õ‡ª≈’Ë¬π

«‘∏’„π°“√∫√‘À“√

5.2 À≈—°°“√„™â¬“ opioids ‰¥â·°à °“√‡√‘Ë¡„™â¬“ strong opioids °“√ª√—∫¢π“¥¬“ morphine ·≈–

°“√„™â rescue analgesics ”À√—∫√—°…“ breakthrough pain (BTP)

5.3 °“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â opioids

§”·π–π”„π°“√„™â¬“ opioids ¡’¥—ßπ’Èë ‡≈◊Õ°™π‘¥¢Õß opioids „Àâ‡À¡“– ¡°—∫§«“¡ª«¥¢ÕßºŸâªÉ«¬ „π°√≥’∑’Ë weak opioids ‰¡à “¡“√∂

§«∫§ÿ¡§«“¡ª«¥‰¥â„Àâ‡ª≈’Ë¬π¬“®“° weak opioids ‡ªìπ strong opioids

ë °“√ —Ëß„™â opioids ·∫∫„Àâ¬“μ“¡‡«≈“ (around-the-clock; ATC) „π°“√√—°…“ºŸâªÉ«¬ cancer pain

´÷Ëß¡’§«“¡ª«¥Õ¬à“ßμàÕ‡π◊ËÕß (continuous pain)

ë À“°ºŸâªÉ«¬‡°‘¥ BTP §◊Õ¡’§«“¡ª«¥°”‡√‘∫¢÷Èπ„π™à«ß —ÈπÊ ·¡â®–‰¥â√—∫¬“·°âª«¥·∫∫ ATC ®π§«∫§ÿ¡

§«“¡ª«¥ à«π„À≠à‰¥â·≈â«°Áμ“¡ §«√¡’°“√ —Ëß¬“·°âª«¥∑’Ë„™â‡æ‘Ë¡ (rescue analgesics) ·≈–ª√–‡¡‘π§«“¡ª«¥

´È”∑ÿ° 48-72 ™—Ë«‚¡ß

ë °“√„™â¡“μ√°“√‡æ◊ËÕªÑÕß°—πÕ“°“√∑âÕßºŸ°≈à«ßÀπâ“„πºŸâªÉ«¬ cancer pain ∑’Ë‰¥â√—∫ opioids „π√–¬–¬“«

ë μ‘¥μ“¡°“√∑”ß“π¢Õßμ—∫·≈–‰μ¢ÕßºŸâªÉ«¬‡ªìπ√–¬–Ê

ë À≈’°‡≈’Ë¬ß°“√„™â pethidine „πºŸâªÉ«¬ chronic cancer pain

5.1 ‡¿ —™«‘∑¬“§≈‘π‘°¢Õß¬“„π°≈ÿà¡ opioids

Weak opioids∑’Ë¡’„™â„πª√–‡∑»‰∑¬ ‰¥â·°à codeine ·≈– tramadol „™â„π°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß√–¥—∫πâÕ¬

∂÷ßª“π°≈“ß‡∑à“π—Èπ ¬“°≈ÿà¡π’È¡’ƒ∑∏‘Ï·°âª«¥®”°—¥ ‡¡◊ËÕ„™â∂÷ß¢π“¥¬“ Ÿß ÿ¥∑’Ë·π–π”À“°¬—ß‰¥âƒ∑∏‘Ï√–ß—∫ª«¥

‰¡à‡ªìπ∑’Ëπà“æÕ„®„Àâ‡ª≈’Ë¬π‡ªìπ¬“„π°≈ÿà¡ strong opioids ‚¥¬„™â equianalgesic dose (¥Ÿ√“¬≈–‡Õ’¬¥„πμ“√“ß

∑’Ë 12 ·≈–μ—«Õ¬à“ß„πμ“√“ß∑’Ë 15)

¿“§ºπ«° 5Opioids


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

Strong opioids¬“„π°≈ÿà¡ strong opioids ‡™àπ morphine ·≈– fentanyl transdermal patch „™â°“√√—°…“§«“¡

ª«¥®“°¡–‡√Áß„π√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß‰¥â¥’ ¬“·°âª«¥°≈ÿà¡π’È¡’ƒ∑∏‘Ï·√ß “¡“√∂ª√—∫¢π“¥¬“‡æ‘Ë¡¢÷Èπ‡√◊ËÕ¬Ê

‚¥¬‰¡à¡’¢π“¥¬“ Ÿß ÿ¥μàÕ«—π ·μàª√—∫μ“¡√–¥—∫§«“¡ª«¥·≈–§«“¡∑πμàÕ¬“¢ÕßºŸâªÉ«¬ ¡’™à«ß¢Õß¢π“¥¬“

∑’Ë„™â„π°“√√—°…“§àÕπ¢â“ß°«â“ß „π°“√„™âμâÕßμ√–Àπ—°∂÷ßÕ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“·≈–¡’°“√ªÑÕß°—π

μ‘¥μ“¡ ·≈–®—¥°“√Õ¬à“ß‡À¡“– ¡ strong opioids ∑’Ë‰¡à·π–π”„Àâ„™âμ‘¥μàÕ°—π„π√–¬–¬“«„πºŸâªÉ«¬¡–‡√Áß§◊Õ

pethidine ‡æ√“–¡’ toxic metabolite §◊Õ norpethidine ÷Ëß¡’æ‘…μàÕ√–∫∫ª√– “∑

ë Morphine

Strong opioids ∑’Ë®—¥‡ªìπ¬“Õ—π¥—∫·√°„π°“√√—°…“§«“¡ª«¥®“°¡–‡√Áß„π√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß§◊Õ

morphine ™π‘¥√—∫ª√–∑“π ·μà„π°√≥’∑’ËμâÕß√–ß—∫ª«¥Õ¬à“ß‡√àß¥à«π§«√„Àâ¥â«¬°“√©’¥‡¢â“„μâº‘«Àπ—ßÀ√◊Õ‡¢â“

À≈Õ¥‡≈◊Õ¥¥” ‰¡à·π–π”„Àâ©’¥‡¢â“°≈â“¡‡π◊ÈÕ‡æ√“–°“√¥Ÿ¥´÷¡‰¡à ¡Ë”‡ ¡Õ∑”„Àâª√–‡¡‘πƒ∑∏‘Ï·°âª«¥¢Õß¬“‰¥â¬“°

equianalgesic dose ¢Õß morphine ™π‘¥©’¥μàÕ™π‘¥√—∫ª√–∑“π§◊Õ 1:3 (μ“√“ß∑’Ë 12)

√Ÿª·∫∫‡¿ —™¿—≥±å¢Õß morphine ∑’Ë¡’„™â„πª√–‡∑»‰∑¬¡’À≈“¬·∫∫‚¥¬·μà≈–·∫∫¡’√–¬–‡«≈“∑’Ë mor-

phine „Àâƒ∑∏‘Ï·°âª«¥ Ÿß ÿ¥·≈–√–¬–‡«≈“∑’Ë¡’ƒ∑∏‘Ï·°âª«¥·μ°μà“ß°—π ¥—ß √ÿª„πμ“√“ß∑’Ë 13 ÷Ëß„™â‡ªìπ·π«∑“ß

„π°“√°”Àπ¥‡«≈“„π°“√ª√–‡¡‘π§«“¡ª«¥À≈—ß„Àâ morphine ·≈–°”Àπ¥√–¬–Àà“ß„π°“√„Àâ morphine

ë Fentanyl transdermal patch

Fentanyl ¡’§«“¡·√ß¡“°°«à“ morphine ª√–¡“≥ 100 ‡∑à“ fentanyl transdermal patch ¡’„™â

„π¢π“¥ 12, 25, 50 ·≈– 100 ¡§°./™—Ë«‚¡ß „™â·ª–∫√‘‡«≥≈”μ—« à«π∫π Àπâ“∑âÕß À√◊ÕÀπâ“¢“ ®–∑”„Àâ¬“

∂Ÿ°¥Ÿ¥´÷¡‡¢â“°√–· ‡≈◊Õ¥ ¬“®–ÕÕ°ƒ∑∏‘Ï‡μÁ¡∑’ËÀ≈—ß®“°·ª–·ºàπ¬“‰ª·≈â« 8-24 ™—Ë«‚¡ß ¥—ßπ—ÈπºŸâªÉ«¬§«√‰¥â√—∫¬“

opioids ∑’Ë‰¥â√—∫Õ¬Ÿà‡¥‘¡„π™à«ß√–¬– 24 ™—Ë«‚¡ß·√° ‚¥¬∑—Ë«‰ª¬“π’È¡’√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ïª√–¡“≥ 48-72

™—Ë«‚¡ß „™â‡©æ“–„πºŸâªÉ«¬∑’Ë‰¥â√—∫ morphine „π¢π“¥§ß∑’Ë¡“·≈â«√–¬–Àπ÷Ëß ‰¡à„™â‡ªìπ rescue analgesics ‰¡à

„™â„π°“√√—°…“ acute pain °“√‡ª≈’Ë¬π™π‘¥¢Õß opioids ‡ªìπ fentanyl °√≥’∑’Ë opioids ∑’Ë„™âÕ¬Ÿà‡¥‘¡‡ªìπ

morphine ™π‘¥√—∫ª√–∑“π„Àâ§”π«π‡ªìπ¢π“¥¬“„π 24 ™—Ë«‚¡ß·≈–„™â equianalgesics dose μ“¡μ“√“ß∑’Ë

14 ·μà°√≥’∑’Ë opioids ∑’Ë„™âÕ¬Ÿà‡¥‘¡‰¡à„™à morphine ™π‘¥√—∫ª√–∑“π„Àâ§”π«π‡ªìπ¢π“¥¬“„π 24 ™—Ë«‚¡ß ·≈–

§”π«≥°≈—∫‡ªìπ morphine ™π‘¥√—∫ª√–∑“π‡ ’¬°àÕπ ¢—ÈπμÕπ·≈–μ—«Õ¬à“ß°“√§”π«≥¥—ß„πμ“√“ß∑’Ë 15

‡π◊ËÕß®“° fentanyl transdermal patch ®“°·μà≈–·À≈àßº≈‘μÕ“®¡’‡¿ —™®≈π»“ μ√å·μ°μà“ß°—π®÷ß§«√„™â

equianalgesic dose μ“¡¢âÕ¡Ÿ≈‡©æ“–¢ÕßºŸâº≈‘μ·μà≈–√“¬

5.2 Equianalgesic dose ¢Õß¬“„π°≈ÿà¡ opioids ·≈–°“√§”π«≥Equianalgesic dose ¢Õß¬“„π°≈ÿà¡ opioids ∑’Ë· ¥ß‰«â„πμ“√“ß∑’Ë 12 ·≈– 14 §◊Õ¢π“¥¬“‡∑’¬∫‡∑à“

‚¥¬ª√–¡“≥´÷Ëß„™â‡ªìπ·π«∑“ß„π°“√°”Àπ¥¢π“¥¬“‡√‘Ë¡μâπ¢Õß opioids ¢π“π„À¡à∑’ËμâÕß°“√„™â´÷Ëß§“¥«à“

opioids ¢π“π„À¡à®–„Àâƒ∑∏‘Ï·°âª«¥·≈–Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ë —¡æ—π∏å°—∫°√–μÿâπ opioid receptor „°≈â‡§’¬ß

°—π∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫∏√√¡™“μ‘¢Õß opioids ∑’Ë‡ª≈’Ë¬π ¿“«–¢ÕßºŸâªÉ«¬ ·≈–¬“∑’Ë„™â√à«¡¥â«¬


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¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

Equianalgesic dose ¢Õß¬“„π°≈ÿà¡ opioids ·≈–°“√§”π«≥®–„™âª√–‚¬™πå„π°√≥’μàÕ‰ªπ’Èë μâÕß°“√‡ª≈’Ë¬π«‘∏’°“√„Àâ¬“ ‡™àπ ®“°¬“©’¥‡ªìπ¬“√—∫ª√–∑“π À√◊Õ®“°¬“√—∫ª√–∑“π‡ªìπ¬“·ºàπ·ª–

‡æ◊ËÕ‡æ‘Ë¡§«“¡ –¥«°¢ÕßºŸâªÉ«¬·≈–‡æ‘Ë¡§«“¡√à«¡¡◊Õ„π°“√„™â¬“ë μâÕß°“√‡ª≈’Ë¬π™π‘¥¢Õß opioids ‡æ◊ËÕ

- ‡æ‘Ë¡ƒ∑∏‘Ï√–ß—∫ª«¥ ‡™àπ °“√‡ª≈’Ë¬π codeine À√◊Õ tramadol ‡ªìπ morphine À√◊Õ‡ª≈’Ë¬πmorphine ‡ªìπ fentanyl

- ·°â ‰¢ªí≠À“Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ë ‰¡à “¡“√∂®—¥°“√‰¥â¥â«¬¡“μ√°“√Õ◊Ëπ ‡™àπ °“√‡ª≈’Ë¬πmorphine ‡ªìπ transdermal fentanyl ‡π◊ËÕß®“°ºŸâªÉ«¬‰¡à “¡“√∂∑πÕ“°“√∑âÕßºŸ° À√◊Õ¡’delirium ®“°°“√„™â morphine

√Ÿª·∫∫ §«“¡·√ß √–¬–‡«≈“∑’Ë‡√‘Ë¡ √–¬–‡«≈“ ¢âÕ§«√√–«—ß‡©æ“–

„Àâƒ∑∏‘Ï·°âª«¥ Ÿß ÿ¥ ∑’Ë¡’ƒ∑∏‘Ï·°âª«¥

™π‘¥√—∫ª√–∑“π

¬“‡¡Á¥·∫∫ª≈¥ª≈àÕ¬ 10 ¡°. 30 π“∑’ ∂÷ß 1 ™—Ë«‚¡ß 3-4 ™—Ë«‚¡ß -

μ—«¬“∑—π∑’

¬“πÈ”‡™◊ËÕ¡ 10 ¡°./5 ¡≈. 30 π“∑’ 3-4 ™—Ë«‚¡ß -

¬“‡¡Á¥·∫∫§«∫§ÿ¡ 10, 30 ·≈– 2-4 ™—Ë«‚¡ß 8-12 ™—Ë«‚¡ß Àâ“¡À—° ·∫àß ∫¥ ‡§’È¬«

°“√ª≈¥ª≈àÕ¬ 60 ¡°. ‡¡Á¥¬“

(MST continus˙)

¬“·§ª´Ÿ≈·∫∫§«∫§ÿ¡ 20, 50 ·≈– 2-4 ™—Ë«‚¡ß 24 ™—Ë«‚¡ß „π°√≥’®”‡ªìπ “¡“√∂

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‡¢â“À≈Õ¥‡≈◊Õ¥¥” 5-20 π“∑’ 3-4 ™—Ë«‚¡ß -

μ“√“ß∑’Ë 13 √–¬–‡«≈“∑’Ë‡√‘Ë¡„Àâƒ∑∏‘Ï·°âª«¥ Ÿß ÿ¥√–¬–‡«≈“∑’Ë¡’ƒ∑∏‘Ï·°âª«¥ ·≈–¢âÕ§«√√–«—ß‡©æ“–¢Õß‡¿ —™¿—≥±å

morphine ·∫∫μà“ßÊ

§«“¡·√ß

10 ¡°./¡≈.

(¢π“¥∫√√®ÿ 1 ¡≈.)


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

5.3 À≈—°°“√„™â¬“„π°≈ÿà¡ opioids°“√‡√‘Ë¡„™â¬“ strong opioidsë „π°√≥’∑’ËºŸâªÉ«¬‰¡à‡§¬‰¥â√—∫ opioids ¡“°àÕπ·≈–‰μ∑”ß“πª°μ‘ ·π–π”„Àâ„™â morphine ·∫∫ª≈¥

ª≈àÕ¬μ—«¬“∑—π∑’ ¢π“¥¬“∑’Ë·π–π”μ“¡μ“√“ß∑’Ë 12 „πºŸâªÉ«¬ ŸßÕ“¬ÿÀ√◊Õ‰μ∫°æ√àÕßÕ“®μâÕßª√—∫≈¥¢π“¥¬“≈ß

„πºŸâªÉ«¬∑’Ëª«¥¡–‡√Áß‡√◊ÈÕ√—ß∫“ß√“¬ “¡“√∂‡√‘Ë¡μâπ¥â«¬ morphine ·∫∫§«∫§ÿ¡°“√ª≈¥ª≈àÕ¬‰¥â ·μàμâÕß„Àâ

rescue analgesics ¥â«¬„π™à«ß·√°

ë „π°√≥’∑’ËºŸâªÉ«¬‡§¬‰¥â√—∫ weak opioids ¡“°àÕπ„Àâ§”π«≥¢π“¥¬“ morphine ‚¥¬„™â equianalgesic

dose μ“¡μ“√“ß∑’Ë 12 ¢—ÈπμÕπ·≈–μ—«Õ¬à“ß°“√§”π«≥μ“¡μ“√“ß∑’Ë 15 μ—«Õ¬à“ß∑’Ë 1

°“√ª√—∫¢π“¥¬“ morphineë °“√ª√—∫¢π“¥ morphine „π√–¬–·√° °√≥’∑’Ë„™â morphine ·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’„Àâª√–‡¡‘π

ƒ∑∏‘Ï·°âª«¥¢Õß¬“μ“¡‡«≈“∑’Ë¬“ÕÕ°ƒ∑∏‘Ï·°âª«¥ Ÿß ÿ¥„πμ“√“ß∑’Ë 13 À≈—ß®“°„Àâ¬“„π¢π“¥‡¥‘¡‰ª·≈â« 2-3 §√—Èß

À“°¬—ß‰¡à “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â„Àâ∑”°“√ª√—∫¢π“¥¬“‡æ‘Ë¡¢÷Èπμ“¡√–¥—∫§«“¡ª«¥

- ª«¥ª“π°≈“ß (pain score 4-6) „Àâæ‘®“√≥“‡æ‘Ë¡¢π“¥¬“¢÷Èπ√âÕ¬≈– 25-50 ¢Õß¢π“¥¬“

morphine ·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’∑’Ë„Àâ°àÕπÀπâ“π—Èπ

- ª«¥√ÿπ·√ß (pain score 7-10) „Àâæ‘®“√≥“‡æ‘Ë¡¢π“¥¬“¢÷Èπ√âÕ¬≈– 50-100 ¢Õß¢π“¥¬“

morphine ·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’∑’Ë„Àâ°àÕπÀπâ“π—Èπ

μ“√“ß∑’Ë 14 Equianalgesic dose ¢Õß morphine ™π‘¥√—∫ª√–∑“π·≈– fentanyl transdermal patch (Õ“®·μ°μà“ß

®“°μ“√“ßπ’È·≈â«·μà§”·π–π”¢ÕßºŸâº≈‘μ)

¢π“¥¬“ morphine ¢π“¥¬“ fentanyl transdermal patch

™π‘¥√—∫ª√–∑“π„π 24 ™—Ë«‚¡ß (¡°.) (¡§°./™—Ë«‚¡ß)

20-44 12

45-134 25

135-224 50

225-314 75

315-404 100

405-494 125

495-584 150

585-674 175

675-764 200

765-854 225

855-944 250

945-1034 275

1035-1124 300


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

μ—«Õ¬à“ß∑’Ë 1 μ—«Õ¬à“ß∑’Ë 2 ¢—ÈπμÕπ ‡ª≈’Ë¬π®“° codeine ™π‘¥ ‡ª≈’Ë¬π®“° morphine

√—∫ª√–∑“π‡ªìπ morphine ™π‘¥©’¥‡ªìπ transdermal fentanyl ™π‘¥√—∫ª√–∑“π

1. §”π«≥¢π“¥¬“„π 24 ™—Ë«‚¡ß Codeine 60 ¡°. ∑ÿ° 4 ™¡. Morphine 20 ¡°. ©’¥ ∑ÿ° 4 ™¡.¢Õß opioids ‡¥‘¡ = 360 ¡°./«—π = 120 ¡°./«—π

2. ‡ª≈’Ë¬π¢π“¥¬“„π 24 ™—Ë«‚¡ß ®“°μ“√“ß∑’Ë 12 ®“°μ“√“ß∑’Ë 12¢Õß opioids ‡¥‘¡„Àâ‡ªìπ¢π“¥ Codeine 360 ¡°./«—π Morphine ©’¥ 120 ¡°./«—π¬“„π 24 ™—Ë«‚¡ß¢Õß opioids = morphine 45 ¡°./«—π = morphine √—∫ª√–∑“π™π‘¥„À¡àμ“¡ equianalgesic 360 ¡°./«—πdose „πμ“√“ß∑’Ë 11 („π°√≥’∑’Ë ®“°μ“√“ß∑’Ë 14opioids ™π‘¥„À¡à‡ªìπ fentanyl = fentanyl transdermal patch„™â¢âÕ¡Ÿ≈®“°μ“√“ß∑’Ë 13 ‰¥â‡≈¬) 100 ¡§°./™¡.

3. ‡≈◊Õ°‡¿ —™¿—≥±å¢Õß opioids Morphine 45 ¡°./«—π Fentanyl transdermal patch™π‘¥„À¡à·≈–‡©≈’Ë¬¢π“¥¬“„π = morphine immediate-release 100 ¡§°./™¡.24 ™—Ë«‚¡ß„Àâ‡À¡“– ¡°—∫ 7.5 ¡°. ∑ÿ° 4 ™¡.§«“¡∂’Ë„π°“√„Àâ¬“ („π°√≥’∑’Ë = MST continus˙ 10 ¡°. 2 ‡¡Á¥opioids ™π‘¥„À¡à‡ªìπ fentanyl ∑ÿ° 12 ™¡.„™â¢âÕ¡Ÿ≈®“°μ“√“ß∑’Ë 14 ‰¥â‡≈¬) = Kapanol˙ 20 ¡°. 2 ·§ª´Ÿ≈

∑ÿ° 24 ™¡.

4. ª√—∫‡æ‘Ë¡ À√◊Õ≈¥¢π“¥¬“μ“¡ - Fentanyl transdermal patch ¿“«–¢ÕßºŸâªÉ«¬·≈–§ÿ≥ ¡∫—μ‘ 100 ¡§°./™¡. ·ª–∑ÿ° 3 «—π¢Õß opioids4.1 °√≥’∑’Ë opioids ‡¥‘¡§ÿ¡§«“¡

ª«¥‰¥â¥’„Àâª√—∫≈¥¢π“¥¬“opioids ™π‘¥„À¡à≈ßª√–¡“≥√âÕ¬≈– 25-50

4.2 °√≥’∑’Ë opioids ‡¥‘¡§ÿ¡§«“¡ª«¥‰¡à‰¥âÕ“®‡√‘Ë¡„™â opioids™π‘¥„À¡à„π¢π“¥∑’Ë§”π«≥‰¥âÀ√◊Õª√—∫‡æ‘Ë¡√âÕ¬≈– 25

5. μ‘¥μ“¡ºŸâªÉ«¬„π√–¬–·√°∑’Ë‡√‘Ë¡ 1-2 «—π 3-6 «—π„™â¬“ opioids ™π‘¥„À¡à ®π°«à“¬“®–‡¢â“ Ÿà√–¥—∫§ß∑’Ë‡æ◊ËÕ‡ΩÑ“√–«—ßÕ“°“√‰¡àæ÷ßª√– ß§å

μ“√“ß∑’Ë 15 ¢—ÈπμÕπ°“√‡ª≈’Ë¬π¬“ opioids ‚¥¬„™â equianalgesic dose ·≈–μ—«Õ¬à“ß°“√§”π«≥


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

- ‡¡◊ËÕ “¡“√∂§ÿ¡§«“¡ª«¥‰¥â¥’‚¥¬°“√„™â morphine ·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’ „Àâ§”π«≥¢π“¥

¬“ morphine ∑’Ë„™â„π 24 ™—Ë«‚¡ß ·≈â«‡ª≈’Ë¬π‡ªìπ·∫∫§«∫§ÿ¡°“√ª≈¥ª≈àÕ¬μ—«¬“‡æ◊ËÕ„Àâ –¥«°·°àºŸâªÉ«¬

·≈–‡æ‘Ë¡§«“¡√à«¡¡◊Õ„π°“√„™â¬“

ë °“√ª√—∫¢π“¥ morphine „π™à«ß maintenance treatment ∑—Èß morphine ·∫∫ª≈¥ª≈àÕ¬μ—«¬“

∑—π∑’ À√◊Õ·∫∫§«∫§ÿ¡°“√ª≈¥ª≈àÕ¬μ—«¬“

- „Àâ§”π«≥¢π“¥¬“ morphine ∑’Ë„™â„π 24 ™—Ë«‚¡ß ·≈â«ª√—∫¢π“¥‡æ‘Ë¡√âÕ¬≈– 25-30 ¢Õß¢π“¥

¬“∑’Ë„™â„π 24 ™—Ë«‚¡ß À√◊Õª√—∫‡æ‘Ë¡‡∑à“°—∫¢π“¥¬“ morphine ∑’Ë„™â‡ªìπ rescue analgesics ”À√—∫ break-

through pain „π 24 ™—Ë«‚¡ß∑’Ëºà“π¡“

- §«“¡‡√Á«„π°“√ª√—∫¢π“¥¬“¢÷Èπ°—∫§«“¡∑πμàÕ¬“¢ÕßºŸâªÉ«¬·μà≈–√“¬ ‚¥¬∑—Ë«‰ª‡¡◊ËÕª√—∫¢π“¥

¬“‡æ‘Ë¡¢÷ÈπºŸâªÉ«¬®–∑πμàÕÕ“°“√‰¡àæ÷ßª√– ß§å∑’Ë‡æ‘Ë¡¢÷Èπ‰¥â¿“¬„π 1-2 —ª¥“Àå

- À“°„™â morphine ·∫∫§«∫§ÿ¡°“√ª≈¥ª≈àÕ¬μ—«¬“·≈â«¬—ß‰¡à “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â

·π«∑“ß°“√·°â ‰¢‡∫◊ÈÕßμâπ§◊Õ ª√—∫¢π“¥¬“ background dose ‡æ‘Ë¡¢÷Èπ

Rescue analgesics ”À√—∫√—°…“ breakthrough pain (BTP)ºŸâªÉ«¬¡–‡√Áß∑’Ë¡’ BTP √–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß§«√‰¥â√—∫ rescue analgesics ‡æ◊ËÕ√–ß—∫ª«¥ ¬“∑’Ë„™â

§«√‡ªìπ·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’ À√◊Õ·∫∫©’¥∑’ËÕÕ°ƒ∑∏‘Ï‡√Á« §«√‡ªìπ™π‘¥‡¥’¬«°—∫¬“∑’Ë„™â·∫∫ ATC À√◊Õ¡’

§«“¡·√ß„π√–¥—∫‡¥’¬«°—π

ë ‡π◊ËÕß®“°¬—ß‰¡à¡’‡¿ —™¿—≥±å¢Õß fentanyl ”À√—∫ BTP „πª√–‡∑»‰∑¬ ®÷ßÕπÿ‚≈¡„Àâ„™â morphine

√—∫ª√–∑“π·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’ À√◊Õ·∫∫©’¥ ‡ªìπ rescue analgesics „πºŸâªÉ«¬∑’Ë„™â fentanyl transdermal

patch ‚¥¬¢π“¥ morphine ∑’Ë„™â§‘¥‡ªìπ√âÕ¬≈– 10-20 ¢Õß equianalgesic dose ¢Õß morphine √—∫ª√–∑“π

·≈– fentanyl transdermal patch „πμ“√“ß∑’Ë 14

ë ¢π“¥ rescue analgesics ∑’Ë„™â§‘¥‡ªìπ√âÕ¬≈– 10-20 ¢Õß¢π“¥¬“∑’Ë„™â„π 24 ™—Ë«‚¡ß „Àâ·∫∫ prn

‰¥â∂’Ë∑’Ë ÿ¥∑ÿ° 1 ™—Ë«‚¡ß (‡«âπ√–¬–Àà“ß®“°¬“·∫∫ª≈¥ª≈àÕ¬μ—«¬“∑—π∑’∑’Ë„™â·∫∫ ATC Õ¬à“ßπâÕ¬ 1 ™—Ë«‚¡ß)

ë ª√–‡¡‘π§«“¡ª«¥ È”„π 48-72 ™—Ë«‚¡ß À“°ºŸâªÉ«¬μâÕß°“√ rescue analgesics ¡“°°«à“ 4 §√—Èß „π

24 ™—Ë«‚¡ß ®”‡ªìπμâÕßª√—∫¢π“¥¬“∑’Ë„™â·∫∫ ATC ‡æ‘Ë¡¢÷Èπ√âÕ¬≈– 25-30 ¢Õß¢π“¥¬“‡¥‘¡ À√◊Õª√—∫‡æ‘Ë¡

‡∑à“°—∫¢π“¥¬“∑’Ë„™â‡ªìπ rescue analgesics ”À√—∫ BTP „π 24 ™—Ë«‚¡ß∑’Ëºà“π¡“

ë ‰¡à§«√„™â¬“·∫∫§«∫§ÿ¡°“√ª≈¥ª≈àÕ¬μ—«¬“‡ªìπ rescue analgesics ‡æ√“–ÕÕ°ƒ∑∏‘Ï™â“·≈–¬“«

π“π‡°‘π‰ª


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

5.4 °“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“„π°≈ÿà¡ opioids‡¡◊ËÕ„™â¬“„π°≈ÿà¡ opioids ®”‡ªìπμâÕß¡’°“√‡ΩÑ“√–«—ß ªÑÕß°—π ·≈–·°â ‰¢Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â

opioids ¡“μ√°“√∑—Ë«‰ª¡’¥—ßπ’È

1. ‡√‘Ë¡„™â„π¢π“¥μË” „Àâ‡√‘Ë¡¥â«¬¢π“¥¬“¢Õß opioids ∑’ËμË”‡∑à“∑’Ë®–∑”‰¥â ‚¥¬‡©æ“–„πºŸâªÉ«¬ ŸßÕ“¬ÿ

·≈–ºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õß‰μ∫°æ√àÕß

2. ª√—∫¢π“¥¬“™â“Ê ºŸâªÉ«¬®–∑πμàÕÕ“°“√‰¡àæ÷ßª√– ß§å à«π„À≠à¢Õß opioids ‰¥âÀ≈—ß®“°‡√‘Ë¡„™âÀ√◊Õ

ª√—∫¢π“¥¬“‡æ‘Ë¡¿“¬„π 1-2 —ª¥“Àå ¬°‡«âπÕ“°“√∑âÕßºŸ°∑’Ë®–§ßÕ¬Ÿàμ√“∫‡∑à“∑’ËºŸâªÉ«¬¬—ß„™â opioids

3. „Àâ°“√√—°…“®”‡æ“–‡∫◊ÈÕßμâπ À√◊Õ°“√ªÑÕß°—πÕ¬à“ß‡À¡“– ¡

4. „™â¬“·°âª«¥°≈ÿà¡Õ◊ËπÀ√◊Õ«‘∏’°“√Õ◊ËπÊ √à«¡¥â«¬‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï·°âª«¥¢Õß opioids ·≈–≈¥§«“¡μâÕß°“√

opioids ≈ß

5. ª√–‡¡‘π “‡ÀμÿÕ◊ËπÊ ¢ÕßÕ“°“√∑’ËÕ“®æ∫√à«¡¥â«¬

6. ∂â“‰¡à “¡“√∂·°â ‰¢Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ë‡°‘¥¢÷Èπ‰¥â „Àâæ‘®“√≥“‡ª≈’Ë¬π™π‘¥¢Õß opioids

°“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â opioids ∑”‰¥â¥—ßμ“√“ß∑’Ë 16


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

Õ“°“√‰¡àæ÷ßª√– ß§å °“√√—°…“

ßà«ßπÕπ ë ≈¥¢π“¥¬“ opioidsë „Àâ methylphenidate „π¢π“¥ 5-10 ¡°. À≈—ßÕ“À“√‡™â“·≈–°≈“ß«—π

∑âÕßºŸ° ë μâÕß„Àâ¬“√–∫“¬‡æ◊ËÕªÑÕß°—πÕ“°“√∑âÕßºŸ°®“° opioids À“°„™â„π√–¬–¬“«ë À“ “‡Àμÿ¢ÕßÕ“°“√∑âÕßºŸ° (¥Ÿ‡æ‘Ë¡‡μ‘¡„π¿“§ºπ«° 1.3 Constipation)ë ¥◊Ë¡πÈ”„Àâ ‰¥âÕ¬à“ßπâÕ¬«—π≈– 2-2.5 ≈‘μ√ (·μàμâÕß√–«—ß„π¿“«–∫“ßÕ¬à“ß ‡™àπ

À—«„®≈â¡‡À≈« ‰μ∑”ß“π∫°æ√àÕß)ë ¬“√–∫“¬°≈ÿà¡ stimulant laxatives, saline laxatives À√◊Õ stool softeners

‡æ◊ËÕªÑÕß°—π·≈–√—°…“ ‡™àπ- Bisacodyl 5 ¡°. √—∫ª√–∑“π§√—Èß≈– 1-2 ‡¡Á¥ «—π≈– 1-3 §√—Èß À√◊Õ

10 ¡°. ‡ÀπÁ∫∑«“√Àπ—°- Senna 7.5 ¡°. §√—Èß≈– 1-4 ‡¡Á¥ «—π≈– 1-2 §√—Èß- Milk of magnesia §√—Èß≈– 15-60 ¡≈. «—π≈– 1 §√—Èß

(§«√√–¡—¥√–«—ß„πºŸâªÉ«¬‚√§‰μ)- Macrogol 4,000 §√—Èß≈– 1-2 ´Õß º ¡πÈ”¥◊Ë¡°àÕππÕπ- Lactulose §√—Èß≈– 15-60 ¡≈. «—π≈– 1 §√—Èß- Docusate sodium 100-400 ¡°. «—π≈– 1-2 §√—Èß- §«√ª√—∫¢π“¥¬“√–∫“¬‡æ‘Ë¡‡¡◊ËÕ‡æ‘Ë¡¢π“¥¬“ opioids À√◊ÕÕ“®„™â¬“

√–∫“¬√à«¡°—π

§≈◊Ëπ‰ â Õ“‡®’¬π ë „Àâ¬“·°âÕ“‡®’¬π‡¡◊ËÕ¡’Õ“°“√ ‡™àπ

- Domperidone 10-20 ¡°. √—∫ª√–∑“π∑ÿ° 6 ™—Ë«‚¡ß- Prochlorperazine 10 ¡°. √—∫ª√–∑“π∑ÿ° 6 ™—Ë«‚¡ß- Metoclopromide 10-20 ¡°. √—∫ª√–∑“π∑ÿ° 6 ™—Ë«‚¡ß- Ondansetron 8 ¡°. √—∫ª√–∑“π«—π≈– 3 §√—Èß- Granisetron 2 ¡°. √—∫ª√–∑“π«—π≈– 1 §√—Èß- Haloperidol 0.5-1.0 ¡°. «—π≈– 1-2 §√—Èß- §«√√–«—ßÕ“°“√‰¡àæ÷ßª√– ß§å extrapyramidal symptoms ®“°°“√„™â

haloperidol, prochlorperazine ·≈– metoclopramide

‡æâÕ (delirium) ë Haloperidol 0.5-2 ¡°. √—∫ª√–∑“πÀ√◊Õ©’¥‡¢â“°≈â“¡ ∑ÿ° 4-6 ™—Ë«‚¡ßë Risperidone 0.25-1 ¡°. √—∫ª√–∑“π«—π≈– 1-2 §√—Èß

¥Ÿ‡æ‘Ë¡‡μ‘¡„π ¿“§ºπ«° 2.4 Delirium

°¥°“√À“¬„® (respiratory ë ‡®◊Õ®“ß naloxone 1 ampule (0.4 ¡°.) „π normal saline 9 ¡≈.·∫àß§√—Èß≈–depression) 1-2 ¡≈. ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”™â“Ê ∑ÿ° 30-60 «‘π“∑’ ®πÕ“°“√¥’¢÷Èπ

ë ∂â“ºŸâªÉ«¬¬—ß‰¡àμÕ∫ πÕß¿“¬„π 10 π“∑’ „Àâ©’¥®π‰¥â¢π“¥√«¡ 1 ¡°.

§—π (pruritus) ë „Àâ antihistamines

°≈â“¡‡π◊ÈÕ°√–μÿ° (myoclonus) ë Clonazepam 0.25-2 ¡°. √—∫ª√–∑“π«—π≈– 1-2 §√—Èßë Lorazepam 0.5-2 ¡°. √—∫ª√–∑“π«—π≈– 1-2 §√—Èß

μ“√“ß∑’Ë 16 °“√®—¥°“√Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â opioids


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 6Non-opioids

¬“·°âª«¥„π°≈ÿà¡ non-opioids ‰¥â·°à NSAIDs °≈ÿà¡‡°à“ (traditional NSAIDs; tNSAIDs), COX-2

inhibitors ·≈– paracetamol ¡’§”·π–π”°“√„™â¬“¥—ßπ’È

ë “¡“√∂„™â ‰¥â„π∑ÿ°√–¥—∫§«“¡ª«¥®“°¡–‡√Áßμ“¡ WHO analgesic ladder ¬°‡«âπ°√≥’ºŸâªÉ«¬¡’

¢âÕÀâ“¡„™â

ë °“√„™â√à«¡°—∫¬“°≈ÿà¡ opioids „πºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥„π√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß®–™à«¬‡æ‘Ë¡

ª√– ‘∑∏‘¿“æ„π°“√≈¥ª«¥·≈–≈¥¢π“¥°“√„™â¬“ opioids ≈ß

ë Àâ“¡„™â‡°‘π¢π“¥¬“ Ÿß ÿ¥∑’Ë·π–π”‡æ√“–¬“„π°≈ÿà¡π’È¡’ ceiling analgesic effects

ë ‰¡àæ∫«à“ª√– ‘∑∏‘¿“æ¢Õß¬“ NSAIDs ·≈– COX-2 inhibitors ·μà≈–μ—«¡’§«“¡·μ°μà“ß°—π

ë „™â¬“ tNSAIDs À√◊Õ COX-2 inhibitors „π¢π“¥μË” ÿ¥·≈–√–¬–‡«≈“ —Èπ∑’Ë ÿ¥∑’Ë„Àâº≈„π°“√§«∫§ÿ¡

Õ“°“√ª«¥

ë °“√„™â¬“ tNSAIDs À√◊Õ COX-2 inhibitors „π√–¬–¬“«μâÕßª√–‡¡‘π§«“¡®”‡ªìπ‡ªìπ√–¬–Ê

ë °“√„™â tNSAIDs À√◊Õ COX-2 inhibitors „π√Ÿª·∫∫©’¥ æ‘®“√≥“‡©æ“–°√≥’ ‡™àπ ª«¥À≈—ßºà“μ—¥

‰¡à·π–π”„Àâ„™â‚¥¬∑—Ë«‰ª„π√–¬–¬“«

ë °“√ªÑÕß°—πæ‘…μàÕμ—∫®“°°“√‰¥â√—∫ paracetamol

- √–¡—¥√–«—ß°“√‡°‘¥ paracetamol overdose ®“°°“√„™â¬“„π√Ÿª·∫∫º ¡√–À«à“ß paracetamol

°—∫ opioid analgesics

- ºŸâ∑’Ë¡’ªí®®—¬‡ ’Ë¬ß„π°“√‡°‘¥æ‘…μàÕμ—∫®“° paracetamol ‰¥â·°à ¡’¿“«–∑ÿæ‚¿™π“°“√ ‰¥â√—∫¬“∑’Ë

‡ªìπ enzyme inducer √à«¡¥â«¬ (isoniazid, rifampicin, carbamazepine, phenytoin) active liver

disease ¥◊Ë¡·Õ≈°ÕŒÕ≈å‡ªìπª√–®” „™â√à«¡°—∫¬“Õ◊Ëπ∑’Ë¡’æ‘…μàÕμ—∫ „Àâ≈¥¢π“¥¬“ Ÿß ÿ¥μàÕ«—π≈ß‡À≈◊Õ√âÕ¬≈–

50-75

μ—«Õ¬à“ß¬“·°âª«¥„π°≈ÿà¡ non-opioids ∑’Ë„™â∫àÕ¬ §«“¡∂’Ë„π°“√„Àâ¬“ ·≈–¢π“¥¬“ Ÿß ÿ¥∑’Ë·π–π”¥—ß

„πμ“√“ß∑’Ë 17 à«π¿“«–∑’Ë‡ªìπ¢âÕÀâ“¡„™â À√◊Õ‰¡à·π–π”„Àâ„™â¬“·°âª«¥„π°≈ÿà¡ NSAIDs ¥—ß· ¥ß„πμ“√“ß∑’Ë

18


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

¬“ §«“¡·√ß §«“¡∂’Ë ¢π“¥ Ÿß ÿ¥

(¡°.) (¡°./«—π)

Paracetamol 325, 500 ∑ÿ° 4-6 ™¡. 4,000

ER 650 ∑ÿ° 8 ™¡. ”À√—∫¬“√Ÿª·∫∫ ER

tNSAIDs Ibuprofen 200, 400, 600 ∑ÿ° 4-6 ™¡. 2,400

Diclofenac 25, 50 ∑ÿ° 8 ™¡.

SR 75, 100 ∑ÿ° 12-24 ™¡. ”À√—∫¬“ 150

√Ÿª·∫∫ SR

Indomethacin 25 ∑ÿ° 8-12 ™¡. 200

Naproxen 250 ∑ÿ° 12 ™¡. 1,000

Naproxen sodium 275 ∑ÿ° 12 ™¡. 1,100

Piroxicam 10, 20 ∑ÿ° 24 ™¡. 20

Preferential COX-2 Meloxicam 7.5 ∑ÿ° 12-24 ™¡. 15

inhibitors

Coxibs Celecoxib 200, 400 ∑ÿ° 12 ™¡. 400

Etoricoxib 30, 60, 90, 120 ∑ÿ° 24 ™¡. 120

¢π“¥ 120 ¡°. „™âμ‘¥μàÕ°—π

‰¡à‡°‘π 8 «—π

μ“√“ß∑’Ë 17 μ—«Õ¬à“ß¬“·°âª«¥„π°≈ÿà¡ non-opioids ∑’Ë„™â∫àÕ¬ §«“¡∂’Ë„π°“√„Àâ¬“ ·≈–¢π“¥¬“ Ÿß ÿ¥∑’Ë·π–π”

§”¬àÕ: ER = Extended release, SR = Sustained release


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¢âÕÀâ“¡„™â ¢âÕ§«√√–«—ß

‡§¬¡’ª√–«—μ‘ cardiovascular Àâ“¡„™â coxibs ‰¡à·π–π”„Àâ„™â tNSAIDsthromboembolic events

‰μ Àâ“¡„™â„πºŸâªÉ«¬∑’Ë¡’ creatinine ‰¡à·π–π”„Àâ„™â„πºŸâªÉ«¬∑’Ë¡’ªí®®—¬‡ ’Ë¬ßclearance πâÕ¬°«à“ 30 ¡≈./π“∑’ ‡™àπ Õ“¬ÿ¡“°°«à“ 60 ªï ‡ ’¬‡≈◊Õ¥¡“°

¢“¥πÈ”, multiple myeloma, diabeticmellitus, interstitial nephritis,papillary necrosis, „™â¬“Õ◊Ëπ∑’Ë¡’æ‘…μàÕ‰μÀ√◊Õ¬“‡§¡’∫”∫—¥∑’Ë¢—∫ÕÕ°∑“ß‰μ‡ªìπÀ≈—°√à«¡¥â«¬

‡≈◊Õ¥ÕÕ°„π∑“ß‡¥‘πÕ“À“√ Àâ“¡„™â„πºŸâªÉ«¬∑’Ë¡’ active bleeding ‰¡à·π–π”„Àâ„™â„πºŸâªÉ«¬∑’Ë¡’ªí®®—¬‡ ’Ë¬ß‡™àπ Õ“¬ÿ¡“°°«à“ 60 ªï ‡§¬¡’ª√–«—μ‘ulcer ¡“°àÕπ „™â NSAIDs À≈“¬™π‘¥√à«¡°—πÀ√◊Õ„™â„π¢π“¥ Ÿß „™â√à«¡°—∫¬“∑’Ë‡æ‘Ë¡ bleeding time ‡™àπ anticoagu-lants, corticosteroids, antiplatelets ¡’°“√∑”ß“π¢ÕßÀ—«„® μ—∫À√◊Õ‰μ∫°æ√àÕß Ÿ∫∫ÿÀ√’ËÀ“°®”‡ªìπ„Àâ„™â√à«¡°—∫ proton pumpinhibitors

‡°≈Á¥‡≈◊Õ¥ Àâ“¡„™â tNSAIDs „πºŸâªÉ«¬∑’Ë¡’¿“«–thrombocytopenia ®“°‡§¡’∫”∫—¥

μ—∫ ¡’ active liver disease À√◊Õ ‡Õπ‰´¡åμ—∫º‘¥ª°μ‘ ‚¥¬‡©æ“–§à“‡Õπ‰´¡åμ—∫¡“°°«à“ 3 ‡∑à“ nimesulide ·≈– diclofenac ¡’§«“¡¢Õß§à“ª°μ‘ ‡ ’Ë¬ß„π°“√‡°‘¥æ‘…μàÕμ—∫¡“°°«à“

NSAIDs μ—«Õ◊Ëπ

¡’ª√–«—μ‘°“√·æâ¬“‡π◊ËÕß¡“®“° Àâ“¡„™â¬“∑’Ë¡’‚§√ß √â“ß∑“ß‡§¡’„π°≈ÿà¡ªØ‘°‘√‘¬“∑“ß¿Ÿ¡‘§ÿâ¡°—π ‡¥’¬«°—π ‡™àπ ºŸâ∑’Ë·æâ¬“„π°≈ÿà¡

sulfonamides „ÀâÀ≈’°‡≈’Ë¬ß nimesulidecelecoxib, ·≈– parecoxib

ª√–«—μ‘°“√·æâ¬“ ·∫∫ Àâ“¡„™â tNSAIDspseudoallergic reactions®“°°“√„™â tNSAIDs ‡™àπbronchospasm, angioedema,urticaria, anaphylactoidreactions

μ“√“ß∑’Ë 18 ¿“«–∑’Ë‡ªìπ¢âÕÀâ“¡„™â À√◊Õ‰¡à·π–π”„Àâ„™â¬“·°âª«¥„π°≈ÿà¡ NSAIDs


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

¬“·°âª«¥„π°≈ÿà¡ adjuvants §◊Õ¬“°≈ÿà¡∑’Ë¡’¢âÕ∫àß„™âÀ≈—°∑“ß§≈‘π‘° ”À√—∫‚√§Õ◊ËπÊ ·μà “¡“√∂π”¡“

„™â√à«¡‡æ◊ËÕ∫”∫—¥§«“¡ª«¥‰¥â À√◊ÕÕ“®‡À¡“– ”À√—∫§«“¡ª«¥∫“ß™π‘¥ ¬“·°âª«¥„π°≈ÿà¡ adjuvants ¡’À≈“¬°≈ÿà¡

‡™àπ antidepressants, anticonvulsants, muscle relaxants, antispasmodics, corticosteroids ·≈–

bisphosphonates ·μà≈–°≈ÿà¡¡’«—μ∂ÿª√– ß§å°“√„™â·μ°μà“ß°—π

Antidepressants ·≈– anticonvulsantsë „™â ”À√—∫ºŸâªÉ«¬∑’Ë¡’¿“«– neuropathic pain

ë °“√‡≈◊Õ°„™â¬“æ‘®“√≥“μ“¡‚√§√à«¡ ª√–«—μ‘°“√μÕ∫ πÕßμàÕ¬“ ·≈–Õ“°“√‰¡àæ÷ßª√– ß§å®“°¬“

ë °“√√—°…“≈”¥—∫·√°§«√‡≈◊Õ°„™â¬“„π°≈ÿà¡ TCAs ‡™àπ amitriptyline, nortriptyline ‚¥¬ nortrip-

tyline ®–¡’Õ“°“√‰¡àæ÷ßª√– ß§åπâÕ¬°«à“ À√◊Õ‡≈◊Õ°„™â anticonvulsants ‡™àπ gabapentin ‚¥¬‡©æ“–Õ¬à“ß

¬‘ËßÀ“°¡’¢âÕÀâ“¡„™â TCAs

ë ‡√‘Ë¡„™â¬“„π¢π“¥μË”·≈–§àÕ¬Ê ‡æ‘Ë¡¢π“¥¬“∑ÿ° 3-14 «—πμ“¡¢âÕ∫àß™’È‡æ◊ËÕ„Àâ ‰¥âº≈°“√√—°…“∑’ËμâÕß°“√

·≈–μ“¡§«“¡ “¡“√∂„π°“√∑πμàÕ¬“

ë √–¡—¥√–«—ß°“√‡°‘¥ serotonin syndrome ®“°°“√„™â TCAs √à«¡°—∫¬“Õ◊Ëπ∑’Ë‡æ‘Ë¡√–¥—∫ serotonin

‡™àπ SSRIs (‡™àπ fluoxetine, sertraline), SNRIs (‡™àπ venlafaxine, duloxetine) ·≈– tramadol

ë ”À√—∫ºŸâªÉ«¬∑’Ë‰¡à “¡“√∂„™â TCAs ‰¥â Õ“®æ‘®“√≥“„™â SNRIs „π°√≥’∑’Ë¡’ neuropathic pain √à«¡

¥â«¬

ë „π°√≥’∑’Ë „™â adjuvants ·≈â«‰¥âº≈√–ß—∫ª«¥¥’¡“°Õ“®æ‘®“√≥“≈¥¢π“¥¬“ opioids ≈ß‰¥â

ª√–¡“≥√âÕ¬≈– 10-25 ‡æ◊ËÕ≈¥Õ“°“√‰¡àæ÷ßª√– ß§å‡æ√“–¬“∫“ß¢π“π¡’Õ“°“√‰¡àæ÷ßª√– ß§å‡ √‘¡°—∫

opioids ‡™àπ ßà«ß´÷¡ ∑âÕßºŸ° ª“°·Àâß ·μàÕ¬à“ß‰√°Áμ“¡„Àâμ‘¥μ“¡§«“¡ª«¥¢ÕßºŸâªÉ«¬‡ªìπ√–¬–Ê μ“¡§«“¡

‡À¡“– ¡

μ—«Õ¬à“ß antidepressants ·≈– anticonvulsants ∑’Ë„™â∫àÕ¬ ¢π“¥¬“ Õ“°“√‰¡àæ÷ßª√– ß§å·≈–¢âÕ

§«√√–«—ß∑’Ë ”§—≠¥—ß· ¥ß„πμ“√“ß∑’Ë 19

Adjuvant analgesics Õ◊ËπÊæ‘®“√≥“„™âμ“¡¢âÕ∫àß™’È∑’Ë‡À¡“– ¡μ“¡μ“√“ß∑’Ë 20

¿“§ºπ«° 7Adjuvants


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¬“ §«“¡·√ß ¢π“¥¬“ √–¬–‡«≈“∑’Ë„™â Õ“°“√‰¡àæ÷ßª√– ß§å

(¡°.) (¡°./ «—π) ª√–‡¡‘π°“√μÕ∫ πÕß ·≈–¢âÕ§«√√–«—ß∑’Ë ”§—≠

Antidepressants

Amitriptyline 10, 25, 50 10-75 6-8 —ª¥“Àå ë Anticholinergic side effects,

Nortriptyline 10, 25 10-75 ·≈– ßà«ßπÕπ À—«„®‡μâπ‡√Á« πÈ”Àπ—°μ—«‡æ‘Ë¡¢÷Èπ

Õ¬à“ßπâÕ¬ 2 —ª¥“Àå ë √–¡—¥√–«—ßÀ√◊ÕÀ≈’°‡≈’Ë¬ß°“√„™â„πºŸâ ŸßÕ“¬ÿ

‡¡◊ËÕ„™â„π¢π“¥ Ÿß ÿ¥ ºŸâªÉ«¬ ¡Õß‡ ◊ËÕ¡ ºŸâªÉ«¬‚√§À—«„® ‚√§μàÕ¡

≈Ÿ°À¡“°‚μ ‚√§μâÕÀ‘π¡ÿ¡ªî¥ ‚√§≈¡™—°

ë √–¡—¥√–«—ß°“√‡°‘¥ serotonin

syndrome ®“°°“√„™â√à«¡°—∫

¬“ tramadol

Anticonvulsants

Gabapentin 100, 300, 300-3,600 3-8 —ª¥“Àå ”À√—∫ ë ßà«ßπÕπ «‘ß‡«’¬π ∫«¡∑’Ë√–¬“ß§å à«πª≈“¬

400, 600 °“√ª√—∫¢π“¥¬“·≈– ë ¢—∫∑“ß‰μ„π√Ÿª‡¥‘¡ ®÷ßμâÕß≈¥¢π“¥

Õ¬à“ßπâÕ¬ 2 —ª¥“Àå „πºŸâªÉ«¬´÷Ëß¡’°“√∑”ß“π¢Õß‰μ∫°æ√àÕß

‡¡◊ËÕ„™â„π¢π“¥ Ÿß ÿ¥

Pregabalin 25, 75 75-600 4 —ª¥“Àå

Carbamazepine 200 100-1,200 - ë ‰¡à·π–π”„Àâ„™â‡ªìπ¬“≈”¥—∫·√°

ë „™â°√≥’ paroxysmal sharp shooting pain

ë §≈◊Ëπ‰ â Õ“‡®’¬π ‡«’¬π»’√…– ‡ÀÁπ¿“æ´âÕπ

ë √–«—ß°“√‡°‘¥¿“«–‚´‡¥’¬¡„π‡≈◊Õ¥μË” ‚¥¬

‡©æ“–À“°‰¥â√—∫¬“¢—∫ªí “«–√à«¡¥â«¬

ë À≈’°‡≈’Ë¬ß°“√„™â„πºŸâªÉ«¬‚√§μ—∫

‚√§‰¢°√–¥Ÿ°

ë √–«—ß°“√‡°‘¥º◊Ëπ·æâ¬“√ÿπ·√ß

ë “¡“√∂‡Àπ’Ë¬«π” CYP450 „πμ—∫‰¥â ®÷ßÕ“®

∑”„Àâ¬“·°âª«¥∫“ß™π‘¥¡’√–¥—∫¬“≈¥≈ß®π

‰¡à‰¥âº≈„π°“√√—°…“ ‡™àπ fentanyl ·≈–

methadone ·≈–Õ“®¡’Õ—πμ√°‘√‘¬“°—∫

¬“Õ◊Ëπ Ÿß

μ“√“ß∑’Ë 19 · ¥ß antidepressants ·≈– anticonvulsants ∑’Ë·π–π” ¢π“¥¬“ Õ“°“√‰¡àæ÷ßª√– ß§å ·≈–¢âÕ§«√

√–«—ß∑’Ë ”§—≠


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

¬“ ¢âÕ∫àß™’È ¢π“¥¬“ ¢âÕ¡Ÿ≈‡æ‘Ë¡‡μ‘¡

Baclofen ë Trigeminal neuralgia 15-80 ¡°. ·∫àß„Àâ Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ëæ∫∫àÕ¬

ë ¬“π’È¡’ƒ∑∏‘Ï antispasticity «—π≈– 3 §√—Èß §◊Õ ßà«ß´÷¡ ·≈–§≈◊Ëπ‰ â Õ“‡®’¬π

·≈–Õ“® “¡“√∂≈¥§«“¡

ª«¥®“°¿“«– muscle

spasm ´÷Ëß¡—°æ∫√à«¡°—∫

°“√‡°‘¥ acute neuro-

pathic pain ‰¥â

Corticosteroids §«“¡ª«¥∑’Ë‡°‘¥®“°¿“«– ¢π“¥¬“·≈â«·μà™π‘¥ ª√–‚¬™πåÕ◊ËπÊ ¢Õß¬“„πºŸâªÉ«¬

(dexamethasone, inflammation, nerve ¢Õß¬“∑’Ë„™â ¡–‡√Áß§◊Õ °“√‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ,

prednisolone) compression, diffuse ·≈–¢âÕ∫àß„™â mood elevation, °√–μÿâπ

bone pain, bowel §«“¡Õ¬“°Õ“À“√ ≈¥Õ“°“√

obstruction, acute §≈◊Ëπ‰ â Õ“‡®’¬π ·≈–§«“¡

management „π¿“«– √Ÿâ ÷°‰¡à ∫“¬À√◊ÕÕàÕπ·Õ¢Õß

pain crisis ®“°æ¬“∏‘ ¿“æ∑’Ë √à“ß°“¬ (malaise)

neural structures À√◊Õ bone, √–¡—¥√–«—ß°“√‡°‘¥Õ“°“√‰¡àæ÷ß

intracranial pressure Ÿß®“° ª√– ß§å®“°°“√„™â¬“√–¬–¬“«

¡–‡√Áß„π ¡Õß

Hyoscine -N- ¥Ÿ‡æ‘Ë¡‡μ‘¡„π ¿“§ºπ«° 4.4 Visceral pain and malignant bowel obstruction

butylbromide

Octreotide

Topical capsaicin ë Post-herpetic neuralgia, 0.0125-0.075% Õ“°“√‰¡àæ÷ßª√– ß§å∑’Ëæ∫‰¥â§◊Õ

diabetic neuropathy ·≈– ∑“«—π≈– 3-4 §√—Èß · ∫√âÕπ (burning, stinging)

painful polyneuropathy ·≈–º◊Ëπ·¥ß (erythema)

ë Musculoskeletal pain

Bisphosphonates ë “¡“√∂æ‘®“√≥“„™â‡ªìπ ‰¡à·π–π”„Àâ„™â¬“π’È‡ªìπ¬“

à«πÀπ÷Ëß¢Õß regimen „π Õ—π¥—∫·√°„π°“√√—°…“ (first

°“√√—°…“§«“¡ª«¥„πºŸâªÉ«¬ line therapy)

∑’Ë¡’¿“«– metastatic bone ‡π◊ËÕß®“°¬“Õ“®¡’æ‘…μàÕ‰μ·≈–

disease Õ“®∑”„Àâ‡°‘¥¿“«– osteone-

crosis of the jaw (ONJ) ®÷ß

·π–π”„Àâ„™â‚¥¬ºŸâ‡™’Ë¬«™“≠

‡∑à“π—Èπ

μ“√“ß∑’Ë 20 · ¥ßμ—«Õ¬à“ß adjuvant analgesics Õ◊ËπÊ ¢âÕ∫àß™’È„π°“√„™â ¢π“¥¬“ ·≈–¢âÕ¡Ÿ≈‡æ‘Ë¡‡μ‘¡¢Õß¬“


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 8Complementary and alternative medicine

°“√·æ∑¬å·∫∫º ¡º “π·≈–°“√·æ∑¬å∑“ß‡≈◊Õ° (complementary and alternative medicine) „™â

‡ªìπ«‘∏’ π—∫ πÿπ°“√√—°…“À≈—°Ê ∑’Ë°≈à“«¡“ ‡ªìπ∑’Ëπ‘¬¡„™â ·μàª√– ‘∑∏‘º≈®“°°“√»÷°…“∑’Ë‰¥âº≈‡ªìπ‡©æ“–°≈ÿà¡

·≈–‡ªìπ√–¬–‡«≈“ —ÈπÊ ‡™àπ °“√π«¥ ÿ§π∏∫”∫—¥ (aromatherapy) ¥πμ√’∫”∫—¥ (music therapy)

Transcutanous electrical nerve stimulation (TENS) °“√Ωíß‡¢Á¡ (accupuncture) ·≈– mind-body

intervention

ë °“√π«¥·≈– ÿ§π∏∫”∫—¥ ‰¥âº≈≈¥ª«¥‡æ’¬ß√–¬– —Èπ ·μà™à«¬≈¥§«“¡«‘μ°°—ß«≈ ·≈–∑”„ÀâºàÕπ

§≈“¬‰¥â¥’ ·μà ”À√—∫°“√≈¥ª«¥¬—ß‰¡à™—¥‡®π

ë ¥πμ√’∫”∫—¥ ¡’º≈„π¥â“π®‘μ„®·≈– —ß§¡ °“√≈¥ª«¥º≈‰¡à™—¥‡®π ¬°‡«âπ°√≥’À≈—ßºà“μ—¥ ·≈–‰¡à„™à

°“√»÷°…“„πºŸâªÉ«¬¡–‡√Áß

ë TENS ‚¥¬„™â°“√°√–μÿâπ¥â«¬‰øøÑ“‚«≈μåμË”‡æ◊ËÕ≈¥ª«¥ ·μàº≈„π°“√≈¥ª«¥¬—ß‰¡à™—¥‡®π

ë °“√Ωíß‡¢Á¡ ·¡â¡’√“¬ß“π¡“°¢÷Èπ‡°’Ë¬«°—∫ª√– ‘∑∏‘¿“æ¢Õß°“√Ωíß‡¢Á¡≈¥ª«¥ ·μà¬—ß‰¡à‡æ’¬ßæÕ„π°“√

„ÀâπÈ”Àπ—°§”·π–π”

ë Mind-body intervention ‡™àπ hypnotherapy, distraction and imagery ∑”‚¥¬ºŸâ‡™’Ë¬«™“≠

„π‡¥Á°∑’Ë‡ªìπ¡–‡√ÁßÕ“®¡’ª√–‚¬™πå„π°“√™à«¬≈¥§«“¡°—ß«≈


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

¿“§ºπ«° 9Pain at the end of life

§«“¡ª«¥„πºŸâªÉ«¬¡–‡√Áß„π√–¬–∑â“¬¢Õß™’«‘μ (pain at the end of life) Õ“®ª√–‡¡‘π®“°æƒμ‘°√√¡

°“√· ¥ßÕÕ°·∑π¡“μ√«—¥§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥ (¥Ÿ Check list: comprehensive pain assessment

Àπâ“ 7)

°“√ ◊ËÕ “√°—∫§√Õ∫§√—«·≈– —ß§¡‡°’Ë¬«°—∫Õ“°“√¢Õß¿“«–„°≈âμ“¬ ™à«¬∑”„Àâ§«“¡«‘μ°°—ß«≈¢Õß ¡“™‘°

„π§√Õ∫§√—«≈¥≈ß‰¥â §«√¬Õ¡√—∫∏√√¡‡π’¬¡ «—≤π∏√√¡ ·≈–„Àâ‡°’¬√μ‘°—∫»“ π“¢ÕßºŸâªÉ«¬∑’Ë¬÷¥∂◊ÕªØ‘∫—μ‘

‡π◊ËÕß®“°„π√–¬–π’È¡’§«“¡‡ ◊ËÕ¡∂Õ¬¢ÕßÕ«—¬«–∑’Ë ”§—≠‡°◊Õ∫∑ÿ°√–∫∫ ®÷ß®”‡ªìπμâÕß¡’°“√ª√–‡¡‘πº≈

°“√√—°…“Õ“°“√ª«¥∂’Ë¡“°¢÷Èπ √âÕ¬≈– 53-70 ®”‡ªìπμâÕß‡ª≈’Ë¬π√Ÿª·∫∫¢Õß¬“ «‘∏’°“√„Àâ¬“ ‚¥¬‡©æ“–„π

™à«ß‡ªìπ«—πÀ√◊Õ™—Ë«‚¡ß°àÕπ°“√μ“¬ μ“√“ß equianalgesic ·≈–°“√¡’ opioid rotation ®÷ß¡’§«“¡ ”§—≠

§«√æ‘®“√≥“≈¥¢π“¥¬“‡¡◊ËÕ¡’¿“«–‰μÀ√◊Õμ—∫«“¬∑’Ë∑”„Àâ°“√¢—∫¬“≈¥≈ßÀ√◊Õ°“√∑”≈“¬¬“™â“≈ß

§«√ªÑÕß°—πº≈¢â“ß‡§’¬ß ‡™àπ ∑âÕßºŸ° ‡ΩÑ“√–«—ßº≈¢Õß¬“μà“ßÊ ∑’Ë„™â·≈â«¡’ interaction ¿“«–º≈

¢â“ß‡§’¬ß ‡™àπ ßà«ß´÷¡ ¿“«– —∫ π (delirium) ∑’Ëæ∫‰¥â„π√–¬–∑â“¬∑’ËÕ“®μâÕß‰¥â¬“≈¥Õ“°“√ ·≈–¿“«–Õ«—¬«–μà“ßÊ

‡ ◊ËÕ¡∂Õ¬

§«√¥Ÿ·≈Õ“°“√Õ◊ËπÊ ∑’Ëæ∫∫àÕ¬„π√–¬–∑â“¬∑’Ëæ∫√à«¡·≈–Õ“®‰¥âª√–‚¬™πå®“°¬“ opioids ‰¥â·°àÕ“°“√

ÀÕ∫‡Àπ◊ËÕ¬

μâÕß∑√“∫ ¿“«–∑’ËÕ◊ËπÊ ∑’Ë‡ªìπ “‡Àμÿ¢ÕßÕ“°“√ª«¥ ‡™àπ ∑âÕßºŸ° ªí “«–§—Ëß §«“¡‰¡à ÿ¢ ∫“¬

®“°ªí®®—¬¥â“πÕ“√¡≥å·≈–®‘μ«‘≠≠“≥ ∑—Èß®“°§«“¡°≈—«°“√μ“¬ °“√∂Ÿ°∑Õ¥∑‘Èß„π√–¬– ÿ¥∑â“¬ ‚¥¬„™âÀ≈—°

palliative care §◊Õ ‰¡à∑√¡“π·≈–¡’™’«‘μ·∫∫¡’§ÿ≥¿“æ

„π°√≥’ºŸâªÉ«¬¡–‡√Áß√–¬–∑â“¬∑’Ë¥◊ÈÕμàÕ°“√√—°…“¥â«¬¬“·°âª«¥ §«√‰¥â√—∫°“√¥Ÿ·≈®“°∑’¡ À “¢“ À√◊Õ

ºŸâ‡™’Ë¬«™“≠¥â“π palliative care


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

∫√√≥“πÿ°√¡·≈–‡Õ° “√·π–π”‡æ‘Ë¡‡μ‘¡

∫∑π”1. °√–∑√«ß “∏“√≥ ÿ¢. ∂‘μ‘ “∏“√≥ ÿ¢ 2553. Available at: http://bps.ops.moph.go.th/Healthinformation/statistic53/statistic53.pdf

Accessed August 1, 2012.

2. Ripamonti CI, Bandieri E, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO ClinicalPractice Guidelines. Ann Oncol 2011;22 Suppl 6:vi69-77.

3. Thienthong S, Pratheepawanit N, Limwattananon C, Maoleekoonpairoj S, Lertsanguansinchai P, Chanvej L. Pain andquality of life of cancer patients: a multi-center study in Thailand. J Med Assoc Thai 2006;89(8):1120-6.

4. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence ofpainin patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007;18(9):1437-49

5. World Health Organization. Cancer control: knowledge into action: WHO guide for effective programmes: Geneva,Switzerland. World Health Organization; 2007.

¿“§ºπ«° 1 Õ“°“√√à«¡Õ◊ËπÊ

1.1 Dyspnea1. Abernethy AP, McDonald CF, Frith PA, Clark K, Herndon JE 2nd, Marcello J, et al. Effect of palliative oxygen versus

room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind randomized controlled trial.Lancet 2010;376:784-93.

2. Bausewein C, Booth S, Gysels M, Higginson IJ. Non pharmacologic interventions for breathlessness in advancedstages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;(2):CD005623.

3. Ben-Aharon I, Gafter-Gvilli A, Paul M, Leibovici L, Semmer SM. Intervention for alleviating cancer.-related dyspnea:A systematic review. J Clin Oncol 2008;26:2396-404.

4. Heyse-Moore LH, Poss V, Mulle MA. How much of a problem is dyspnea in advanced cancer? Palliat Med 1991;5:20-6.

5. Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professionals:Assessment, Burden and Etiologies. J Palliat Care Med 2011;14(10):1167-72.

6. Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professionals:Treatment Goals and Therapeutic options. J Palliat Care Med 2012;15(1):106-14.

7. Mancini I, Body JJ. Assessment of dyspnea in advanced cancer patients. Support Care Cancer 1999;7(4):229-32.

8. Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer 1999;7(4):233-43.

9. Shoemaker LK, Estfan B, Induru R, Walsh TD. Symptom management: an important part of cancer care. Cleve Clin JMed 2011;78(1):25-34.

10. Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepine for the relief of breathlessness in advancedmalignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2010;(1):CD007354.


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

11. Violar R, Kiteley C, Lloyd NS, Mackay JA, Wilson J, Wong RK. The management of dyspnea in cancer patients:A systematic review. Supportive Care Cancer 2008;16:329-37.

1.2 Lymphedema1. Cheville AL, McGarvey CL, Petrek JA, Russo SA, Taylor ME, Thiadens SR. Lymphedema management. Semin Radiat

Oncol 2003;13(3):290-301.

2. Cohen SR, Payne DK. Tunkel RS. Lymphedema: Strategies for management. Cancer 2001;92(4 Suppl):980-7.

3. Harris SR., Hugi MR., Olivotto IAN., Levine M. Clinical practice guidelines for the care and treatment of breast cancer:11. Lymphedema. CMAJ 2001;164:191-9.

4. Warren AG, Brorson H, Bored LJ, Slavin SA. Lymphedema: A comprehensive review. Annals of Plastic Surgery. 2007;59:464-72.

5. Watson MS, Lucus CF, Hoy AM, Back IN. Oxford Handbook of Palliative Care. 1st ed. Oxford: Oxford University Press,2005:316-7.

1.3 Constipation1. Leavitt MA, Goodheart CR. Managing opioid-induced constipation in ambulatory-care patients. Pain Treatment Topics,

2006. Available at: http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf. Accessed July 1, 2012.

2. McMillan SC. Assessing and managing opiate-induced constipation in adults with cancer. Cancer Control 2004;11(3 Suppl):3-9.

3. Panchal SJ, Müer-Schwefe P, Wurzelmann JI. Opioid-induced bowel dysfunction: prevalence, pathophysiology andburden. Int J Clin Pract 2007;61(7):1181-7.

4. Scott M. Fishman, Jane C. Ballantyne, James P. Rathmell. Pain due to Cancer. Bonicaûs Management of Pain. 4th ed.Lippincott Williams & Wilkins Press, 2010:588-9.

5. Thomas JR, Cooney GA, Slatkin NE. Palliative care and pain: new strategies for managing opioid bowel dysfunction. JPalliat Med 2008;11 Suppl 1:S1-19; quiz S21-2.

6. Wall and Melzack. Cancer pain, In: Stephen B. McMahon, Martin Koltzenburg, eds. Textbook of Pain, 5th ed. ChurchillLivingstone, Elservier Press; 2006:1085-126.

7. Yuan CS, ed. Handbook of Opioid Bowel Syndrome. NewYork: Haworth Medical Press, 2005:101-18.

1.4 Deconditioning and fatigue1. Blaney J, Lowe-Strong A, Rankin J, Campbell A, Allen J, Gracey J. The cancer rehabilitation journey: barriers to and

facilitators of exercise among patients with cancer-related fatigue. Phys Ther 2010;90(8):1135-47.

2. Gupta AD, Lewis S, Shute R. Patients living with cancer - the role of rehabilitation. Aust Fam Physician 2010;39(11):844-6.

3. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Cancer-relatedfatigue, version1; 2006. Available at: http://www.nccn. org/professionals/physician_gls/PDF/fatigue.pdf/. Accessed October12, 2006.


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

4. Silver JK, Gilchrist LS. Cancer rehabilitation with a focus on evidence-based outpatient physical and occupationaltherapy interventions. Am J Phys Med Rehabil 2011;90(5 Suppl 1):S5-15.

¿“§ºπ«° 2 ¿“«–∑“ß®‘μ‡«™1. ∏π“π‘≈™—¬‚°«‘∑¬å, ¡“‚π™À≈àÕμ√–°Ÿ≈, Õÿ¡“¿√≥å‰æ»“≈ ÿ∑∏‘‡¥™. °“√æ—≤π“·∫∫ Õ∫∂“¡ Hospital Anxiety and Depression Scale

©∫—∫¿“…“‰∑¬„πºŸâªÉ«¬‚√§¡–‡√Áß. «“√ “√ ¡“§¡®‘μ·æ∑¬å·Ààßª√–‡∑»‰∑¬; 2539:41(1):18-30.

2. “«‘μ√’ ‡®μ‘¬“πÿ«—μ√, ¿ÿ™ß§å ‡À≈à“√ÿ®‘ «— ¥‘Ï. §«“¡‡∑’Ë¬ßμ√ß¢Õß·∫∫ Õ∫∂“¡ Distress Thermometer ©∫—∫¿“…“‰∑¬ (ª√Õ∑«—¥∑ÿ°¢å)«“√ “√ ¡“§¡®‘μ·æ∑¬å·Ààßª√–‡∑»‰∑¬ (°”≈—ßμ’æ‘¡æå).

3. Devlin JW, Roberts RJ, Fong JJ, Skrobik Y, Riker RR, Hill NS, Robbins T, Garpestad E. Efficacy and safety ofquetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlledpilot study. Crit Care Med 2010;38:419-27

4. European Palliative Care Research Collaborative. The management of depression in palliative care. European ClinicalGuidelines, 2010. Available at: http://www.epcrc.org/publication_listfiles.php?id=B37xKfhn62SbYlFIsBsd. Accessed 16June, 2012.

5. Jackson KC, Lipman AG. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev.2004;(2):CD004770.

6. Minton O, Richardson A, Sharpe M, Hotopf M, Stone P. Drug therapy for the management of cancer-related fatigue.Cochrane Database Syst Rev 2010;(7):CD006704.

7. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Distress Management,version 1, 2013. Available at: http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf. Accessed September15, 2012.

8. Rodin G, Katz M, Lloyd N, Green E, Mackay JA, Wong RK. Treatment of depression in cancer patients. Curr Oncol2007;14(5):180-8.

¿“§ºπ«° 4 Õ“°“√‡©æ“–Õ◊ËπÊ4.1 Neuropathic cancer pain1. Bennett MI, Rayment C, Hjermstad M, Aass N, Caraceni A, Kaasa S. Prevalence and aetiology of neuropathic pain in

cancer patients: a systematic review. Pain 2012;153:359-65.

2. Bennett MI. Effectiveness of antiepileptic or antidepressant drugs when added to opioids for cancer pain: systematicreview. Palliat Med 2011;25:553-9.

3. Naleschinski D, Baron R, Miaskowski C. Identification and treatment of neuropathic pain in patients with cancer. PainClinical Update 2012;20:1-5.

4. Vadalouca A, Raptis E, Moka E, Zis P, Sykioti P, Siafaka I. Pharmacological treatment of neuropathic cancer pain:a comprehensive review of the current literature. Pain Pract. 2012;12:219-51.


·π«∑“ß‡«™ªØ‘∫—μ‘§«“¡ª«¥®“°¡–‡√Áß

4.2 Cancer-induced bone pain1. Middlemiss T, Laird BJ, Fallon MT. Mechanisms of cancer-induced bone pain.Clin Oncol (R Coll Radiol). 2011;23(6):

387-92.

2. Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative radiotherapy trials for bone metastases: a systematic review.J Clin Oncol 2007;25(11):1423-36.

3. Ripamonti CI, Bandieri E, Roila F. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2011;22Suppl 6:vi69-77.

4. McQuay HJ, Collins SL, Carroll D, Moore RA. Radiotherapy for the palliation of painful bone metastases. CochraneDatabase Syst Rev 2000(2):CD001793.

5. Roque IFM, Martinez-Zapata MJ, Scott-Brown M, Alonso-Coello P. Radioisotopes for metastatic bone pain. CochraneDatabase Syst Rev 2011(7):CD003347.

6. McNicol E, Strassels SA, Goudas L, Lau J, Carr DB. NSAIDS or paracetamol, alone or combined with opioids, forcancer pain. Cochrane Database Syst Rev 2005(1):CD005180.

7. Wong R, Wiffen PJ. Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database SystRev 2002(2):CD002068.

8. Seccareccia D. Cancer-related hypercalcemia. Can Fam Physician 2010;56(3):244-6, e90-2.

9. Martinez-Zapata MJ, Roque M, Alonso-Coello P, Catala E. Calcitonin for metastatic bone pain. Cochrane DatabaseSyst Rev 2006;3:CD003223.

10. Paley CA, Johnson MI. Acupuncture for cancer-induced bone pain: a pilot study. Acupunct Med 2011;29(1):71-3.

4.3 Tumor-induced headache1. Soffietti R, Cornu P, Delattre JY, et al. Brain metastases, In: Gilhus NE, Barnes MP, Brainin M, eds. European Handbook

of Neurological Management. 2nd ed, Blackwell Publishing, 2011:437-75.

2. Sarin R, Murthy V. Medical decompressive therapy for primary and metastatic intracranial tumours. Lancet Neurol2003:2:357-65.

3. Diener HC, Johansson U, Dodick DW. Headache attributed to non-vascular intracranial disorder. In: Nappi O, MoskowitzMA, eds. Handbook of Clinical Neurology. vol.97 (3rd series). Elsevier, 2011:547-87.

4.4 Visceral pain and malignant bowel obstruction1. Dolan EA. Malignant bowel obstruction: A review of current treatment strategies. Am J Hosp Palliat Care 2011;28(8):

576-82.

2. Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer 2008;44:1105-15.

3. Ripamonti C, Bruera E. Palliative management of malignant bowel obstructon. Int J Gynecol Cancer 2002;12:135-43.

4. Ripamonti C. Management of bowel obstruction in advanced cancer. Curr Opin Oncol 1994;6:351-7.


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5. Soriano A, Davis MP. Malignant bowel obstruction : individualized treatment near the end of life. Clev Clin J Med2011;78(3):197-206.

6. Davis MP, Nouneh C. Modern management of cancer-related intestinal obstruction. Curr Pain Headache Rep 2001;5:257-64.

¿“§ºπ«° 5 Opioids, ¿“§ºπ«° 6 Non-opioids ·≈– ¿“§ºπ«° 7 Adjuvants1. American College of Rheumatology Ad Hoc Group on Use of Selective and Nonselective Nonsteroidal Antiinflammatory

Drugs. Recommendations for use of selective and nonselective nonsteroidal antiinflammatory drugs: An AmericanCollege of Rheumatology white paper. Arthritis Rheum 2008;59(8):1058-73.

2. Cancer pain management (general). In: Bader P, Echtle D, Fonteyne V, Livadas K, De Meerleer G, Paez Borda A,Papaioannou EG, Vranken JH. Guidelines on pain management. Arnhem, The Netherlands: European Association ofUrology (EAU);2010 Apr. p.13-42.

3. Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al; European Palliative Care Research Collaborative(EPCRC); European Association for Palliative Care (EAPC). Use of opioid analgesics in the treatment of cancer pain:evidence-based recommendations from the EAPC. Lancet Oncol 2012;13(2):e58-68.

4. Gordon DB, Stevenson KK, Griffie J, Muchka S, Rapp C, Ford-Roberts K. Opioid equianalgesic calculations. J PalliatMed 1999;2(2):209-18.

5. Inturrisi CE. Clinical pharmacology of opioids for pain. Clin J Pain 2002;18(4 Suppl):S3-13.

6. Mercadante S. Pharmacotherapy for breakthrough cancer pain. Drugs. 2012;72(2):181-90.

7. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Adult cancer pain,version 2, 2012. Available at: http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed June1, 2012.

8. Ripamonti CI, Bandieri E, Roila F. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2011;22Suppl6:vi69-77.

9. Scottish Intercollegiate Guidelines Network. Control of pain in adults with cancer: A national clinical guideline, 2008.Available at http://www.sign.ac.uk/pdf/SIGN106.pdf. Accessed June 1, 2012.

10. Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirinand coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol 2010;24:121-32.

11. Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74(8):1347-54.

12. Vallejo R, Barkin RL, Wang VC. Pharmacology of opioids in the treatment of chronic pain syndromes. Pain Physician2011;14(4):E343-60.

¿“§ºπ«° 8 Complementary and alternative medicine1. Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. (Cochrane

Review). Cochrane Database Syst Rev 2004;(2):CD002287.


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2. Zhang JM, Wang P, Yao JX, Zhao L, Davis MP, Walsh D, Yue GH. Music interventions for psychological and physicaloutcomes in cancer: a systematic review and meta-analysis. Support Care Cancer. 2012;20(12):3043-53.

3. Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancerpatients. Cochrane Database Syst Rev 2011;(8):CD006911.

4. Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. Cochrane Database Syst Rev 2006;(2):CD004843.

5. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults.Cochrane Database Syst Rev2011;(1):CD007753.

6. Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG. Transcutaneous electric nerve stimulation(TENS) for cancer pain in adults. Cochrane Database Syst Rev 2012;3:CD006276.

7. Landier W, Tse AM. Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: an integrative review. Pediatr Nurs 2010;25(6):566-79.

¿“§ºπ«° 9 Pain at the end of life1. Chapman L, Ellershaw J. Care in the last hours and days of life. Medicine 2011;39:674-7.

2. Fürst CJ, Doyle D. The terminal phase. In Doyle D, Hanks G, Cherny NI, Calman K, eds. Oxford textbook of palliativemedicine, 3rd ed. New York: Oxford University Press; 2004. p. 1117-33.

3. Sykes N. Eur J Cancer 2008;44(8):1157-62.


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Clinical practice guideline for cancer pain

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