From the Guidelines
Opioid use in end-stage renal disease patients requires careful consideration due to altered drug metabolism and increased risks, and the safest approach is for ESRD patients to consult their nephrologist or pain management specialist to determine if opioids are appropriate and, if so, which ones at what doses. The management of pain in patients with end-stage renal disease (ESRD) is complex and requires careful consideration of the potential risks and benefits of opioid therapy. According to the most recent and highest quality study, fentanyl, sufentanil, and methadone are preferred opioids for patients with renal insufficiency or ESRD due to their lack of active metabolites 1. Some key points to consider when managing pain in ESRD patients include:
- Avoiding meperidine, codeine, and morphine due to active metabolites and accumulation in renal insufficiency and ESRD 1
- Using hydrocodone, oxycodone, and hydromorphone with caution and adjusting dosage in renal insufficiency and ESRD 1
- Considering non-opioid pain management options first when possible
- Consulting a nephrologist or pain management specialist to determine the best course of treatment for individual patients It's also important to note that buprenorphine may have a role in the analgesic therapy of patients with renal impairment undergoing hemodialysis treatment, as it is mainly converted in the liver to norbuprenorphine, a metabolite 40 times less potent than the parent compound 1. However, the dose conversion from other opioids to buprenorphine can be complex, and palliative care advice is recommended 1. Ultimately, the goal of pain management in ESRD patients is to improve quality of life while minimizing the risks associated with opioid therapy. By working closely with a healthcare team and carefully considering the potential risks and benefits of opioid therapy, ESRD patients can receive effective pain management tailored to their individual needs.
From the Research
Opioid Recommendations for ESRD Patients
The following opioids are recommended for patients with End-Stage Renal Disease (ESRD):
- Fentanyl, alfentanil, and methadone are recommended as Step 3 analgesics 2
- Buprenorphine is considered a promising and safer option due to its partial agonism at the mu opioid receptor 3, 4, 5, 6
- Oxycodone and hydromorphone can be safely used, but adequate dosage adjustments are required in CKD patients 3, 5, 6
- Tramadol is the least problematic of the Step 2 analgesics, although dose reduction and increased dosing interval are required 2
Opioids to Avoid in ESRD Patients
The following opioids are not recommended or should be used with caution in ESRD patients:
- Morphine and diamorphine are not recommended due to the accumulation of potentially toxic metabolites 2, 5, 6
- Codeine should be used with very caution and possibly avoided in renal failure/dialysis patients 5, 6