Page 32 - Christiana Care Focus April 2019

Pharmacy Services |
Use of opioids in patients with renal failure and on hemodialysis
Opioids are a class of drugs that are used to reduce pain. Examples include morphine, hydromorphone, oxycodone, fentanyl, methadone, etc.
Opioid medications work by binding to opioid receptors (delta, mu and kappa) that are located in the central and peripheral nervous system. When activated, they block the transmission of pain signals, thereby dulling a person’s perception of pain.
Due to opioid receptors in peripheral tissues, they can also be used for cough, intractable diarrhea and dyspnea. Additionally, they may also cause side effects such as urinary retention, constipation,
Ozioma O. Duru, Pharm.D.
euphoria, itching, respiratory depression, central nervous system depression and increased risk of falls, especially in the elderly.1
The presence of renal failure affects the pharmacokinetics of many drugs, including opioids. As a result, when prescribing opioids, one must consider the effect of renal failure on both the parent compound and its metabolites. Despite the scarcity of data on
the safe and effective use of opioids in the setting of dialysis and chronic kidney disease (CKD), clinical practice guidelines for prescribing opioids, generally based on limited pharmacokinetic data and literature, consistently advise on the following, 2, 3, 4, 5, 6 which is also recommended by the Coalition for Supportive Care of Kidney Patients:
PAIN MEDICATIONS IN CKD/ESRD 3
RECOMMENDED
USE WITH CAUTION
DO NOT USE
Acetaminophen
Tramadol
Limit dose to 50mg twice daily. Higher doses have been used but caution needs to be taken since pharmacokinetics are not well-established.
Morphine
Hydromorphone
Potentially unsafe if patient stops dialysis OR is CKD stage 4 or 5. The kidney-excreted active metabolite, hydromorphone-3-glucoronide, builds up since it is not adequately cleared in worsening CKD.
Hydrocodone/Oxycodone
Insufficient pharmacokinetic evidence to establish safety in CKD, but literature reports use without major adverse effects.
Codeine
Fentanyl
Desipramine/Nortriptyline
Alternative to treat neuropathic pain, but more adverse effects than gabapentin and pregabalin.
Meperidine
Methadone
Propoxyphene
Gabapentin
Doses in ESRD up to 300mg/day are generally considered safe, but higher doses should be
used with caution; note that gabapentin use for neuropathic pain is off-label but effectiveness has been documented.
Renally excreted metabolites accumulate in CKD causing neurotoxicity.
Pregabalin
Doses up to 100mg/day are generally considered safe in ESRD.
30 CHRISTIANA CARE HEALTH SYSTEM
THERAPEUTIC NOTES