From the Guidelines
Patients with End-Stage Renal Disease (ESRD) should avoid pain medications such as morphine, codeine, meperidine, and tramadol due to the risk of accumulation of toxic metabolites and increased risk of adverse effects, including respiratory depression and neurological effects, as recommended by the most recent and highest quality study 1. When managing pain in ESRD patients, it is essential to consider the impaired kidney function and the potential for medication accumulation.
- NSAIDs, such as ibuprofen, naproxen, and ketorolac, should be avoided as they can worsen kidney function and increase the risk of acute kidney injury.
- Meperidine and tramadol should be avoided due to the risk of seizures and other neurological effects caused by the accumulation of their metabolites.
- Certain opioids, such as morphine, codeine, and hydromorphone, require dose adjustments in ESRD patients, as their metabolites can accumulate and cause toxicity.
- Acetaminophen is generally considered the safest over-the-counter pain reliever for ESRD patients, though the maximum daily dose should be reduced to 3000mg or less, as suggested by 1 and 1. The kidneys play a crucial role in eliminating medications and their metabolites from the body, and when kidney function is severely compromised in ESRD, these substances can accumulate to toxic levels, causing adverse effects ranging from nausea to life-threatening complications, highlighting the importance of careful medication management in ESRD patients, as emphasized by 1.
From the FDA Drug Label
The use of these products should be reserved for cases where the benefits of opioid analgesia outweigh the known risks of respiratory depression, altered mental state, and postural hypotension Use of meperidine may be associated with increased potential risks and should be used with caution in the following conditions: ... severe impairment of hepatic, pulmonary, or renal function;
Meperidine should be used with caution and consideration should be given to starting with a reduced dosage in patients who are concurrently receiving other central nervous system depressants including sedatives or hypnotics, general anesthetics, phenothiazines, other tranquilizers, and alcohol
Pain medications to avoid in ESRD:
- Meperidine, due to the potential for increased risks in patients with severe renal impairment. It is recommended to use alternative pain medications and to consult with a healthcare professional for proper management of pain in patients with ESRD 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
- Codeine and pethidine should be avoided entirely in patients with renal impairment 4
- Meperidine is also not recommended as its metabolite, normeperidine, can cause neurotoxicity in patients with renal failure 5
- Hydromorphone and oxycodone are not recommended due to limited evidence, although they may be considered as alternatives with reduced doses 3, 4
Alternative Pain Medications for ESRD
- Acetaminophen (paracetamol) is recommended as a first-line analgesic 3
- Tramadol can be used with caution and in reduced doses 3, 6, 4
- Fentanyl, alfentanil, and buprenorphine are recommended due to their pharmacokinetic properties 3, 6, 4
- Methadone can be used with caution and in reduced doses 3, 6, 4
- Gabapentin and pregabalin can be used to control neuropathic pain 6, 7