Severe and even chronic pain is common in chronic kidney disease (CKD) patients undergoing hemodialysis, yet few treatment guidelines exist to help doctors in managing patients’ pain, according to a new study published in the Journal of Pain Research.
Pain management in CKD patients is complicated and requires special attention because of the decreased renal activity caused by the disease, which can affect patients’ response to pain medications available to them.
An altered ability to eliminate medications and their components, and changes in the distribution and absorption of analgesic drugs in the body, or in drug-drug interactions, are among the issues making pain management in advanced CKD patients a difficult goal to achieve.
In the study, “Pharmacotherapeutic considerations for chronic pain in chronic kidney and end-stage renal disease,” researchers provide a comprehensive overview of approaches available to clinicians treating patients with CKD.
Adequate pain management is commonly achieved by therapeutic administration of either opioids or non-steroidal anti-inflammatory drugs (NSAIDs).
Opioids are commonly seen as a first-line pain treatment, considering their lower toxicity compared to NSAIDs. However, the risk of respiratory depression and of abuse associated with opioids demands caution in prescribing them. Patients should be monitored closely before and after therapy with opioids, the researchers said.
A specific group of opioid analgesic, including Nucynta (tapentadol), has been proposed as the safest and best first treatment choice for advanced CKD patients, but clinical trials are still needed, the study noted. What makes these drugs more suited for this population is their low impact on the overall kidney activity.
NSAIDs, in contrast, can induce renal toxicity leading to acute kidney injury and CKD progression. Given this, the American Society of Nephrology has recommended that CKD patients avoid these drugs. The authors add that this recommendation should extend to dialysis patients.
The researchers also explored two other groups of analgesics, tricyclic antidepressants (TCAs) and serotonin-NE reuptake inhibitors (SNRIs), used specifically for the treatment of pain caused by damage to nerve fibers.
Some drugs in these groups have shown promising results in CKD patients, with reduced drug-drug interactions and low impact on kidney function. But a number of them require careful dose control and monitoring.
Overall, the study’s authors concluded that while safe and effective pain treatments for CKD and end-stage renal disease patients exist, research is needed to establish and offer guidance as to the best-suited and beneficial approaches.
“In the absence of evidence-based guidelines, one must use the known pharmacology to design the safest and most efficacious patient-centered treatment plan,” the authors concluded.