Nemigos gydymo rekomendacijos

Nemigos gydymo rekomendacijos

Nemigos gydymo rekomendacijos

 

Gyd. Mindaugas Šablevičius

Gyd. M. Šablevičiaus kabinetas

 

 

Nemigos problema

 

Nusiskundimai nemiga yra dažni ne tik gydytojų psichiatrų, bet ir šeimos gydytojų bei kitų medicinos sričių praktikoje. Nemigos išvarginti žmonės jaučiasi dirglūs, suprastėja jų nuotaika ir darbingumas, jie negali susikaupti, dieną užeina mieguistumo epizodai. Vakarais kyla potraukis pavartoti alkoholio ar raminamųjų vaistų ilgiau, nei leidžia šių vaistų medicininės indikacijos (žr. žemiau). Dėl užsitęsusios nemigos blogėja ir somatinė pacientų būklė, pavyzdžiui, pablogėja arterinė hipertenzija, lėtiniai uždegiminiai procesai, sustiprėja įvairios kilmės skausminiai sindromai. Be to, po nusiskundimais nemiga ir prašymais išrašyti raminamųjų vaistų gali būti pasislėpę kiti psichikos sutrikimai.

 

 

Nemigos apibūdinimas

 

Remiantis Sisteminio ligų sąrašo (TLK-10-AM) kriterijais, nemiga, kaip atskiras psichikos sutrikimas apibūdinamas sunkiu užmigimu, dažnais prabudimais arba ypač ankstyvu prabudimu. Taip pat galimas miego kokybės sutrikimas, kai, nors ir nėra sunkumo užmigti ar dažnų prabudimų, po miego nėra teigiamo poilsio jausmo, jaučiamasi neišsimiegojus. Tokie atskiri arba kartu pasireiškiantys miego sutrikimai turėtų trukti mažiausiai 3 k./sav. ne trumpiau kaip 1 mėnesį. Klinikinę nemigą lydi pačios nemigos baimė – žmogus baiminasi minčių apie miegojimą, kad atsigulus miegoti, vėl prasidės nemiga. Taip pat pasireiškia baimė, kad ryte teks susidurti su prasta savijauta dėl neišsimiegojimo. Ir dar vienas kriterijus – nepatenkinama miego kokybė ir / ar trukmė sukelia ryškų distresą arba sutrikdo socialinę ir darbinę veiklą.

 

 

Nemigos tipai klinikiniu požiūriu

 

TLK-10-AM neskirsto nemigos į pirminę (nesusijusią su kitais psichikos sutrikimais) ir antrinę (susijusią su kitais psichikos sutrikimais), tačiau tai svarbu praktiniu ir klinikiniu požiūriu. Esant antrinei nemigai ir neišgydžius ją palaikančių sutrikimų, neįmanoma pagerinti ir miego būklės.

Sakyčiau, tipiškas pirminės nemigos pavyzdys būtų nemiga, sukelta skrydžių per daug laiko juostų (angl. jet lag) ar pamaininio naktinio darbo (pvz., naktinio sargo, nepertraukiamo gamybos proceso darbininko, budinčio mediko, kt.). Antrinė nemiga yra kito psichikos sutrikimo vienas simptomų, to sutrikimo dalis. Tie kiti psichikos sutrikimai – tai įvairūs nerimo sutrikimai (generalizuotas nerimas, įvairios fobijos, kt.), depresiniai sutrikimai, dvipolis afektinis sutrikimas, šizofrenijos spektro sutrikimai, piktnaudžiavimas psichoaktyviosiomis medžiagomis (alkoholis, kofeinas, nelegalūs psichostimuliatoriai).

Atskira antrinės nemigos grupė – su demencija susijusi nemiga, kada demencija sergantis žmogus dėl dezorientacijos laike ir vietoje naktimis neva eina dirbti, važiuoja namo ir pan.

Dar vieną atskirą antrinės nemigos grupę sudaro vyresnio amžiaus žmonės, kurių užsitęsusi nemiga yra susijusi su daugybe medicininių, psichologinių ir socialinių priežasčių: somatinės ligos su skausminiu sindromu, polifarmakoterapija, vienatvė, mirties baimė, kognityvinis defektas, depresiniai sutrikimai, motyvacijos keistis gyvenime nebebuvimas manant, Ai, kiek man čia liko gyventi… Ši grupė ypač linkusi į pripratimą prie raminamųjų vaistų.

Ir pirminės, ir antrinės nemigos simptomų turi dienos ir nakties režimo sutrikimų sukelta nemiga, vadinamasis naktinėjimas, kada žmogus ilgai neina miegoti, nes, pavyzdžiui, naktimis naršo internete ar dirba kompiuteriu, tada miega iki pusiaudienio. Ilgainiui susiformuoja toks apverstas dienos ir nakties atžvilgiu būdravimo ir miego režimas, kuris tampa stabiliu ir kenkia žmogaus sveikatai.

Atskirą miego sutrikimų grupę sudaro somatinių ligų sukelti miego sutrikimai, kada miegą trikdo tam tikra somatinė liga, pasireiškianti būtent miegant, pavyzdžiui, širdies ritmo sutrikimai, epilepsijos priepuoliai, miego apnėja dėl nutukimo, kt. Suprantama, kad šiuos sutrikimus gydo atitinkamų somatinių ligų gydytojai.

Žinoma, griežtos ribos tarp pirminės ir antrinės nemigos nėra. Sakyčiau, į šeimos gydytojus dažniausiai kreipiasi pacientai, varginami būtent vadinamosios tarpinės tarp pirminės ir antrinės nemigos, t. y. vyrauja pirminio tipo nemiga, tačiau išsamiau panagrinėjus, aiškėja lydintys nerimo ir depresijos simptomai.

 

Nemigos gydymas

 

Čia pasinaudosiu psichofarmakoterapijos eksperto iš Jungtinių Amerikos Valstijų S. M. Stahlo sudarytu algoritmu (1 pav.). Algoritme pavaizduotas pirminės nemigos gydymas. Jei nemigą sukelia depresinė būklė, skiriamas gydymas nuo depresijos, jei psichoziniai sutrikimai – vaistų nuo psichozės ir pan.
nemiga

1 pav. Nemigos gydymo algoritmas

KET − kognityvinė elgesio terapija, GHB – gama hidroksibutiratas, TAR – teigiami alosteriniai reguliatoriai.

 

Pirmoje ir antroje apatinėse algoritmo pasirinkimo eilutėse pateikti pirmos eilės vaistai pirminei nemigai gydyti – zopiklonas, zolpidemas ir kiti migdomieji vaistai, vadinamieji Z hipnotikai (taip pat ir melatonino receptorių agonistas ramelteonas, kuris nėra registruotas Lietuvoje). Čia išskirtos 2 pirmo pasirinkimo linijos – kada nemiga pasireiškia tik sunkiu užmigimu ir kada pasireiškia sunkiu užmigimu su ankstyvu prabudimu. Z hipnotikų veikimas paremtas selektyvia alosterine gama aminosviesto rūgšties receptorių moduliacija.

Antro pasirinkimo linijoje pateikti trumpo veikimo benzodiazepinai – triazolamas, estazolamas ir kt. Benzodiazepinų veikimas paremtas mažiau selektyvia alosterine gama aminosviesto rūgšties receptorių moduliacija, todėl benzodiazepinai veikia platų spektrą nerimo ir miego sutrikimų. Čia svarbu pabrėžti, kad ir benzodiazepinų, ir Z hipnotikų informaciniuose lapeliuose prie vaisto indikacijų įspėjama dėl gydymo šiais vaistais trukmės, pavyzdžiui, trumpalaikis simptominis nerimo ir nerimo sukeltos nemigos gydymas, trumpalaikis vidutinio sunkumo ar sunkaus nerimo sutrikimo ir su depresija susijusio nerimo gydymas, trumpalaikis nemigos gydymas suaugusiesiems ir pan.

Taigi, jeigu 1–2 mėnesių trukmės nemigos gydymas benzodiazepinais ir Z hipnotikais yra neefektyvus, reikia skirti vaistų, kurie nesukelia pripratimo ar priklausomybės ir gydymo trukmė jais neribojama. Algoritme matyti, kad pirmasis vaistas pagal tokį pasirinkimą yra trazodonas, esantis antrojo pasirinkimo eilutėje greta trumpo veikimo benzodiazepinų. Jo veikimo mechanizmas paremtas visiškai kitokiu principu negu benzodiazepinų ir Z hipnotikų. Trazodonas miego būklę gerina veikdamas serotonino 5HT2Air 5HT2C bei histamino H1 receptorius. Mažesnės šio vaisto dozės (iki 50 mg, 2 pav.) pasižymi nemigą gydančiu, didesnės – anksiolitiniu ir antidepresiniu poveikiu. Iš Jungtinėse Amerikos Valstijose nemigai gydyti skiriamų vaistų beveik pusę jų sudaro būtent trazodonas [3].

Kognityvinė elgesio terapija, kuri algoritme paminėta eilutėje Papildomos priemonės, galima kiekviename nemigos gydymo lygyje. Taip pat galimi ir kiti nemedikamentiniai pagalbos būdai: žalingų įpročių atsisakymas, sveika mityba (ypač prieš miegą), atpalaiduojamoji fizinė veikla, meditacija, dvasinės praktikos ir pan.

Apibendrinimas

 

Nemigą dažnai lydi įvairūs nerimo ir depresijos sutrikimai, todėl svarbus somatinis ir psichologinis paciento būklės įvertinimas. Jeigu nemiga yra antrinė, būtina gydyti pagrindinį sutrikimą. Nemigos gydymą galima pradėti nuo trumpalaikių raminamųjų ir migdomųjų vaistų kursų. Tačiau, jeigu šiais gydymo metodais nepavyksta koreguoti nemigos, reikia skirti vaistų, skirtų užsitęsusiai nemigai gydyti. Trazodonas (Trittico®) yra vienas iš pirmos eilės vaistų gydant užsitęsusią, ilgiau kaip keletą mėnesių trunkančią nemigą.

 

 

Literatūra:

  1. Preparatų charakteristikų santraukos. Prieiga per internetą: <www.vvkt.lt>.
  2. Stahl St. Stahl’s Essential Psychopharmacology. IIIrd ed. 2008.
  3. Stahl St. Stahl’s Essential Psychopharmacology. IIIrd ed. p. 845. 2008.

 


139 mintys apie “Nemigos gydymo rekomendacijos

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