What are the considerations for using opioids in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

Opioids should be used with extreme caution in patients with chronic kidney disease (CKD), and the selection of opioid should be based on the presence of active metabolites and the patient's renal function, with methadone, fentanyl, and hydromorphone being preferred options due to their lower risk of accumulation and toxicity 1. When managing pain in CKD patients, it is essential to consider the altered pharmacokinetics and pharmacodynamics of opioids, which can lead to increased risk of adverse effects, such as respiratory depression, constipation, and neurotoxicity 1. Key considerations for opioid use in CKD patients include:

• Avoiding opioids with active metabolites that accumulate in renal impairment, such as morphine, codeine, and meperidine 1
• Using opioids with no active metabolites, such as fentanyl and methadone, which are preferred options in patients with renal insufficiency or end-stage renal disease (ESRD) 1
• Carefully titrating and frequently monitoring opioids primarily eliminated in urine, such as hydromorphone and oxycodone, to minimize the risk of accumulation and toxicity 1
• Considering non-opioid alternatives, such as acetaminophen and topical analgesics, as first-line options for pain management in CKD patients, when appropriate 1 Regular reassessment of pain control and kidney function is crucial to ensure safe and effective pain management in CKD patients, and opioid doses should be adjusted accordingly to minimize the risk of adverse effects 1.

From the Research

Opioid Use in CKD Patients

• Opioids can be used to manage chronic pain in patients with chronic kidney disease (CKD), but their use requires careful consideration due to the risk of adverse events 2, 3, 4, 5.
• The choice of opioid and dosage should be based on the severity of renal insufficiency and the patient's individual needs 2, 3, 5.
• Some opioids, such as morphine and codeine, are not recommended for use in CKD patients due to the risk of neurotoxic side effects 3, 5.
• Other opioids, such as hydromorphone and oxycodone, can be used safely in CKD patients, but require careful dosage adjustments 2, 3, 5.
• Lipophilic opioids, such as methadone, fentanyl, and buprenorphine, may be suitable for use in CKD patients, but fentanyl is not recommended for patients undergoing hemodialysis 3, 5.

Safe Use of Opioids in CKD Patients

• Accurate pain diagnosis and opioid titration are essential to minimize the risks associated with opioid use in CKD patients 3, 4.
• Collaboration among an interprofessional clinical team can help ensure safe prescription of opioids in CKD patients 2.
• Patients with CKD may require more frequent monitoring and dosage adjustments due to changes in kidney function 2, 3, 5.
• Common comorbidities among CKD patients, such as constipation, may exacerbate opioid-related adverse effects 3.

Impact of Guidelines on Opioid Prescription Rates

• The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain has been associated with a decrease in tramadol and opioid prescription rates in CKD patients 6.
• However, further research is needed to determine the long-term impact of these guidelines on opioid use and pain management in CKD patients.

Opioid-Related Adverse Effects

• Opioid-related adverse effects, such as constipation, can be managed with peripherally-acting-μ-opioid-receptor-antagonists (PAMORA) 3.
• Naldemedine, a PAMORA, does not require dose adjustment in CKD and hemodialysis patients, making it a suitable option for managing opioid-induced constipation in these patients 3.