From the Guidelines
Morphine should not be given to patients with Chronic Kidney Disease (CKD), especially in advanced stages, due to the risk of accumulation of its active metabolite and increased risk of adverse effects. According to the most recent and highest quality study 1, morphine is not recommended in patients with renal insufficiency (GFR <30 mL/min/1.73 m2) and End-Stage Renal Disease (ESRD) due to the accumulation of its active metabolites.
Some key points to consider when managing pain in CKD patients include:
- Avoiding morphine, codeine, and meperidine in renal insufficiency and ESRD
- Using hydrocodone, oxycodone, and hydromorphone with caution and adjusting dosage in renal insufficiency and ESRD
- Preferring opioids with no active metabolites, such as fentanyl, sufentanil, and methadone, for patients with renal insufficiency or ESRD
- Considering non-opioid pain management strategies, including acetaminophen, certain NSAIDs, and non-pharmacological approaches like physical therapy, as first-line options when possible
It's essential to regularly assess pain control, renal function, and side effects in CKD patients receiving opioids. Alternative opioids like fentanyl, hydromorphone, or buprenorphine are generally safer choices for CKD patients, as they have fewer active metabolites dependent on renal clearance 1.
From the FDA Drug Label
Morphine pharmacokinetics are altered in patients with renal failure The AUC is increased and clearance is decreased and the metabolites, M3G and M6G, may accumulate to much higher plasma levels in patients with renal failure as compared to patients with normal renal function. Morphine 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 these patients with a lower than normal dosage of Morphine Sulfate Injection and titrate slowly while monitoring for signs of respiratory depression, sedation, and hypotension
Morphine use in CKD patients requires caution. The drug's pharmacokinetics are altered in renal failure, leading to increased AUC and decreased clearance. This may result in higher plasma levels of morphine and its metabolites, increasing the risk of adverse reactions.
- Dose adjustment is necessary: Start with a lower than normal dosage and titrate slowly.
- Monitor for adverse effects: Watch for signs of respiratory depression, sedation, and hypotension.
- Use with caution: Morphine may not be suitable for all CKD patients, and alternative analgesics should be considered if possible 2, 2.
From the Research
Opioid Use in Chronic Kidney Disease (CKD)
- The use of opioids in patients with CKD is a complex issue due to altered pharmacokinetics and the risk of adverse events 3, 4, 5, 6, 7.
- Morphine is not recommended for use in CKD patients due to the accumulation of its metabolites, which may cause neurotoxic symptoms 3, 5, 6.
Safe Opioid Alternatives for CKD Patients
- Oxycodone and hydromorphone can be safely used in CKD patients, but require careful dosage adjustments 3, 4, 6.
- Buprenorphine and fentanyl are considered safer options for CKD patients, but fentanyl is not suitable for patients undergoing hemodialysis 3, 4, 5, 6.
- Tapentadol does not require dosage adjustment in mild-to-moderate renal impairment, but its use in end-stage renal disease (ESRD) is not well-studied 3.
Considerations for Opioid Use in CKD
- Opioid-related side effects may be exacerbated by common comorbidities in CKD patients, such as opioid-induced constipation 3.
- Accurate pain diagnosis, opioid titration, and tailoring are essential to minimize risks and improve outcomes in CKD patients 3, 4.
- Collaboration among an interprofessional clinical team is crucial to ensure safe prescription of opioids in CKD patients 5.