What medication adjustment is recommended for a 79-year-old male with metastatic prostate cancer and impaired renal function (Decreased renal function), weighing 45 kg, who has achieved adequate pain control with Dilaudid (Hydromorphone) 2.5 mg every 4 hours, for discharge?

From the Guidelines

For a 79-year-old male with metastatic prostate cancer and impaired renal function, the best option would be to discontinue hydromorphone (Dilaudid) and switch to a transdermal fentanyl patch. This approach is most appropriate for several reasons. Fentanyl patches provide continuous pain relief without the peaks and troughs of oral medications, which is beneficial for chronic cancer pain management. Unlike hydromorphone, fentanyl does not produce active metabolites that accumulate in renal impairment, making it safer for this patient with significantly reduced kidney function 1. The patch formulation also improves adherence and quality of life by eliminating the need for frequent dosing. When converting from hydromorphone 2.5 mg every 4 hours (15 mg daily), an appropriate starting dose would be a 12-25 mcg/hour fentanyl patch changed every 72 hours, with breakthrough pain medication as needed 1. The patient's low body weight (45 kg) should be considered when determining the initial dose, potentially starting at the lower end of the range. Regular reassessment of pain control and side effects would be necessary after initiating the fentanyl patch. It is also important to note that morphine, hydromorphone, and codeine should be used with caution in patients with fluctuating renal function due to potential accumulation of renally cleared metabolites that may cause neurologic toxicity 1. Additionally, methadone can be a good alternative since it is primarily metabolized in the liver, but it should only be used by experienced clinicians 1. However, given the patient's current adequate pain control with hydromorphone and the need for a simple and effective solution for discharge, switching to a transdermal fentanyl patch is the most appropriate option. Key considerations for this patient include:

• Avoiding opioids that accumulate in renal impairment, such as hydromorphone and morphine
• Choosing an opioid with a safer profile in renal impairment, such as fentanyl
• Selecting a formulation that improves adherence and quality of life, such as a transdermal patch
• Carefully converting the patient from hydromorphone to fentanyl to avoid overdosing or underdosing
• Regularly reassessing pain control and side effects after initiating the new medication.

From the FDA Drug Label

2.4 Dosage Modifications in Patients with Renal Impairment Initiate treatment with one-fourth to one-half the usual hydromorphone hydrochloride starting dose depending on the degree of impairment 8.7 Renal Impairment The pharmacokinetics of hydromorphone is affected by renal impairment. In addition, in patients with severe renal impairment, hydromorphone appeared to be more slowly eliminated with a longer terminal elimination half-life. 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

For a 79-year-old male with metastatic prostate cancer and impaired renal function, who has achieved adequate pain control with Dilaudid (Hydromorphone) 2.5 mg every 4 hours, the recommended medication adjustment for discharge is to:

• Continue to monitor the patient closely for signs of respiratory depression and opioid-related adverse reactions
• Consider reducing the dose by 25% to 50% or more, depending on the degree of renal impairment, as the patient has impaired renal function and hydromorphone is known to be substantially excreted by the kidney
• Titrate the dosage slowly and monitor closely for signs of central nervous system and respiratory depression
• Consider a supplemental dose of 5 to 15% of the total daily usage may be administered every two hours on an as-needed basis for chronic pain 2
• Closely monitor during dose titration as patients with renal impairment should be started on a lower dose 2
• Starting dose should be even more conservative in patients with severe renal impairment 2

From the Research

Medication Adjustment for Discharge

The patient is a 79-year-old male with metastatic prostate cancer and impaired renal function, weighing 45 kg, who has achieved adequate pain control with Dilaudid (Hydromorphone) 2.5 mg every 4 hours. For discharge, the following medication adjustments are recommended:

• Reduced dose hydromorphone is an alternative for patients with renal impairment 3
• Hydromorphone can be used with caution and close patient monitoring in patients with renal impairment 4, 5
• Dose reduction is recommended for hydromorphone in patients with renal failure 5

Safe Opioid Options for Renal Impairment

The following opioids can be used safely in patients with renal impairment:

• Fentanyl 3, 5, 6
• Alfentanil 3, 5
• Buprenorphine 3, 5, 6
• Methadone 3, 5, 6
• Tramadol and oxycodone can be used with caution and in reduced doses 3, 5

Opioids to Avoid in Renal Impairment

The following opioids should be avoided in patients with renal impairment:

• Codeine and pethidine should be avoided entirely 3, 5
• Morphine should be avoided if the creatinine clearance is below 30 ml/min 3