Opioids in Patients on Renal Dialysis

Abstract

Renal impairment is common in patients with advanced illness and can complicate management when attempting to control pain. The ideal opioid to use in renal failure is one that is completely metabolized to inactive components that are not dependent on the kidneys for elimination. The drugs thought to meet these criteria to the greatest extent are the lipophilic opioids (fentanyl, alfentanil, and sufentanil) and methadone.Delivering opioids to patients on dialysis and achieving pain control poses an even greater challenge. The opioid must be suitable for patients with grossly abnormal renal function. It is also preferable if it is not removed completely during dialysis.The factors that determine whether or not a drug is filtered during dialysis are the molecular weight (MW) of the compound and its degree of protein binding, volume of distribution (VD), and solubility (WS). 1 Molecules less likely to be removed by dialysis have low MW and WS, are highly protein bound, and have a high VD. Using these criteria, one would anticipate that morphine, a drug of relatively low protein binding and moderate WS, would be removed by dialysis, whereas methadone with its high protein binding, high VD, and low MW would not be removed. Fentanyl and sufentanil are highly protein bound, with low WS and a high VD. Therefore, these drugs should not be removed during dialysis. Reports that support this premise have been published. 2 We present a case of a young man rendered anephric following surgery for bilateral ureteric transitional cell carcinoma (TCC), with

Dialyzability of Oxycodone and Its Metabolites in Chronic Noncancer Pain Patients with End‐Stage Renal Disease

“…Although oxycodone thus appears to be potentially dialyzable, its relatively large V d , possibly increased in uremic and in old age patients, may induce lower plasma concentration and limited removal. Our data show, in accordance with the limited literature, that oxycodone dialyzability is possible, though limited. Indeed, arterial concentration of oxycodone was significantly reduced from T0 to T240 by almost 50% in group HDF but not in group HD, in which the reduction was limited and not significant.…”

Management of pain in end‐stage renal disease patients: Short review

“…If pain control is not optimal, then substitution/addition of opioid analgesics are indicated. Commonly used opioids for the pain control in ESRD patients are tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine . Opioids to be avoided in ESRD patients are morphine, codeine, hydrocodone, although, hydrocodone may be used cautiously.…”

“…Commonly used opioids for the pain control in ESRD patients are tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. 13,27 Opioids to be avoided in ESRD patients are morphine, codeine, hydrocodone, 13 although, hydrocodone may be used cautiously. Ideal analgesic is one whose pharmacokinetics is not affected by ESRD and one which is not removed by dialysis.…”