Is 2.5 mg of Endone (oxycodone) safe for a patient with severe Chronic Kidney Disease (CKD) and Impaired Renal Function, with an estimated Glomerular Filtration Rate (eGFR) of 12, who is dependent on haemodialysis (2 times weekly)?

Oxycodone Dosing in Severe CKD with Hemodialysis

For a patient with eGFR 12 on hemodialysis twice weekly, 2.5 mg oxycodone (Endone) can be used cautiously as a starting dose, but requires careful monitoring and likely dose reduction or extended dosing intervals due to accumulation risk of active metabolites in severe renal impairment. 1, 2

Opioid Selection in Severe CKD/Hemodialysis

Oxycodone is considered a second-line agent in hemodialysis patients and requires significant dosage adjustments compared to patients with normal renal function. 1

• Oxycodone and its active metabolites (noroxycodone and oxymorphone) accumulate in severe CKD, necessitating dose reduction and extended intervals between doses 1, 2
• In hemodialysis patients specifically, oxycodone should be used with careful monitoring as a second-line option, not first-line 1
• The 2.5 mg dose represents a conservative starting point, but even this low dose may accumulate with twice-weekly dialysis 2

Preferred First-Line Opioids in This Population

Buprenorphine and methadone are considered first-line opioids for patients with severe CKD and hemodialysis because they undergo primarily hepatic metabolism without significant renal excretion of active metabolites. 1, 2, 3

• Buprenorphine can be administered at normal doses without adjustment in renal dysfunction and hemodialysis patients, as it is mainly excreted through the liver 3
• Buprenorphine pharmacokinetics remain unchanged in hemodialysis patients, eliminating the need for dose reduction 3
• Methadone is also lipophilic and appropriate for CKD patients, though requires careful titration 2

Opioids to Avoid Completely

Morphine and codeine are contraindicated in severe CKD and hemodialysis due to dangerous accumulation of neurotoxic metabolites. 1, 2

• Morphine-6-glucuronide and morphine-3-glucuronide accumulate significantly, causing neurotoxic symptoms including myoclonus, seizures, and altered mental status 1, 2
• Codeine metabolites similarly accumulate and cause toxicity 1
• Morphine is particularly problematic in hemodialysis due to "rebound" of metabolites between dialysis sessions 3

Practical Dosing Strategy if Using Oxycodone

If oxycodone must be used despite being second-line:

• Start with 2.5 mg every 8-12 hours (not every 4-6 hours as in normal renal function), monitoring closely for sedation, confusion, or respiratory depression 1, 2
• Extend dosing intervals significantly - consider every 12 hours or even once daily initially, as drug clearance is markedly reduced 4, 5
• Avoid dosing immediately before dialysis - oxycodone is partially dialyzable, which can cause unpredictable fluctuations in drug levels 4
• Monitor for accumulation signs including excessive sedation, confusion, myoclonus, or respiratory depression at each dialysis session 1, 2

Critical Monitoring Parameters

• Assess mental status and sedation level before each dialysis session 1
• Watch for opioid-induced constipation, which is exacerbated in CKD patients and may require peripherally-acting μ-opioid receptor antagonists (PAMORA) like naldemedine, which requires no dose adjustment in hemodialysis 1
• Monitor respiratory rate and oxygen saturation, as respiratory depression risk is heightened 2
• Evaluate pain control adequacy - if 2.5 mg is insufficient, consider switching to buprenorphine rather than escalating oxycodone dose 1, 3

Common Pitfalls to Avoid

Do not use standard dosing intervals - the typical every 4-6 hour dosing for immediate-release oxycodone will cause dangerous accumulation in this patient 4, 5

Do not assume dialysis adequately clears the drug - twice-weekly hemodialysis is insufficient to prevent accumulation of oxycodone and its metabolites between sessions 1, 3

Do not combine with other CNS depressants without extreme caution, as CKD patients have increased sensitivity to sedative effects 2, 5