From the Guidelines
Suboxone can be used in patients with chronic kidney disease (CKD), but dose adjustments may be necessary depending on the severity of kidney impairment. For patients with mild to moderate CKD, standard Suboxone dosing is typically acceptable. However, for those with severe CKD (GFR <30 ml/min) or end-stage renal disease, consider reducing the dose by 25-50% and monitoring closely for signs of opioid toxicity, as suggested by guidelines for opioid use in renal impairment 1. Start with lower doses (e.g., 2-4 mg daily) and titrate slowly based on response. Buprenorphine, the active ingredient in Suboxone, is primarily metabolized by the liver, with only about 30% excreted through the kidneys, making it relatively safer than full opioid agonists in kidney disease. The naloxone component has minimal systemic absorption when taken as prescribed sublingually.
Key Considerations
- Patients with CKD should have more frequent monitoring of kidney function, electrolytes, and drug levels if possible.
- Watch for signs of accumulation such as increased sedation, respiratory depression, or confusion.
- Concurrent medications that are renally cleared should be reviewed for potential interactions.
- Suboxone remains an appropriate option for opioid use disorder treatment in CKD patients when properly dosed and monitored, similar to how fentanyl and buprenorphine are recommended for patients with chronic kidney disease stages 4 or 5 1.
Monitoring and Dose Adjustment
- Regularly assess the intensity of pain and treatment outcomes using visual analogue scales (VAS), verbal rating scale (VRS), or numerical rating scale (NRS) 1.
- Consider the use of rescue doses for breakthrough pain episodes, as well as the use of laxatives to prevent opioid-induced constipation 1.
From the FDA Drug Label
8.7 Renal Impairment No differences in buprenorphine pharmacokinetics were observed between 9 dialysis-dependent and 6 normal patients following IV administration of 0.3 mg buprenorphine.
Buprenorphine pharmacokinetics in patients with renal impairment: The FDA drug label states that there were no differences in buprenorphine pharmacokinetics between dialysis-dependent and normal patients.
- Key point: No dose adjustment is recommended for patients with renal impairment based on the provided information.
- Clinical decision: Patients with chronic kidney disease (CKD) can be treated with buprenorphine, but it is essential to monitor them for signs and symptoms of toxicity or overdose, as with any patient taking this medication 2.
From the Research
Suboxone and CKD
- Suboxone, which contains buprenorphine, is an opioid medication used to treat opioid addiction 3.
- Buprenorphine can be administered at normal doses in patients with renal dysfunction because it is mainly excreted through the liver 3.
- In patients with reduced renal function, chronic renal insufficiency, and haemodialysis, buprenorphine appears to be a safe choice when opioid treatment is initiated 3.
- However, it is essential to consider the severity of renal insufficiency when prescribing opioid analgesics, including buprenorphine, to patients with chronic kidney disease (CKD) 4.
- Patients with CKD may benefit from opioid analgesics that are lipophilic, such as methadone, fentanyl, and buprenorphine, as the first line 4.
CKD Diagnosis and Management
- Chronic kidney disease (CKD) is defined as a persistent abnormality in kidney structure or function for more than 3 months, with a glomerular filtration rate (GFR) <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 hours 5, 6.
- CKD affects 8% to 16% of the population worldwide, and its management includes cardiovascular risk reduction, treatment of albuminuria, avoidance of potential nephrotoxins, and adjustments to drug dosing 5.
- Patients with CKD require monitoring for complications, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5, 6.
Opioid Prescription in CKD Patients
- Opioid prescription in CKD patients should be based on the severity of renal insufficiency, and the dosage of hydrophilic drugs and drugs with active metabolites should be adjusted accordingly 4.
- The accumulation of morphine and codeine metabolites may result in neurotoxic side effects, while hydromorphone and oxycodone are considered safe to administer but require careful adjustments in dosage 4.
- Common comorbidities among patients with CKD may amplify opioid-related adverse effects, emphasizing the need for careful consideration when prescribing opioids to these patients 4.