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October 2013Case
A 70-year-old male with end-stage renal disease (ESRD) on hemodialysis presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his pain be managed?
Overview
Pain is a common problem in patients with renal insufficiency and ESRD, and can have a significant effect on the patient’s quality of life.1 When assessing a patient’s pain, assess both the severity of the pain (such as on an analogue scale, 0–10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both. Nociceptive pain can be further classified as arising from either somatic or visceral sources, and is often described as dull, throbbing, cramping, and/or pressurelike.1 Neuropathic pain is often described as tingling, numbing, burning, and/or stabbing.
It is a challenge to manage pain in patients with renal insufficiency and dialysis. Renal insufficiency affects the pharmacokinetic properties of most pain medications, including their distribution, clearance, and excretion. The magnitude of the effect of renal insufficiency on drug metabolism varies depending on the agent itself, its metabolite, and the extent of renal failure.3 Multiple factors should be considered when prescribing pain medications for patients on dialysis, including the properties of the parent drug and its metabolites; the physical properties of the dialysis equipment, such as the filter pore size, the flow rate, and the efficiency of the technique used; and the dialysis method (intermittent versus continuous).3 Table 1 provides the recommended dosing of the most commonly prescribed agents, based on the degree of renal impairment. A modified World Health Organization (WHO) ladder has been suggested to treat pain in patients with ESRD, which can lead to effective pain relief in as many as 96% of patients (see Figure 1).2
Review of Data
Nonopioid options. Nonopioids, such as acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), have no associated tolerance but have a ceiling effect for analgesia, and NSAIDs are associated with dose-dependent acute renal failure, gastrointestinal ulceration and bleeding, and cardiac events. The nonopioids that are considered safe options in patients with renal insufficiency include acetaminophen, ibuprofen, and fenoprofen (Nalfon). However, in the elderly, American Geriatric Society (AGS) guidelines currently recommend avoiding all NSAIDs due to their safety profile in the geriatric population.4 Although all NSAIDs can potentially be used for pain, selected NSAIDs with a Food and Drug Administration (FDA) indication for acute or chronic pain were included for this review.
Are pain MEDS like morphine or Demerol used to control pain
in last stage kidney failure?
Thank you.
Jim
Physician Editor Dr. Simon Helfgott replied: This is not an easy question to answer. Patients with renal failure do not metabolize medications effectively, so your kidney doctor would need to work with the doctor who prescribes the pain medicine to determine the optimal choice of drugs and the doses.
I was taking Lyrica for diabetic neuropathy and have recently begun dialysis. I have had three episodes of passing out afe my treatment and the doctor says it may be from the interacation of the lyrica. I stopped the lyrica and these episodes have not reoccurred. He is recommending I take gabapentin. Will the same thing happen? I am afraid to try it but the pain is severe. Help!
My mom was on other medications at the time she was put on gabapentin she had been living with me for 2 weeks then took one 100mg gabapentin & she fell that night, gabapentin has some horrible side effects but she has taken the gabapentin since only a lower dose & after her medications were lowered & she seemed to do alright taking it then, she was still able to walk with her walker to & from the bathroom but if you don’t absolutely need it then I wouldn’t take it, her doctor has taken her off that medication too. Feel like it’s going to be tough finding something to help control her pain without some bad side effects, I pray we can figure it out soon & good luck to you & I’ll be praying for you too, hopefully your doctor can control your pain, I feel for you knowing how horrible neuropathy is seeing my mom in pain.
My mom’s kidney function has come back and they are stopping dialysis, but she has real bad pain in her back and taking Tylenol for it. It is not helping and her regular dr. Wants to use a narcotic like vicadin isn’t that bad for someone who started dialysis because she had been drugged for a whole month trying to recover from open heart surgery and kidney function stopped because of it? Please help!
Mike, we cannot give personal medical advice in this forum. We hope your mother has a full recovery.
My mother has been on dialysis for about 2 1/2 years & a diabetic since she was 19 yrs old, she didn’t realize the severity of diabetes or what the long term effects could be if she didn’t control her sugar levels, she is 60 yrs old now & had been taking medications for anxiety for 25 yrs after being on dialysis for about 2 1/2 years she finally left her husband & is now living with me since Jan 15, 2017 so I haven’t been taking care of her long but after two weeks, I noticed her anxiety medication (klonopin) seemed to be making her confusion alot worse she didn’t even know who I was at times she was so confused she forgot she lived here with me she thought she lived with her aunt that she hadn’t talked to in years, she was in an almost comatose state all the time, she didn’t even feel much pain because her klonopin was building up in her blood stream the dialysis wasn’t filtering it out so for years my mom had been in this comatose state, sleeping all the time, getting seriously confused, couldn’t go to the bathroom on her own, couldn’t hardly walk & now after the Dr made some changes to her medications for ex. Instead of taking 1mg klonopin 3 times a day to only a 0.5mg klonopin every 12 hours & lowered her tranzadone, the difference this made was literally life changing, I was so upset thinking my mom didn’t have long to live, I would hide in my room & cry because with the shape she was in I seriously thought she would be taken from me within several months but after correcting her medications she hasn’t been confused since the klonopin was lowered & she’s alert, not sleepy all the time, she’s able to walk better, even goes to the bathroom on her own & she just looks so much better & now I’m thinking she’ll be with me for years to come & I’m so happy to have my mom back. Now she’s aware of pain she wasn’t feeling before but hopefully we’ll get that straightened out soon.