Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure

Davison, Sara N.

doi:10.2215/cjn.05180418

Cited by 101 publications

(118 citation statements)

References 55 publications

(53 reference statements)

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“…In the overall cohort, patients with other pre-ESRD non-opiate analgesic use had similar survival compared to those with no analgesic use, even after accounting for differences in pain severity and specific pain conditions (i.e., neuropathy); however, in analyses stratified by kidney function, those who used other non-opiate analgesics with lower eGFRs (i.e., <30 mL/min/1.73 m 2 ) in the prelude period had higher post-ESRD death risk. While our data suggest that non-opiate analgesics other than gabapentin/pregabalin may be a preferred analgesic alternative to opiates in patients with mild-to-moderate kidney dysfunction (eGFR ≥ 30 mL/ min/1.73 m 2 ), there should be cautious administration and/or consideration of nonpharmacologic interventions in advanced CKD patients given alterations in drug absorption, bioavailability, distribution, metabolism, and excretion [15].…”

Section: Discussionmentioning

confidence: 73%

“…Yet, several limitations of our study should be acknowledged. First, given the retrospective nature of our study, we were not able to precisely determine the indications for which opiate and non-opiate analgesics were prescribed (i.e., nociceptive vs. neuropathic pain) [15], nor if analgesics were administered for conditions other than pain (i.e., epilepsy and pruritus); however, upon examining pre-existing conditions associated with opiate use in our multivariable models (i.e., neuropathy), we observed robust associations between pre-ESRD opiate use and post-ESRD death. Second, due to data limitations we were unable to ascertain use of analgesics outside of the VA healthcare system (i.e., overthe-counter and prescription from non-VA providers), DOI: 10.1159/000509451 nor the type of analgesic prescribers (i.e., primary care and nephrology).…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, in the CKD population chronic pain has been associated with adverse sequelae, including impaired health-related quality of life, disability, kidney function decline, hospitalization, and higher death risk [9][10][11][12][13][14]. However, the treatment of chronic pain in this population is oftentimes suboptimal, owing to limited analgesic options due to altered pharmacokinetics and pharmacodynamics in CKD [15].…”

Section: Introductionmentioning

confidence: 99%

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Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

et al. 2020

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Background: Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. Methods: We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other nonopiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. Results: Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). Conclusions: In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.

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Section: Discussionmentioning

confidence: 73%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

et al. 2020

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“…The authors recognise that opioids are not considered appropriate for chronic pain. However, this is an acute pain arising in response to tissue injury and death [ 18 ] and therefore, we recommend an opioid as first line therapy.…”

Section: Recommendationsmentioning

confidence: 99%

Pain management in patients with end-stage renal disease and calciphylaxis- a survey of clinical practices among physicians

et al. 2020

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Background Calciphylaxis is a rare condition usually seen in patients with end-stage renal disease. Pain is a hallmark of this condition and can be extremely difficult to control. Anecdotal data suggests that pain management in calciphylaxis is challenging with variable approaches across the United Kingdom (UK) and internationally. A knowledge and practice survey was conducted to establish current practice in the management of pain in patients with calciphylaxis, in the UK. Based on the results and clinical experience the authors suggest a clinical practice guideline. Methods An online questionnaire was circulated among physicians (renal and palliative care) involved in the management of pain in calciphylaxis. The questionnaire included a mix of open-ended questions and questions with drop down options. Results One hundred and six clinicians responded to the survey of which 60 (57%) respondents were from palliative medicine; the remaining 46 (43%) were from renal medicine. 31 (30%) respondents across both specialties had not encountered any patients with a diagnosis of calciphylaxis (renal-2, palliative care-29). A referral to the palliative care team was undertaken by 18% of renal physicians, 32% referred to the pain team and 50% referred to both. Only 3% of the palliative medicine respondents indicated that they had received a referral from the renal team at the time of diagnosis. Opioids were the preferred initial drug of choice for the management of all types of pain. Paracetamol was universally selected as the preferred first-choice adjuvant agent for management of all types of pain. The importance of advance care planning was highlighted with 72% undertaking advanced care planning discussions often or most of the time. Conclusion There was wide variation in the current practice of pain management in patients with calciphylaxis, with variation between renal specialists and palliative care specialists. Referral to specialists in pain management is not universal despite the severe nature of the pain experienced by patients with calciphylaxis. The data generated has facilitated the development of a clinical practice guideline to support complex pain management in a group of patients with multiple comorbidities.

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“…The authors recommend alfentanil as it is not removed by dialysis, it does not cause toxicity in an ESRD population and it occupies a low volume in syringe drivers. This guidance is drawn from literature on the use of opioids in cancer patients with severe and end stage terminal illness (18)(19)(20) and is supported by the clinical pharmacology literature (17). Fentanyl by CSCI is an alternative.…”

Section: Background Pain Controlmentioning

confidence: 99%

Pain management in patients with end-stage renal disease and calciphylaxis- A survey among physicians and clinical practice recommendations

Chinnadurai

Sinha

Lowney

et al. 2020

Preprint

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Background Calciphylaxis is a rare condition usually seen in patients with end-stage renal disease. Pain is a hallmark of this condition and can be extremely difficult to control. Anecdotal data suggests that pain management in calciphylaxis is challenging with variable approaches across the United Kingdom (UK) and internationally. A knowledge and practice survey was conducted to establish current practice in the management of pain in patients with calciphylaxis, in the UK. Based on the results and clinical experience the authors suggest a clinical practice guideline.Methods An online questionnaire was circulated among physicians (renal and palliative care) involved in the management of pain in calciphylaxis. The questionnaire included a mix of open-ended questions and questions with drop down options. Results One hundred and six clinicians responded to the survey of which 60 (57%) respondents were from palliative medicine; the remaining 46 (43%) were from renal medicine. 31 (30%) respondents across both specialties had not encountered any patients with a diagnosis of calciphylaxis (renal-2, palliative care-29). A referral to the palliative care team was undertaken by 18% of renal physicians, 32% referred to the pain team and 50% referred to both. Only 3% of the palliative medicine respondents indicated that they had received a referral from the renal team at the time of diagnosis. Opioids were the preferred initial drug of choice for the management of all types of pain. Paracetamol was universally selected as the preferred first-choice adjuvant agent for management of all types of pain. The importance of advance care planning was highlighted with 72% undertaking advanced care planning discussions often or most of the time.Conclusion There was wide variation in the current practice of pain management in patients with calciphylaxis, with variation between renal specialists and palliative care specialists. Referral to specialists in pain management is not universal despite the severe nature of the pain experienced by patients with calciphylaxis. The data generated has facilitated the development of a clinical practice guideline to support complex pain management in a group of patients with multiple comorbidities.

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Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure

Cited by 101 publications

References 55 publications

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

Pain management in patients with end-stage renal disease and calciphylaxis- a survey of clinical practices among physicians

Pain management in patients with end-stage renal disease and calciphylaxis- A survey among physicians and clinical practice recommendations

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