The Use of Major Analgesics in Patients with Renal Dysfunction

Abstract

Pain in patients with impaired renal function may be a significant problem requiring treatment with opioids. However, pharmacokinetic and metabolic changes associated with an impaired renal function may raise some concerns about side effects and overdosing associated with opioid agents in this patient's population. In order to give recommendations on this issue, we review the available evidences on the pharmacokinetics and side effects of most common opioids used to treat pain. The results of this review show that the half-life of the parent opioid compounds and of their metabolites is increased in the presence of renal dysfunction, for which careful monitoring of the patient, dose reduction and a longer time interval between doses are recommended. Among opioids, morphine and codeine used with very caution and possibly avoided in renal failure/dialysis patients; tramadol, hydromorphone and oxycodone can be used with caution and close patient's monitoring, whereas transdermal buprenorphine, methadone and fentanyl/sufentanil appear to be safe to use in patients with renal failure.

Opioid and Benzodiazepine Use in End-Stage Renal Disease

“…The potential for adverse effects is compounded in dialysis patients because of reduced renal clearance of active metabolites, the uremic environment, and the presence of multiple comorbidities. Different classes of opioids may have differential effects in this regard (30,31) Although opioids may be underutilized in some patients, they may be prescribed inappropriately in others. The reasons for prescription of opioids in ESRD patients are not always clear, as was suggested by our review.…”

Pain in malignant hematology

“…The class of drug should be selected according to the intensity and the type (nociceptive, neuropathic and breakthrough) of pain. The selection of the most appropriate agent should be based largely on reported clinical experiences from other cancer settings, and on the physician's preferences and skills; moreover, concurrent medications (i.e., polypharmacy and the risk of drug interactions) and the patient's specific clinical conditions (i.e., renal failure, hepatic impairment, peptic ulcer, psychiatric illness, cardiovascular disease, diabetes mellitus and other chronic illnesses) [73][74][75][76] should be taken carefully into account with the view of their possible influence on the efficacy and tolerability of analgesic treatment. TaBle 1 lists the most commonly used pain medications and usual starting dose to treat cancer pain applicable in patients with HM.…”

“…The incidence of tramadol-related adverse effects has been reported as being lower compared with other opioids. In particular, at analgesic doses, respiratory depression is believed to be rare during chronic tramadol use [82], although high caution and dose adjustments are required in patients with renal impairment [75]. Therefore, this drug is easily manageable and can be proposed as an alternative for patients not suitable for NSAIDs or for other opioids.…”

Analgesics Use in Dentistry

“…But special caution should also be exercised in patients with end-stage renal disease without dialysis whereby the use of opioids such as codeine, dihydrocodeine, dextropropocyphene and hydrocodone is not recommended (tramadol may be used with caution). Also, only short-term treatment must be prescribed for morphine, diamorphine, or dose reduction in fentanyl by 25-50% or methadone 50-70% with specialist advice on prescribing and special care in the elderly due to highly variable pharmacokinetics [76,77].…”