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Analgesia in renal impairment

Remember the 5 phrases of pain management:

  1. By mouth (Avoid haemodialysis (HD) IV route unless critical)

  2. By the clock (Consider dosing after HD)

  3. By the ladder (Sustained release versions are not recommended)

  4. For the individual (Consider all patient factors)

  5. Attention to detail (Long term studies are limited. Assess regularly for SE)



Paracetamol:

- Safe in moderate renal failure - 1g QID

- Severe renal failure - 1g TDS (but mainly due to concomitant liver concerns...)


NSAIDs:

- Avoid chronic use particularly in CKD (bleeding, cardiac events, psychiatric events)

- Topical NSAIDs are possible


Tramadol:

- Removed by haemodialysis

- If pain not controlled after 48hrs (steady state), increase by 30-50%

Codeine:

- Avoid. Severe side effects


Opioids generally:

- Metabolised in the liver

- 19% excreted in the urine - so use immediate release preparations only (Oxynorm liquid 1mg/ml)

- Wait 72 hrs to reach steady state before adjusting dose

Fentanyl:

- Mainly metabolised in liver so useful in renal impairment

- Transdermal takes 72 hrs to reach steady state


Buprenorphine:

- Thought to be safe in renal failure but evidence is limited

- Risky if become respiratory suppressed due to variable response to naltrexone


Methadone:

- Complicated! Metabolised primarily in liver and excreted in faeces

- Not removed by haemodialysis - Reduce dose to 75% in severe renal impairment

- Prolongs QT interval - which can also be a risk in renal failure


Morphine:

- Active metabolites accumulate quickly in renal failure

- Use only if have to...

- Better would by hydromorphone

Subcut opioids:

- Oxycodone can be converted to subcut route (Oral: subcut - 3:1)


Gabapentin:

- Almost exclusively cleared by the kidneys so substantial reduction required in impairment

- Consider carbamazepine instead (no dose alterations required in renal impairment)


TCA:

- Not well tolerated due to side effects

- Dose reduction not necessary but usually lower doses required than normal


Ketamine:

- No dose adjustments required


SNRI/SSRI:

- Insufficient data


Reference:

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