What's on this Page
How does narcotic pain management differ in patients with CKD?
Meperidine
This drug should be avoided in patients with kidney failure because of accumulation of its metabolite (normeperidine), which undergoes kidney elimination.
Normeperidine also has an excitatory effect on the central nervous system and causes seizures if it accumulates.
Propoxyphene should also be avoided in patients with kidney failure because of the accumulation of a metabolite (norpropoxyphene). Both can cause ventricular arrhythmias as a result of class IA antiarrhythmic properties. Another complication, propoxyphene-induced hypoglycemia, can be seen in patients with CKD.
Morphine should be used with caution in patients with kidney failure. Morphine undergoes glucuronidation to morphine-6-glucuronide (M6G) and morphine-3-glucuronide. M6G accumulates in kidney failure and is a more potent analgesic than the parent compound. In patients with end-stage kidney disease, the half-life of M6G is estimated to be 38 to 103 hours.
Codeine is metabolized in the liver to codeine-6-glucuronide, norcodeine, and morphine. A dose reduction of 50% is generally recommended in kidney failure.
Hydromorphone is considered to be relatively safe and effective in patients with kidney failure. It is metabolized in the liver to hydromorphone-3-glucuronide followed by a reduction to 6-a-hydroxyhydromorphone and 6-b-hydroxyhydromorphone, both of which are less potent analgesics than the parent drug. Seizure activity and cognitive impairment have been reported in patients with kidney failure receiving high-dose hydromorphone therapy.
Fentanyl is another good option for pain management in patients with kidney failure, even though the kidneys eliminate both the parent drug and its metabolites.
