Pain Management in Dialysis Patients: What to Do?

Source: Steve Thorpe

I recently admitted a dialysis patient with chronic severe pain. She came in because of altered mental status – the delerium was thought due to excessive dosing of Dilaudid (or hydromorphone). The question came up about what are the ideal drugs for pain management in dialysis patients? Are some better than others? 

5 practice points about the use of opiods in dialysis patients:

1. One needs to consider the properties of the parent opoid drug and its metabolites, as well as the dialysis prescription – the dialysis membrane, flow rate, the efficiency of the dialysis

2. Here are a list of do’s and don’ts on various agents (Table 1):

Table 1

3. A suggested approach to treating severe pain in dialysis patients (source-2):

• Start at 0.5 ‐1 mg PO hydromorphone q 4 hours plus 1 mg PO q 2 hours prn pain. Titrate dosage every 2 –3 days.
• If pain is not controlled, is continuous, and 24‐hour dose exceeds 12 mg, substitute transdermal fentanyl 25mcg/h for regular dose of hydromorphone.
• If further “as needed” hydromorphone exceeds 12 mg/24 hours, increase dose of fentanyl patch by further 25 mcg.
• Titrate upwards in similar manner if pain is not controlled.

4. Details on 2 key medications (source-2)

A. Hydromorphone:

• Start at 0.5 ‐1 mg PO q 4 hours plus 1 mg PO q 2 hours prn pain. Titrate dosage every 2 –3 days.
• If pain is not controlled, is continuous, and 24‐hour dose exceeds 12 mg, substitute transdermal fentanyl 25mcg/h for regular dose of hydromorphone.
• If further “as needed” hydromorphone exceeds 12 mg/24 hours, increase dose of fentanyl patch by further 25 mcg. Titrate upwards in similar manner if pain is not controlled.
• Caution: Toxic metabolite, H3G, accumulates if dialysis is stopped.

B. Fentanyl Transdermal Patches:

• Useful for patients with chronic, stable pain. Start after immediate‐release opioid dose is established. Analgesia may not be obtained for 12‐24 hours, so continue previous prn analgesics for 12 hours to ensure a smooth transition.
• Initial dose for opioid‐naïve patients is 12 mcg/h (increase dose every 3 – 6 days as needed for pain). Useful choice if dialysis non‐adherence or stopping dialysis are concerns.
• Fentanyl patches above 12 mcg/hr should not be used in opioid‐naïve patients due to risk of respiratory depression.
• Prescribe medication for breakthrough pain.

5. The most common reasons for stopping opioids are adverse effects, especially respiratory depression, hallucinations and confusional states, constipation, nausea and vomiting. Management of excessive sedation, compromised respiration with low O2 saturation

• Dilute 0.4 mg of Naloxone in 10 ml NS and administer 1 ml IV q 1‐2 minutes until patient arouses.
• Continue to monitor for return of sedation or slowed respirations (half‐life of Naloxone is shorter than half‐life of opioids).

Key sources for the above information, that are available open access, 1, 2