Table. Analgesic use in dialysis 6,9-11.

Drug	Clearance	Suggested starting dose	Comments
Hydromorphone	Its major renally excreted metabolite hydromorphone-3-glucuronide is inactive	0.5–1 mg orally 4 times a day	Preferred oral opioid in dialysis patients
Oxycodone	Both oxycodone and its active metabolite oxymorphone are renally excreted	2.5–5 mg orally 3 times a day	Use controlled-release preparations with caution
Tramadol	Active renally excreted metabolite O-desmethyltramadol	50 mg orally twice a day	Maximum 100 mg twice a day Avoid controlled-release preparations
Buprenorphine	Hepatic metabolism with no accumulation of metabolites	5 microgram/hour transdermally	Not dialysed
Fentanyl	Hepatic metabolism with no active metabolites	12 microgram/hour transdermally	Not dialysed Use with caution in opioid-naïve patients
Gabapentin	Renal excretion	100 mg orally at night on dialysis days	Large dose reductions required Can treat uraemic pruritis and restless legs syndrome
Pregabalin	Renal excretion	25 mg orally at night on dialysis days	Large dose reductions required Can treat uraemic pruritis and restless legs syndrome
Morphine	Metabolised to renally excreted glucuronide metabolites (M-6-G and M-3-G) M-6-G is active and accumulates within the central nervous system, M-3-G lacks analgesic activity but may cause hyperalgesia and allodynia	2.5 mg orally 3 times a day	Avoid if possible Could be used for emergency analgesia if hydromorphone or fentanyl not immediately available
Codeine	Renally excreted active metabolites	–	Avoid
Dextro-propoxyphene	Cardiotoxic metabolite norpropoxyphene accumulates	–	Avoid
Paracetamol	Hepatic clearance	1 g orally 3–4 times a day	Preferred simple analgesic