Acute pain management in adults with renal impairment

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  • The doses quoted are for haemodialysis (HD), peritoneal dialysis (PD) and patients with creatinine clearance less than 30mL/min.
  • The doses quoted are suggested starting doses; these can be gradually increased as necessary according to response. Review analgesia regularly, at least once a day. Increased dose or increased frequency will depend on pain relief verses side-effects with current dose, but will be patient-specific.
  • Avoid modified release preparations in renal impairment as drug half life will be further extended and increase the risk of accumulation.
To calculate estimated creatinine clearance use the equation below:

Est CrCl (mL/min) = (140 – age) x body weight (kg) x 1·23 for men or 1·04 for women
Creatinine (micromol/L)

This equation is less accurate at extremes of weight. In obese patients use ideal body weight calculated as below.
If further advice is needed contact pharmacy.

Ideal body weight

Males = 50kg + 0·9kg for every cm above 150cm
Females= 45·5kg + 0·9kg for every cm above 150cm

Mild pain

 Paracetamol

  • Oral: 1g four times daily, consider dose reduction if less than 50kg body weight
  • IV: Greater than 50kg, give 1g every 6 hours. Less than 50kg, give 15mg/kg every 6 hours
  • IV: dose interval should be increased to 8 hourly for patients with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition or dehydration

+/- Adjuvant / other analgesics, see 'Other'

Moderate and severe pain

Avoid morphine!

Paracetamol: dose as above
+
Oxycodone oral

  • HD and PD: 2·5mg every 6 hours when required
  • CrCl less than 30mL/min: 2·5mg or 5 mg every 6 hours when required
  • CrCl less than 20mL/min: 2·5mg every 6 hours when required

OR
Oxycodone subcutaneous injection

  • HD and PD: 1·25mg every 6 hours when required
  • CrCl less than 30mL/min: 1·25mg every 6 hours when required
  • If using a subcutaneous catheter there is a dead space of 0·2mL so give 4mg for first dose to take account of this

OR
Oxycodone for patient controlled analgesia – specialist use only

Fentanyl for patient controlled analgesia – specialist use only

If pain is still uncontrolled seek specialist advice

Nociceptive pain

Nefopam can be considered for moderate pain as an alternative to opioids and NSAIDS, starting at 30mg three times daily as required. Sympathomimetic and antimuscarinic side-effects, eg dry mouth, dizziness, confusion and urinary retention, may be troublesome, especially in the elderly.

NSAIDS: Avoid if possible
HD and PD:

  • Avoid NSAIDS in patients with any residual renal function – this needs to be checked with renal specialists prior to prescribing.
  • For patients who do not pass any urine NSAIDs can be prescribed with caution.
  • Prescribe prophylactic ranitidine or proton pump inhibitor cover for uraemic patients.
  • Start with 200mg ibuprofen stat and continue with 200mg every eight hours when required. Review after 72 hours.

CrCl less than 30mL/min: Avoid
Avoid in renal transplant recipients.

Neuropathic pain

Gabapentin
HD

  • 100mg after each dialysis session titrated in 100mg increments every 7 days to 300mg post HD according to tolerability.

PD and Est CrCl less than 30mL/min

  • Dose 100mg at night initially, increased according to tolerability.

Amitriptyline (unlicensed indication)

HD, PD and EstCrCl less than 30mL/min

  • Dose 10mg at night
Procedural pain

First-line – Oxycodone oral

  • HD, PD and CrCl less than 30mL/min 2·5mg 30 to 60 minutes before procedure. 

Second-line - On specialist advice only, contact renal team or acute pain team. For use only in patients who are receiving regular opioid therapy.      

  • Fentanyl sublingual (unlicensed indication) – HD, PD and CrCl less than 30mL/min initially 100micrograms 15 to 30 minutes before procedure.
Musculoskeletal pain – anti-spasmodic

HD, PD or CrCl less than 30mL/min

  • Diazepam 2mg as a stat dose.  Seek specialist advice if further doses required as increased cerebral sensitivity in patients with renal impairment.

 

Editorial Information

Last reviewed: 30 November 2018

Next review: 30 November 2020

Author(s): Acute Pain Team

Version: 4

Approved By: TAM subgroup of the ADTC

Reviewer Name(s): Acute Pain Nurse Specialist, Consultant Nephrologist

Document Id: TAM103