Removal of methadone by extended dialysis using a high cut-off dialyzer: implications for the treatment of overdose and for pain management in patients undergoing light chain removal

Abstract

The synthetic opioid methadone hydrochloride has a low molecular weight of 346 D, a high volume of distribution (4 - 7 L/kg), and is lipophilic. It is used as an analgesic and for the maintenance treatment of opiate dependence. In drug addicts, methadone is frequently involved in mixed intoxications that can lead to death. Here we present the case of a drug addict in whom a high cut-off dialysis membrane together with extended dialysis was used in the setting of suspected overdose and acute kidney injury. Although the observed dialyzer plasma clearance (31.5 mL/min) and reduction ratio (38%) were higher than previously reported for standard hemodialysis, the total amount of methadone in the spent dialysate after 1 extended dialysis session was quite low. Hence, even extended dialysis with a high cut-off membrane does not seem to offer a clinically relevant benefit in the setting of overdose for enhanced methadone removal. On the other hand, in patients undergoing high cut-off dialysis for the removal of light chains, methadone could still be used as an analgesic without an additional dose after high cut-off hemodialysis.

KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation

“…HCO-HD can effectively remove light chains 29 and has been shown to remove cytotoxic agents 30 and analgesics. 31 Data from uncontrolled trials suggest that using HCO-HD can lead to improvement in renal endpoints. 32,33 However, in a study of patients with myeloma cast nephropathy treated with a bortezomib-based chemotherapy regimen, the use of HCO-HD compared with conventional hemodialysis did not result in a statistically significant difference in hemodialysis independence at 3 months.…”

The causes of hospital mortality in methadone associated poisonings: analysis of the data from the Kyiv toxicological center for 2005–2019

“…In mixed intoxications that are accompanied by changes in the patient's homeostasis and can lead to death, hemodialysis is used at low speed with high permeability dialysis membranes or with the so-called "high cut-off dialysis membranes", which allow prolonged dialysis (within 4-6 hours) to achieve a significant reduction in the level of medium molecules and some other endotoxins in the serum. However, such dialysis does not affect the concentration of MTD, benzodiazepines, and some other drugs in the blood, except ethanol [26,27]. It should be noted that the use of hemodialysis in cases of combined poisoning with synthetic opioids significantly increases the cost of treatment and creates a significant financial burden on the budgets of intensive care units.…”