What narcotic is safe to use in end-stage kidney disease (ESKD)?

From the Guidelines

Fentanyl is the safest narcotic option to use in end-stage kidney disease (ESKD) due to its minimal renal clearance and lack of active metabolites that could accumulate in patients with kidney failure. According to the most recent and highest quality study 1, opioids primarily eliminated in urine, such as oxycodone and hydromorphone, should be carefully titrated and frequently monitored for risk of accumulation of the parent drug or active metabolites. Morphine, meperidine, codeine, and tramadol should be avoided in ESKD patients unless there are no alternatives. Other relatively safer options include hydromorphone and methadone, which require dose adjustments but can be used with careful monitoring 1.

Some key points to consider when using narcotics in ESKD patients include:

• Starting with reduced doses (typically 25-50% of the normal starting dose)
• Extending dosing intervals
• Titrating slowly while monitoring for side effects such as excessive sedation, respiratory depression, and mental status changes
• Regular reassessment is essential as even safer opioids can accumulate with repeated dosing in ESKD patients.

It's also important to note that methadone should be administered only by clinicians experienced in its use because of the risk of accumulation 1. Overall, the goal is to balance effective pain management with the need to minimize the risk of adverse effects in patients with ESKD.

From the FDA Drug Label

Hydromorphone is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Start patients with renal impairment on one-fourth to one-half the usual starting dose depending on the degree of impairment Patients with renal impairment should be closely monitored during dose titration

The narcotic hydromorphone can be used in end-stage kidney disease (ESKD), but with caution.

• The dose should be reduced to one-fourth to one-half of the usual starting dose.
• Patients should be closely monitored during dose titration due to the increased risk of adverse reactions 2.

From the Research

Narcotics Safe to Use in End-Stage Kidney Disease (ESKD)

The following narcotics are considered safe to use in patients with end-stage kidney disease (ESKD):

• Acetaminophen (paracetamol) is recommended as the first-line analgesic 3
• Tramadol is the least problematic among Step 2 analgesics, but dose reduction and increased dosing interval are required 3
• Fentanyl, alfentanil, and methadone are recommended among Step 3 analgesics 3
• Buprenorphine may be a good choice for ESKD patients, although there is limited evidence 3, 4, 5
• Oxycodone and hydromorphone may be used, but with caution and careful monitoring 4, 5

Narcotics to Avoid in ESKD

The following narcotics should be avoided or used with caution in patients with ESKD:

• Morphine and diamorphine are not recommended due to the accumulation of potentially toxic metabolites 3, 6
• Codeine and dihydrocodeine may cause respiratory depression due to prolonged elimination half-life 7
• Meperidine is not recommended due to the risk of normeperidine accumulation and neurotoxic effects 7, 6
• Propoxyphene is not recommended due to the risk of hepatotoxicity 7

Key Considerations

When managing pain in ESKD patients, it is essential to:

• Use non-pharmacologic therapies and non-opioid analgesics as first-line treatments 4, 5
• Minimize opioid use and reserve it for patients who have failed other therapies 4
• Carefully monitor patients for adverse events and adjust doses accordingly 4, 5