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Acute pain management in adults with renal impairment

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  • This guideline applies to haemodialysis (HD), peritoneal dialysis (PD) and patients with creatinine clearance (CrCl) <30ml/min. These patients are at greater risk of toxicity from analgesia due to potential accumulation and an increased sensitivity to side effects.
  • 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. Increases to dose or frequency will require consideration of degree of pain relief versus tolerability of side effects and will be patient specific.
  • Avoid modified release (MR) preparations, in renal impairment due to risk of toxicity (drug half-life will be extended and will result in accumulation)
  • To calculate estimated creatinine clearance in patients with renal impairment (NB do not use for HD or PD patients) NHS Highland Renal MDT recommends the use of MDCalc (insert link). Refer to TAM-prescribing medicines in renal impairment for further guidance or contact pharmacy.

If calculating manually the equation is: 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 (IBW)/adjusted body weight as per MD Calc. If underweight use actual body weight.  Seek advice from pharmacy for patients with amputations.

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 (if oral route unavailable): 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
Moderate and severe pain

**AVOID morphine and dihydrocodeine!  High risk of toxicity!**

Paracetamol: dose as above
+
Oxycodone Oral

  • HD and PD: 2.5mg every 6 hours when required
  • CrCl <20ml/min: 2.5mg every 6 hours when required
  • CrCl <30ml/min: 2.5mg or 5 mg every 6 hours when required

OR

Oxycodone Subcutaneous Injection

  • HD and PD: 1.25mg every 6 hours when required
  • CrCl< 30ml/min: 1.25mg every 6 hours when required
  • If using a subcutaneous catheter there is a dead space of 0.2mls 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

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 e.g. dry mouth, dizziness, confusion and urinary retention, may be troublesome, especially in the elderly.  Efficacy is variable and should be reviewed regularly.

NSAIDS: Avoid if possible

HD and PD:

  • Avoid NSAIDS in patients with any residual renal function –confirm with renal specialists before prescribing.
  • For patients who do not pass any urine NSAIDs may be prescribed with caution.  There is an increased risk of GI side effects- consider prescribing ranitidine or proton pump inhibitor as gastroprotection and monitor for signs of bleed
  • Start with 200mg ibuprofen stat and continue with 200mg every eight hours when required. Review after 72 hours.

CrCl<30ml/min: Avoid

Avoid in renal transplant recipients.

Neuropathic pain

**Patients with renal  impairment are more sensitive to neurological side effects of these drugs and should be carefully monitored**

Gabapentin

HD

  • 100mg after each dialysis session, if required the dose may be titrated in 100mg increments every 7 days to 300mg post HD according to response and tolerability.

PD and CrCl<30ml/min

  • Dose: 100mg at night initially, increased according to response and tolerability (usual max. 300mg/day).

Amitriptyline (unlicensed indication)

HD, PD and CrCl<30ml/min

  • Dose: 10mg at night
Procedural pain

First Line – Oxycodone Oral

  • HD, PD and CrCl<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<30ml/min initially 100micrograms 15 to 30 minutes before procedure.
Musculoskeletal pain – anti-spasmodic

HD,PD or CrCl <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: 11 November 2020

Next review: 11 November 2022

Author(s): Acute Pain Team

Version: 3

Approved By: TAM subgroup of the ADTC

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

Document Id: TAM103