From the Guidelines
Patients with End-Stage Renal Disease (ESRD) should avoid NSAIDs, such as ibuprofen, naproxen, diclofenac, and celecoxib, as well as certain opioids like meperidine, morphine, codeine, and tramadol, due to the risk of worsening kidney function, acute kidney injury, and accumulation of toxic metabolites. According to the most recent guideline 1, opioids primarily eliminated in urine, such as fentanyl, oxycodone, and hydromorphone, should be carefully titrated and frequently monitored for risk of accumulation of the parent drug or active metabolites.
Some key points to consider when managing pain in ESRD patients include:
- Avoiding NSAIDs and certain opioids to prevent further kidney damage and toxicity
- Using acetaminophen as a first-line option for pain management, with a maximum daily dose of 3g or less in malnourished patients
- Carefully selecting and dosing opioids, such as hydromorphone, oxycodone, or fentanyl, and monitoring for signs of accumulation or toxicity
- Avoiding combination products containing acetaminophen with an NSAID
- Considering alternative pain management strategies, such as non-pharmacological interventions or specialist referral, when necessary.
The rationale for avoiding certain medications in ESRD patients is based on the impaired kidney function and the risk of accumulation of toxic metabolites, which can lead to adverse effects or toxicity 1. By carefully selecting and managing pain medications, healthcare providers can help minimize the risks and improve the quality of life for patients with ESRD.
From the FDA Drug Label
Use morphine sulfate injection with caution and in reduced dosages in patients with severe renal or hepatic impairment, Addison’s disease, hypothyroidism, prostatic hypertrophy, or urethral stricture, and in elderly or debilitated patients.
- Morphine should be used with caution in patients with severe renal impairment, such as those with End-Stage Renal Disease (ESRD).
- It is recommended to use reduced dosages in these patients.
- The use of morphine in ESRD patients requires careful consideration of the potential risks and benefits, and alternative pain management options may be necessary 2.
From the Research
Pain Medications to Avoid in ESRD
- Morphine and diamorphine are not recommended due to the accumulation of potentially toxic metabolites 3
- NSAIDs are often avoided in ESRD patients due to their reputation for nephrotoxic side effects, although limited use may be justified in some cases 4, 5
- Hydromorphone and oxycodone have extremely limited evidence for use in ESRD patients, although they may be better choices than morphine or diamorphine 3
- Codeine should be used with very caution and possibly avoided in renal failure/dialysis patients 6
Alternative Pain Medications for ESRD
- Acetaminophen (paracetamol) is recommended as a first-line analgesic 3
- Tramadol is the least problematic of the Step 2 analgesics, although dose reduction and increased dosing interval are required 3
- Fentanyl, alfentanil, and methadone are recommended as Step 3 analgesics 3
- Buprenorphine may be a good choice for ESRD patients, although there is limited evidence 3, 7, 6
- Gabapentin and pregabalin can be used to control neuropathic pain 7