From the Guidelines
When prescribing pain medications for dialysis patients, acetaminophen is the safest first-line option at standard doses (up to 3000 mg daily in divided doses) 1. For mild to moderate pain, tramadol should be avoided due to its potential to increase the likelihood of toxicity in renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD 1. Instead, certain opioids can be prescribed with appropriate dose adjustments:
- hydromorphone (starting at 0.5-1 mg every 6 hours)
- fentanyl (patch or injectable forms)
- methadone (starting at 2.5 mg every 8-12 hours) 1. NSAIDs should generally be avoided due to their potential to worsen kidney function, increase bleeding risk, and cause fluid retention 1. Gabapentin and pregabalin can be used for neuropathic pain but require significant dose reductions (gabapentin 100-300 mg after each dialysis session; pregabalin 25-75 mg daily). These recommendations are based on the altered pharmacokinetics in dialysis patients, as impaired kidney function affects drug clearance and can lead to accumulation of medications or their metabolites, potentially causing toxicity or adverse effects if not properly adjusted. Some key considerations for opioid use in dialysis patients include:
- Avoiding meperidine, codeine, and morphine due to active metabolites and accumulation in renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD 1
- Using hydrocodone, oxycodone, and hydromorphone with caution and adjusting dosage in renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD 1
- Preferring opioids with no active metabolites, such as fentanyl, sufentanil, and methadone, for patients with renal insufficiency or ESRD 1.
From the Research
Pain Medicines for Dialysis Patients
The following pain medicines can be considered for patients undergoing dialysis:
- Acetaminophen: a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older 2
- Nonsteroidal anti-inflammatory drugs (NSAIDs): may be used in CKD and ESKD for short durations with careful monitoring 3
- Opioids:
- Morphine and codeine: should be used with very caution and possibly avoided in renal failure/dialysis patients 4
- Tramadol, hydromorphone and oxycodone: can be used with caution and close patient's monitoring 4
- Transdermal buprenorphine, methadone and fentanyl/sufentanil: appear to be safe to use in patients with renal failure 4
- Buprenorphine: a promising and safer option due to its partial agonism at the mu opioid receptor 3
Considerations for Pain Management in Dialysis Patients
When managing pain in dialysis patients, the following should be considered:
- Nonpharmacologic therapies: physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management 3
- 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 3
- Opioid use: should be minimized and reserved for patients who have failed other therapies, with careful monitoring and dose adjustment 3