Acute pain management in renal impairment (Guidelines)

Paracetamol

ORAL

• 1g four times daily.
• Reduce dose to 500mg four times daily if less than 50kg body weight.

IV (if oral route unavailable)

• Greater than 50kg: 1g every 6 hours.
• Less than 50kg: 15mg/kg every 6 hours
• Dose interval should be increased to 8 hourly for patients with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition or dehydration.

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

Paracetamol

• dose as above

AND

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 to 5 mg every 6 hours when required

Consider use of lower doses in opioid naive, frail elderly patients
Dose increments of less than 5mg will require the use of oxycodone 1mg/mL oral solution.

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 0.2mL, 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)

Nefopam

• Can be considered for moderate pain as an alternative to opioids and NSAIDS, starting at 30mg three times daily as required.
• Avoid in epilepsy.
• 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 use should be reviewed regularly, with a view to stopping if no benefit.  

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 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**

**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

First Line: Oxycodone, oral

HD, PD and CrCl <30mL/min:

• 2.5mg 30 to 60 minutes before procedure.

Second Line: Fentanyl, sublingual (unlicensed indication)

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

 HD, PD and CrCl <30mL/min:

• Initially 100micrograms 15 to 30 minutes before procedure.

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.