What is the appropriate pain management for a 94-year-old female patient with impaired renal function (GFR of 54), presenting with difficulty walking and a history of falls, who typically takes ibuprofen (ibuprofen) at home?

From the Guidelines

I strongly recommend avoiding ibuprofen for this 94-year-old patient with a GFR of 54 and instead using acetaminophen for pain management, as supported by the most recent and highest quality study 1. Acetaminophen 650-1000 mg every 6 hours as needed (not exceeding 3000 mg daily) would be an appropriate alternative. For a 94-year-old patient with reduced kidney function, NSAIDs like ibuprofen carry significant risks including acute kidney injury, gastrointestinal bleeding, and cardiovascular complications, as highlighted in a study from 2020 1. The patient's age and moderately reduced kidney function (GFR 54) make these risks particularly concerning. Acetaminophen provides effective pain relief without the kidney or gastrointestinal risks of NSAIDs. Additionally, since the patient presented with a fall, it's essential to consider that pain medications can increase fall risk, so the lowest effective dose should be used and the patient should be cautioned about potential dizziness. A comprehensive fall risk assessment and physical therapy evaluation would also be beneficial given the presenting complaint of difficulty walking, as emphasized in a study from 2023 1. The use of acetaminophen is further supported by a study from 2022 1, which suggests that acetaminophen is a valid and effective option for pain management in a multimodal regimen. Overall, the benefits of using acetaminophen for pain management in this patient outweigh the risks, and it is the most appropriate choice based on the available evidence.

From the FDA Drug Label

Advanced Renal Disease No information is available from controlled clinical studies regarding the use of ibuprofen tablets in patients with advanced renal disease. Therefore, treatment with ibuprofen tablets is not recommended in these patients with advanced renal disease If ibuprofen tablets therapy must be initiated, close monitoring of the patients renal function is advisable.

The patient has a GFR of 54, which indicates impaired renal function. Given the patient's age (94 years) and renal function, the use of ibuprofen tablets should be approached with caution.

• The patient's renal function should be closely monitored if ibuprofen therapy is initiated.
• Consider alternate therapies that do not involve NSAIDs for patients with impaired renal function. 2

From the Research

Patient Assessment

The patient is a 94-year-old female presenting with fall and difficulty walking, and is requesting pain management. Her attending physician is Miller, and she typically takes ibuprofen at home. Her glomerular filtration rate (GFR) is 54, indicating some level of kidney impairment.

Pain Management Options

Considering the patient's kidney function, the following options are available for pain management:

• Ibuprofen: As a nonsteroidal anti-inflammatory drug (NSAID), ibuprofen may not be the best option for this patient due to its potential to decrease glomerular filtration rate (GFR) in patients with renal insufficiency 3.
• Paracetamol (acetaminophen): This may be a suitable first-line analgesic for mild to moderate acute pain in adults with kidney disease, as it is generally well-tolerated at recommended doses and has a lower risk of adverse effects compared to NSAIDs 4.
• Opioids: While opioids may be effective for pain management, their use should be cautious and individualized, especially in patients with kidney disease, due to the potential for adverse effects and interactions with other medications 5.
• Other options: Muscle relaxants, antibiotics, and antidepressants may also be considered for pain management, but their effectiveness and safety in this patient population are less clear 6.

Considerations for Patients with Kidney Disease

Patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) are at increased risk for adverse effects of analgesic agents due to enhanced drug sensitivity, comorbid conditions, and concurrent medication use 7. Therefore, dose adjustment and avoidance of certain analgesics may be required in these patients.

Key Points to Consider

• The patient's kidney function should be closely monitored when using any analgesic medication.
• Paracetamol may be a suitable first-line option for pain management in this patient.
• Ibuprofen and other NSAIDs should be used with caution due to their potential to decrease GFR.
• Opioids and other medications should be used judiciously and with careful consideration of their potential risks and benefits.