From the Guidelines
Tramadol is not recommended for patients with severe chronic kidney disease (CKD) or end-stage renal disease (ESRD) due to the risk of accumulation and increased toxicity 1. When considering the use of tramadol in patients with CKD, it's essential to assess the severity of kidney impairment. For mild to moderate CKD (GFR >30 mL/min), dose adjustments may be necessary to minimize the risk of adverse effects. However, the most recent and highest quality study suggests that tramadol should be avoided in patients with severe CKD (GFR <30 mL/min) and ESRD 1. Some key points to consider when managing pain in CKD patients include:
- Avoiding tramadol and tapentadol in renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD 1
- Using hydrocodone, oxycodone, and hydromorphone with caution and adjusting dosage in renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD 1
- Preferring opioids with no active metabolites, such as fentanyl, sufentanil, and methadone, for patients with renal insufficiency or ESRD 1 Close monitoring for side effects is crucial when using any opioid in CKD patients, as the risk of accumulation and toxicity is increased. Alternative pain management options with less renal impact, such as acetaminophen, may be preferable for long-term pain management in advanced CKD patients.
From the FDA Drug Label
Impaired renal function results in a decreased rate and extent of excretion of tramadol and its active metabolite, M1. In patients with creatinine clearances of less than 30 mL/min, dosing reduction is recommended (see DOSAGE AND ADMINISTRATION).
Renal Impaired renal function results in a decreased rate and extent of excretion of tramadol and its active metabolite, M1 In patients with creatinine clearances of less than 30 mL/min, adjustment of the dosing regimen is recommended (see DOSAGE AND ADMINISTRATION).
Renal Impaired renal function results in a decreased rate and extent of excretion of tramadol and its active metabolite, M1
Tramadol can be given to patients with chronic kidney disease (CKD), but dosing reduction is recommended in patients with creatinine clearances of less than 30 mL/min 2, 2, 2. Adjustment of the dosing regimen is necessary to avoid increased plasma concentrations and potential adverse events.
From the Research
Tramadol Use in CKD Patients
- Tramadol can be used in patients with chronic kidney disease (CKD) with patient monitoring 3.
- The use of tramadol in CKD patients is considered safer compared to other opioids like morphine and codeine, which should be avoided or used with caution in patients with renal impairment 3.
- A study found that new tramadol and opioid prescription rates upon hospital discharge for CKD stage IV and V and ESRD patients decreased significantly after the publication of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (GPOCP) 4.
Considerations for Tramadol Use in CKD
- Tramadol dosing should be adjusted based on kidney function to minimize the risk of adverse effects 4.
- Clinically significant drug-drug interactions with tramadol should be monitored in CKD patients 4.
- The use of tramadol in CKD patients should be weighed against the potential benefits and risks, considering alternative pain management options 5.
Alternative Pain Management Options for CKD Patients
- Acetaminophen alone or combined with low-potency opioid dose is considered a safer pain-relieving option for CKD patients 3.
- Other alternatives like gabapentin and baclofen have weak evidence to support their use and strong evidence to show their harm in patients with CKD 5.
- NSAIDs can be used in CKD patients, but with caution, due to the risk of acute kidney injury, electrolyte imbalances, and increased blood pressure 5.