Currently, there are approximately 30 million adults in the United States who have chronic kidney disease.1 Chronic kidney disease, defined by the Kidney Disease Improving Global Outcomes guidelines as an estimated glomerular filtration rate <60 mL/min/1.73m2 for >3 months,2 is more common in women,1 and approximately 72% of patients are over the age of 60 years.3 While chronic pain is recognized as highly prevalent among patients with end-stage renal disease,4, 5, 6 less research has been conducted in patients with nondialysis chronic kidney disease.7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 In one study, 60.7% of participants with nondialysis chronic kidney disease reported chronic pain.21 Chronic kidney disease is also known to have a significant negative impact on patients’ quality-of-life scores, due to the symptom load (including chronic pain) and severity of comorbid pain.22
Chronic pain has been under-recognized and under-treated in the chronic kidney disease patient population, and the scarce research in this area has been heterogeneous.22, 23, 24 While aggressive pain management has been advocated for the end-stage renal disease population, there are no specific guidelines for the management of chronic pain in older adults with chronic kidney disease.25 The 2018 United States Renal Data System reported that 43.8% of chronic kidney disease patients were prescribed at least one opioid in 2016.26 Opioid prescription type and duration in those with chronic kidney disease and end-stage renal disease has followed national prescribing patterns for the general Medicare population, which may lead to improper opioid prescription in older adults with chronic kidney disease due to changes in pharmacokinetics and pharmacodynamics caused by chronic kidney disease and age.25
Because of the increased risk for adverse events, such as nausea, confusion, constipation, sedation, respiratory depression, and myoclonus, safe prescription of opioids is critical in the older, nondialysis chronic kidney disease patient population.8, 27, 28 It is imperative to state that opioids should be used only when absolutely indicated, and initiated at the lowest dose or shortest duration possible. The primary objectives of this review are to summarize which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients and to provide guidance on how to properly prescribe them given the scarcity of clinical evidence.
We review the sparse primary evidence and lack of specific clinical prescribing guidelines for the use of opioids in older adults with nondialysis chronic kidney disease and provide recommendations for the management of oral and transdermal opioids in older adults with nondialysis chronic kidney disease. We present a modified approach to pain using the American Geriatrics Society Beers Criteria and Pharmacological Management of Persistent Pain in Older Persons guidelines adapted for older adults with nondialysis chronic kidney disease. Finally, we present strategies for switching from one oral opioid to another safer agent, as well as strategies for collaboration in complex pain management. Further studies are urgently needed in this area to address the pain management needs of the growing population of older adults with chronic kidney disease.25
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-Montgomery T. Owsiany, MS, Chelsea E. Hawley, PharmD, Laura K. Triantafylidis, PharmD, Julie M. Paik, MD, ScD, MPH
This article originally appeared in the December 2019 issue of The American Journal of Medicine.
