Table 2. Summary of Recommended Pain Medication for CKD Patients.

Medication	MME	Metabolism	Normal dose	Dose adjustment	Common adverse effect
Acetaminophen	-	Hepatically metabolized	650 mg every 4–6 hr	Max daily dose 4,000 mg	Hepatotoxicity
		Excreted in the urine primarily as nontoxic metabolites		CLCr 10–50 mL/min: 650 mg q 6 hr prn
		High oral bioavailability 85%–98%		CLCr < 10 mL/min or dialysis: 650 mg q 8 hr prn
Tramadol (short acting)	0.1	Hepatically metabolized to more potent opioid analgesic metabolites M1	50–100 mg every 4–6 hr	Start at 25 mg every 12 hr	Constipation, nausea, CNS depression
				CLCr 30–50 mL/min: 50–100 mg every 8–12 hr
		High oral bioavailability 87%–95%
		Excreted renally		CLCr < 30 mL/min: avoid using
Oxycodone (short acting)	1.5	Hepatically metabolized	10–30 mg every 4–6 hr	Start at 5 mg every 4–6 hr prn	CNS and respiratory depression, hypotension, nausea, constipation, pruritus
		High oral bioavailability 50%–87%		CLCr 10–50 mL/min: 10 mg q 6 hr prn
				CLCr < 15 mL/min not on dialysis: 2.5–5 mg q 8–12 hr
Hydromorphone (short acting)	4	Hepatically metabolized	2–4 mg every 4–6 hr	Start at 1 mg every 6 hr prn	CNS and respiratory depression, hypotension, nausea, constipation, pruritus
		Low to moderate oral bioavailability		CLCr 30–50 mL/min: dose reduction
				CLCr < 30 mL/min: increase dosing interval
				Well dialyzed, but no supplemental dose required post-HD
Fentanyl (long acting)	2.4	Hepatically metabolized	Dose variable based on opioid equivalent dose of patient's oral medication	Should only be initiated in patients with chronic pain who have been on opioids prior	CNS and respiratory depression, hypotension, nausea, constipation, pruritus
		10%–20% excreted renally
		Low oral bioavailability
				Start at 12.5–25 µg patch

CKD: chronic kidney disease, MME: morphine milligram equivalent, CLCr: creatinine clearance, CNS: central nervous system, HD: hemodialysis.