Table 2. Recommendations for commonly used opioids in CKD.
The dose adjustment based on eGFR shown is the percentage of recommended normal dose, 75% of recommended dose means 25% dose reduction, 50% of recommended dose means 50% dose reduction and 25% of recommended dose means 75% dose reduction.
| IN CKD | Opioid | Comments | Dialyzability | Dose adjustment based on eGFR | Recommendation(s) | |||
|---|---|---|---|---|---|---|---|---|
| Normal | CKD (eGFR/ml) | |||||||
| >50 | 10–50 | <10/RRT | ||||||
| PARENT COMPOUND | Morphine | Metabolites accumulate in renal failure, CNS and Respiratory depression,
20–25% of patients may tolerate well |
Yes, but M6G slowly re-equilibrates across the blood brain barrier, delaying the response to hemodialysis;
Very small amount removed by CVVH or CVVHD |
75–100%
2.5–5 mg q6h |
50–75%
2.5–5 mg q6-8h |
25–50%
small dose 1.25–2.5 mg q8-12h |
Short-term use
Avoid standing order Reassess dose q24-48h Not recommended for long-term use |
|
| RECOMMENDED/USE WITH CAUTION | Hydromorphone | Metabolite H3G accumulates in renal failure, has no analgesic activity but possibly neuro-excitatory | Yes | 1.3 mg q6h | 100% | 75% Start with 0.5 mg q6-8h | 50% Start with 0.5 mg q6-8h | RECOMMENDED, Use carefully |
| Fentanyl | Inactive metabolite, highly protein bound, large volume of distribution (V
d).
CNS & Respiratory depression reported with infusion and Transdermal patch |
No | 25–100 mcg q4-6h SC | 100% | 75% | 25–50% |
RECOMMENDED, starting dose 25–50 mcg q4-6h SC.
Transdermal patch takes 3 days to reach steady state Do NOT use patch in opioid naïve patients |
|
| Tramadol | 20% protein bound | Slowly removed , 50% clearance by HD | 50–100 mg q6h | 100% | 50% q12h | 50% q12h | Use with caution, dose after hemodialysis on dialysis days | |
| Oxycodone | 50% protein bound | To some extent | 5–10 mg q6h | 100% q6h | 50–75% q8h | 25–50% 18–12h | Limited evidence, use with caution | |
| Buprenorphine | Partial opioid agonist, ceiling analgesic effect, 96% protein bound | unlikely | 0.3 mg IM/IV
8–16 mg S/L |
Reduce dose and increase interval | Reduce dose and increase interval | Use with caution | ||
| NOT RECOMMENDED | Codeine | Both codeine and its metabolites accumulate in renal failure | 100% q6h | 75% q8h | 50% q12h | Not recommended in dialysis patients | ||
| Dihydrocodeine | NA | NA | NA | NA | NA | Not recommended | ||
| Meperidine | Toxic metabolite, normeperidine accumulates in renal failure and can cause seizures | Yes | 75–100% | 50% | Avoid | AVOID | ||
| (Dextro)Propoxyphene | Toxic metabolite, norpropoxyphene accumulates in renal failure, can cause seizures, hypoglycemia and cardiac conduction disturbances | No | Avoid | Avoid | Avoid | AVOID | ||