Table 3. Pain management in CKD.

Pain intensity	WHO analgesic step	Agent(s) of choice	Comments
Mild pain Score 1–3	Non-opioid ± Adjuvant	Acetaminophen 500 mg q6h (by the clock) and 325 mg every 6–8h as required	Not to exceed total dose of 3g in 24-hours; If unable to take orally, then consider suppository NSAIDs/Cox-2 inhibitors are not recommended, but may consider, for short-term ONLY, under close observation
Moderate pain Score 4–6	Non-opioid ± Adjuvant ± Weak opioid	± Tramadol 50 mg every 12h, if required or Oxycodone with acetaminophen every 8–12h	Maximum dose 200 mg in stage 4 CKD and 100 mg in stage 5 CKD, dose after dialysis
Severe pain Score 7–10	Non-opioid ± Adjuvant ± Strong opioid	± Hydromorphone 1.3 mg every 8h or Oxycodone 2.5 mg every 8–12h or Fentanyl 25–50 mcg SQ every 4–6h or Buprenorphine 0.3 mg every 6h IM/IV 8–16 mg sublingual daily Transdermal Patch – 5 mcg/hr–20 mcg/hr or Morphine 1.25–2.5 mg every 8–12h (for short-term use)	Use laxatives to avoid constipation, when using opioids Do not write standing (or long-term) orders for opioids. Reassess the need and dose of opioids every 24–48 hours Monitoring for CNS and respiratory effects is required for protracted periods. Fentanyl and methadone are highly protein bound and not dialyzable. Avoid fentanyl transdermal patch and methadone in opioid-naïve patients