2014年一月,“腎臟國際期刊(Kidney International)”線上刊登了一篇Thomas Mettang大師的回顧整理文章(review article),這位大師是德國人,他對於透析患者的癢有很深入的研究。以下是這篇文章的內容摘要:
透析搔癢症的發生率與概況
洗腎的患者中約有四成,一直被慢性的癢所困擾著,而會癢的患者中,全身性的癢佔了一半。但是關於怎麼治療的研究,實在是不多,而且有時候這個研究結果說這個治療有效,但另一個研究卻說沒效,這樣互相打臉(不一致)的情形蠻常見的,為什麼呢?除了每個洗腎患者的狀況差異很大之外,透析搔癢症的真正機轉仍然不很確定,所以很難針對病因來治療,只能用“一個一個試”的方式治療。這篇回顧裡面,整理了一些作者認為比較可行的治療方式。
透析搔癢症的局部治療
1. 皮膚乾燥,是很多腎臟病患者常有的情況(澄清一下,不是洗太乾才會皮膚乾燥喔!是因為皮脂腺與汗腺萎縮的關係,使得流汗變少,分泌油脂能力也下降的緣故),而作者認為,乾燥本身不一定會癢,但是皮膚乾燥的情況會加重癢的程度,因此,擦拭能夠保溼的乳液,是最基本的第一步治療,乳液中含有涼涼的內含物,效果更佳,如:薄荷醇(menthol)。
2. Tacrolimus藥膏(一種抗排斥藥的藥膏),因為透析搔癢症的機轉裡,有人認為和發炎反應有關係,所以可以試著用這種藥膏來治療,得到不錯的效果。
3. γ-次亞麻油酸藥膏,γ-次亞麻油酸是身體裡抗發炎反應的原料,因為和上一點一樣的理由,所以台灣有這樣的研究說效果好。
透析搔癢症的口服藥物治療
1. Gabapentin或pregabalin,當局部治療效果不好時,這兩種藥物可以是接下來很有機會的選項,研究中使用的方式是100 mg gabapentin一周三次,也有人使用到300mg gabapentin一周三次的劑量,治療四周,如果 gabapentin對患者會產生副作用的話,有人使用 pregabalin也能有類似的結果,這樣的用法頗為安全,又能有效果。
2. 在研究皮膚癢感的時候,我們都會學到 μ-受器與κ-受器是產生這些感覺的來源,而透析搔癢症的機轉假說,是認為這兩種神經受器的不平衡所導致,而且偏向 μ-受器太活化、而 κ-受器太被壓抑了。因此,能夠抑制 μ-受器的藥物,Naltrexone,就被拿來試著治療,可惜結果並不一致。而另一方面,促進 κ-受器活化的藥物,Nalfurafine,也拿來試過,效果很不錯,可惜當停藥之後,癢又復發了。因此這兩種藥物,最好保留給超級難治療的患者,因為效果如何,難以保證。
3. Pentoxifylline,是個很弱的TNF-α抑制劑(也是能稍為抑制發炎),有人試著用 600mg 靜脈注射,一周三次的治療,據說效果很好,而且治療完四週之後,效果至少還能維持四週,但是,有四位接受治療者中途因為健康因素,而中斷的治療,所以這個劑量無法得到安全的認可。也因此,只有無計可施的情形之下,才會考慮。
透析搔癢症的照光治療
照光治療的頻譜要選用UVB才有效,而選擇窄頻譜的UVB(narrow-band UVB-radiation)治療,副作用較少,不過照光治療,要小心皮膚癌的發生,以及長期下來可能會造成免疫力不良。
透析搔癢症的針灸治療
這個很有趣,這個部份有兩個研究,一個是比利時根特大學的研究,使用帶電的針來做針灸,針哪裡?從文獻摘要中看不出來,另一個是中國醫藥大學腎臟科的周哲毅醫師,做了40個患者的研究,選擇“曲池穴”下針,針的準比針不準(離穴道兩公分處下針)來的有效,這是一個很有趣的方向。
講了這麼多可能的治療,重要的是先後順序對吧?但這一篇實在已經太長了,下一篇會講考慮治療的順序,以及一點點個人的看法分享。
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