Can Oxycodone be given to a patient with Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) stage 5, also known as End-Stage Renal Disease (ESRD)?

From the Guidelines

Oxycodone should be used with extreme caution in patients with Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) stage 5, and generally should be avoided if possible. According to the most recent guideline from the Journal of Clinical Oncology 1, opioids primarily eliminated in urine, such as oxycodone, should be carefully titrated and frequently monitored for risk or accumulation of the parent drug or active metabolites.

Key Considerations

• If oxycodone must be used, significant dose reduction (50-75% of normal dose) and extended dosing intervals are necessary, starting with the lowest possible dose, such as 2.5 mg orally every 8-12 hours, and carefully titrating based on response and side effects 1.
• Close monitoring for respiratory depression, sedation, and mental status changes is essential as oxycodone and its active metabolites accumulate in renal failure.
• Consider alternative analgesics with less renal impact, such as fentanyl or hydromorphone, which may be safer options, as suggested by the European Society for Medical Oncology guidelines 1.
• Patients on dialysis require additional dose adjustments and timing of administration relative to dialysis sessions, as oxycodone is not significantly removed by dialysis.

Rationale

The concern with oxycodone in severe renal impairment stems from its metabolism to active compounds that rely on renal clearance, leading to prolonged drug effects and increased toxicity risk. The American Society of Clinical Oncology guideline 1 recommends rotating to methadone, if not contraindicated, as this agent is excreted fecally, and avoiding morphine, meperidine, codeine, and tramadol in patients with renal impairment, unless there are no alternatives.

Clinical Implications

Given the potential risks and the availability of alternative analgesics, it is crucial to prioritize caution and consider alternative options when managing pain in patients with AKI and CKD stage 5. Clinicians should perform more frequent clinical observation and opioid dose adjustment, as recommended by the Journal of Clinical Oncology guideline 1.

From the FDA Drug Label

Oxycodone 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. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. 8.7 Renal Impairment Because oxycodone is known to be substantially excreted by the kidney, its clearance may decrease in patients with renal impairment. Initiate therapy with a lower than usual dosage of oxycodone hydrochloride tablets and titrate carefully. Monitor closely for adverse events such as respiratory depression, sedation, and hypotension [see Clinical Pharmacology (12.3)] .

Oxycodone use in patients with Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) stage 5 should be approached with caution.

• The drug label recommends initiating therapy with a lower than usual dosage and titrating carefully in patients with renal impairment.
• It is advised to monitor closely for adverse events such as respiratory depression, sedation, and hypotension.
• Given the patient's End-Stage Renal Disease (ESRD), it is essential to carefully consider the potential risks and benefits of oxycodone use 2.

From the Research

Opioid Use in Patients with Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) Stage 5

• Oxycodone can be used in patients with CKD and End-Stage Renal Disease (ESRD), but with caution and careful monitoring 3, 4, 5, 6, 7.
• The use of opioids in patients with renal impairment requires careful consideration of the pharmacokinetic properties of the opioid and the patient's renal function 4, 6.
• Oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine are considered safer options for use in patients with kidney disease, but dose adjustments may be necessary 3, 4, 5, 6, 7.
• Morphine and codeine should be avoided or used with extreme caution in patients with renal impairment due to the risk of accumulation of toxic metabolites 4, 5, 6, 7.
• Patients with CKD and ESRD require careful monitoring for opioid-related side effects, and opioid-induced constipation can be managed with peripherally-acting-μ-opioid-receptor-antagonists (PAMORA) 7.

Key Considerations for Oxycodone Use

• Oxycodone can be used in patients with CKD and ESRD, but the dose should be adjusted according to the patient's renal function 4, 5, 6, 7.
• Close patient monitoring is required to minimize the risk of adverse events 3, 4, 5, 6, 7.
• Oxycodone should be used as a second-line agent in dialyzed patients, and alternative opioids such as buprenorphine and fentanyl may be considered as first-line agents 7.