Pain management in patients with chronic kidney disease and end-stage kidney disease

Abstract

Purpose of Review-This review evaluates current recommendations for pain management in CKD and ESKD with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine.Recent Findings-Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants may be considered based on pain etiology and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/ benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor.Summary-Pain is poorly managed in patients with kidney disease. Non-pharmacological and non-opioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.

Medication Burden and Prescribing Patterns in Patients on Hemodialysis in the USA, 2013–2017

“…Our study on more contemporary prescribing patterns found that patients on hemodialysis were prescribed on average approximately 7 medications per day. Our findings of an overall slight decrease in the number of medications over time likely reflects the incorporation of updated guidelines and recommendations, and greater awareness among clinicians regarding medication management safety [11], efforts to improve medication management [37-40], and address pain management with nonopioid analgesics [41, 42]. We found that the prescribing of harmful medications decreased in the overall population and across subgroups by age, sex, race, and LIS status.…”

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“…Selected large retrospective studies are summarized in Table 1. Pain management in patients with end‐stage kidney disease requires experience in using NSAIDs and these opioids, which seem to be the safest for the kidney function, including buprenorphine, fentanyl, hydromorphone methadone, and oxycodone 48 …”

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

“…Paracetamol is safe to use in patients with ESRF and may be used without dose adjustment, but long-term use can cause analgesic nephropathy [ 149 ].…”

“…Some analgesics, such as lidocaine and capsaicin, can be applied as patches, and are safe and effective in the treatment of acute and chronic pain when used in a limited area. This approach provides localized analgesia in patients with kidney disease [ 149 ].…”