Opioids and Renal Disease

Patients with chronic pain who also have chronic renal disease can be difficult to treat. Pain is very common in this subset of patients with 82% experiencing moderate to severe pain. The way the opioid is processed and breaks down in the body can cause all sorts of issues.

It’s important to select the right opioid, dosing frequency, and titration to minimize the risk of side effects but still have the analgesic effect. Some of those opioids have metabolites which are the active and inactive substances that are left after the drug is processed in the liver or kidney. These metabolites can accumulate in renal failure patients because they are unable to clear them quickly. This can cause many uncomfortable side effects. The metabolites can cause symptoms such as myoclonus (muscle twitches, usually in the extremities), hyperalgesia (increased sensitivity to noxious stimuli), delirium, hallucinations, and sometimes seizures. Hyperalgesia can misrepresent itself and looks like increasing pain, which leads to increased opioid doses and an additional increase in symptoms to manage.

 There are a few opioids that are not recommended for use in poor renal function:

1. Codeine: This can cause profound toxicity very quickly even at low doses. If the patient's GFR is <30 mL/min. it should be avoided!
2. Morphine and Hydromorphone: These both have 3-glucuronide metabolites that can build up and cause those ugly neurotoxic symptoms. Please use caution with these opioids, especially if GFR is <30 mL/min. The patient should be regularly monitored and assessed.
3. Oxycodone: This does have metabolites, however, it may be less likely to cause clinically significant neurotoxicity. However, the dose and frequency may need to be modified and we still have to monitor for those types of side effects.

<h2>What opioids are best for patients with chronic renal disease? </h2>

Fentanyl, Methadone, and Buprenorphine are all relatively safe in renal failure.

These opioids are the only ones that do not have active metabolites. This doesn’t mean that they are necessarily the right choice for a patient because we must also factor in the estimated length of life and previous opioid treatment(s) and doses.

For patients with renal failure, we must keep in mind that they are not going to clear some of the opioid metabolites quickly. The metabolites can accumulate and cause us to believe the patient has increased pain. It is essential that the patient’s care team stop and consider what side effects may be caused by those metabolites.

DiGi Graham, Doctor of Pharmacy
Chief Corporate Pharmacist
Crossroads Hospice & Palliative Care 

Crossroads Hospice & Palliative Care supports patients with serious and terminal illness. To learn more about how we serve patients with renal disease, please call 1-888-564-3405.

Reference:
Arnold, R. et al. Fast Facts #161 Opioid Use in Renal Failure. Palliative Care Network of Wisconsin. Accessed July 14, 2022.

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