From the Guidelines
For this 74-year-old female with arthritis pain inadequately controlled by Tylenol, I recommend avoiding NSAIDs and considering alternative pain management options, such as tramadol or low-dose opioids, with careful titration and monitoring of kidney function, as NSAIDs are contraindicated in patients with eGFR <30 ml/min per 1.73 m2, as stated in the 2021 Mayo Clinic Proceedings guideline 1. Given her impaired kidney function (eGFR 25), it is crucial to prioritize pain management options that do not further compromise her renal health.
- The patient's current acetaminophen dose should be optimized to the lowest clinically effective dose, not exceeding 4 g/d, due to safety concerns such as hepatotoxicity, as recommended in the 2021 Mayo Clinic Proceedings guideline 1.
- Tramadol may be considered, but its use requires caution and dose reduction in renal impairment, as it can accumulate and increase the risk of adverse effects.
- Alternatively, low-dose opioids like hydrocodone/acetaminophen 5/325mg every 8 hours with extended dosing intervals may be considered, but with careful monitoring and titration to minimize the risk of medication accumulation and adverse effects.
- Topical therapies, such as diclofenac gel or lidocaine patches, may provide localized relief without systemic effects and are a viable option for patients with impaired kidney function.
- Non-pharmacological approaches, including physical therapy, heat/cold therapy, and assistive devices, should be incorporated to provide comprehensive pain management and improve the patient's quality of life. The 2012 Annals of Oncology guideline 2 recommends using fentanyl and buprenorphine via the transdermal route or intravenously as the safest opioids of choice in patients with chronic kidney disease stages 4 or 5, but this should be considered on a case-by-case basis, taking into account the patient's individual needs and medical history.
From the FDA Drug Label
Dosage adjustment in patients 12 years of age and older with compromised renal function or undergoing hemodialysis is recommended, as follows
TABLE 1 Gabapentin Tablets Dosage Based on Renal Function
Renal Function Creatinine Clearance (mL/min) Total Daily Dose Range (mg/day) Dose Regimen (mg)
...
15a 100-300 100 QD 125 QD 150 QD 200 QD 300 QD
a For patients with creatinine clearance <15 mL/min, reduce daily dose in proportion to creatinine clearance (e.g., patients with a creatinine clearance of 7. 5 mL/min should receive one-half the daily dose that patients with a creatinine clearance of 15 mL/min receive).
- 4 Dosage in Elderly Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and dose should be adjusted based on creatinine clearance values in these patients.
The patient has an eGFR of 25, indicating severe chronic kidney disease.
- The creatinine clearance is not explicitly stated, but the eGFR can be used as an estimate of renal function.
- According to the dosage adjustment guidelines, for patients with creatinine clearance <15 mL/min, the daily dose should be reduced in proportion to creatinine clearance.
- Since the patient's eGFR is 25, which is greater than 15, but still indicates severe kidney dysfunction, the dose should be adjusted based on the guidelines for creatinine clearance >15-29 mL/min.
- The recommended total daily dose range for patients with creatinine clearance >15-29 mL/min is 200-700 mg/day, with a dose regimen of 200 QD, 300 QD, 400 QD, 500 QD, or 700 QD.
- Considering the patient's age and renal function, a conservative approach would be to start with a lower dose, such as 200-300 mg/day, and titrate up as needed and tolerated.
- It is essential to monitor the patient's renal function and adjust the dose accordingly.
- The patient is currently taking Tylenol (acetaminophen) 650mg twice daily, and the addition of gabapentin should be done with caution, considering the potential for increased risk of adverse effects.
- The patient's pain management should be regularly assessed, and the dose of gabapentin adjusted as needed to achieve adequate pain relief while minimizing the risk of adverse effects 3.
From the Research
Pain Management for a 74-year-old Female Patient with Arthritis Pain and Impaired Renal Function
The patient is currently on Tylenol (acetaminophen) 650mg twice daily and as needed every 6 hours, but is experiencing inadequate pain relief. Considering the patient's impaired renal function with a creatinine level indicating severe kidney dysfunction and an estimated glomerular filtration rate (eGFR) of 25, the following points should be taken into account:
- NSAID Use: Guidelines recommend avoiding NSAIDs in patients with eGFR < 30 mL/min/1.73 m2, and long-lasting therapy is not recommended in people with chronic kidney disease 4.
- Alternative Pain Management Options: Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease 5.
- Opioid Use: Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient 5.
- Safe Analgesic Agents: In the presence of renal impairment, those drugs which exhibit the safest pharmacological profile are alfentanil, buprenorphine, fentanyl, ketamine, paracetamol (except with compound analgesics), remifentanil and sufentanil 6.
- Dose Adjustment: Dose adjustment should be based on an ongoing assessment of clinical status and risk versus the benefit of the used regimen. When determining the most appropriate dosing regimen serum creatinine-based formulas should never be used naively but always in combination with clinical and pharmacological assessment of the individual patient 7.
Some key considerations for pain management in this patient include:
- Avoiding NSAIDs due to the patient's severe kidney dysfunction
- Carefully selecting alternative pain management options, such as nonopioid analgesics or opioids with caution
- Monitoring the patient's renal function and adjusting the pain management plan as needed
- Considering the use of safe analgesic agents, such as those listed above, and adjusting doses based on the patient's clinical status and risk/benefit assessment.