Pain Management in Patients with Chronic Kidney Disease (Renal Insufficiency or ESRD on Dialysis)

Management of chronic pain in chronic kidney disease

Safe options for pain management in renally impaired and dialysis patients include:

• Acetaminophen …
• Tramadol in lower doses may also be safely used in renally impaired and dialysis patients.
• Fentanyl, hydrocodone, and hydromorphone are the safest opioids to use in renally-impaired and dialysis patients.
• Low-dose gabapentin and lidocaine patches can be safely used as adjunctive therapy in renally impaired and dialysis patients; TCAs may also be used in lower doses in renally impaired patients.
• In patients with significant renal or hepatic dysfunction, fentanyl (given IV) is the opioid of choice. Methadone also is also good for patients with renal problems.

For Chronic Nociceptive Pain in CKD patients, try this step-wise approach:
1) Start with Acetaminophen.
2) If it doesn’t work, add Tramadol to Acetaminophen to give Acetaminophen + Tramadol.
3) If that doesn’t work, replace tramadol with an opioid such as Fentanyl, hydromorphone, methadone, or buprenorphine. E.g. Acetaminophen + Fentanyl / Hydromorphone.

For Neuropathic pain in CKD patients
1) Gabapentin / Pregabalin is safe.
2) If the maximum safe dose of gabapentin/pregabalin doesn’t work, switch to a TCA. TCAs are a second-line therapy for neuropathic pain in CKD.

For Mixed nociceptive/neuropathic pain in CKD patients, use this step-wise approach:
1) Acetaminophen + Gabapentin/Pregabalin. If that isn’t enough, try,
2) Acetaminophen + Gabapentin/Pregabalin + Tramadol. If that isn’t enough, drop tramadol and add an opioid as in step 3 below.
3) Acetaminophen + Gabapentin/Pregabalin + an opioid as fentanyl, hydromorphone, methadone, or buprenorphine. The preferred opioid for mixed nociceptive/neuropathic pain is methadone.

Drugs to avoid in CKD patients

1. NSAIDs
2. Codeine,
3. Dextropropoxyphene,
4. Morphine,
5. Meperidine/pethidine, or
6. Propoxyphene.