Patients with CKD experience pain at a similar burden to patients suffering from cancer. This causes a negative impact on quality of life, but also leads to missed dialysis treatments and increased ER visits and hospitalizations.
Pain management will become part of the ESRD Quality Incentive Program and is an essential skill for dialysis providers. In a recent review published in AJKD, Koncicki et al provide a nephrologist’s guide for pain management in CKD.
AJKDBlog: Nearly all nephrologists know to avoid NSAIDs in their patients with CKD, and thus typically recommend over-the-counter acetaminophen (Tylenol). For patients suffering from nociceptive non-neuropathic pain, what is the most appropriate next step if they do not obtain relief with this recommendation?
JS: When a first-line agent to address nociceptive pain like acetominophen is ineffective, it is helpful to step back and consider what is causing the pain and whether non-pharmacologic techniques have been explored. Non-pharmacologic techniques can range from physical therapy, massage, and joint-specific strategies to consideration for psychological therapies such as mindfulness and cognitive behavioral therapy. If non-pharmacologic techniques fail or do not adequately address the pain, I think about low-dose tramadol before moving to opioids. It’s important to remember that tramadol has side effects including disorientation and causes constipation similar to opioids and therefore, patients should be started on laxative or stool softener.
AJKDBlog: Many nephrologists fear prescribing narcotics or opioids for their patients due to concerns of addiction or abuse. How do you reconcile this concern with the desire to alleviate the patient’s pain burden?
JS: Whenever opioids are prescribed, a trusting relationship between the provider and patient must be established. This is best accomplished by setting expectations that includes an open discussion about expectations of pain management. I will proactively ask patients about risk factors including personal or family history of substance abuse, psychiatric illness, and their concerns about taking opioids. I would also encourage providers to use prescription drug monitoring program to identify aberrant behavior in patients on opioids.
AJKDBlog: When should a nephrology provider feel that a referral to a pain specialist is indicated?
JS: Managing pain is difficult especially given the busy life of a nephrology provider. However, our hope is that guides such as this review in AJKD will provide nephrology providers with tools to manage simple pain symptoms either nociceptive or neuropathic. I would recommend referral to palliative care or pain specialist for complex pain symptoms (mixed neuropathic/nociceptive, unremitting symptoms), concern for aberrant use, and patients who may be facing limited life expectancy. For the latter case, I would strongly recommend working with palliative care services.
AJKDBlog: Are there specific pain medications other than NSAIDs that need complete avoidance in CKD patients? What about medications that warrant caution due to decreased GFR?
JS: A big no-no is morphine as it is renally excreted into active agents that can cause neuroexcitability. We see this clinically as myoclonus, delirium, hyperalgesia (increasing sensitivity to pain), and allodynia (pain elicited from typically non-painful stimuli). With kidney disease, most opioids should be started at a lower dose and spaced to greater dosing frequency than patients with non-renal disease. Unless a patient has severe symptoms, I follow the advice of “Start low and go slow!”
AJKDBlog: Gabapentin (Neurontin) and pregabalin (Lyrica) are commonly used for neuropathic pain. What is the recommended dose adjustment for these medications based on diminished eGFR?
JS: Yikes…both of these medications are renally dosed and require thoughtful prescribing! Gabapentin is recommended no higher than 300 mg/day in patients with advanced CKD; however, side effects should be monitored and dosing adjusted accordingly. Pregabalin is dosed twice a day for eGFR > 30 mL/min/1.73 m2. However, as GFR drops beyond this, the dose should be decreased to daily. For dialysis patients, it should be given every other day. For both gabapentin and pregabalin, a small post-dialysis dose is often necessary to maintain effect. As much as I wish there was a ‘recipe’ for dosing these medications, often it is starting at a low dose and gently titrating dose for symptom effect and avoidance of adverse effects.
AJKDBlog: When medications are instituted in our CKD or dialysis patients, when should practitioners expect an improvement in symptoms, and when should this be reassessed?
JS: For most pain syndromes, it is important to emphasize with patients that getting to 0/10 on the pain scale may not be possible and that pain control may require titration over time to achieve improvement. I start by asking, “What number would your pain be considered tolerable?” Most patients will name a lower number that can serve as a pain management goal.
Also, it is important in the pain history to ask about the nature of the pain: When does it occur? What makes it worse? What makes it better? By exploring the nature of the pain, I can direct the patient to take the pain medications prior to activities that exacerbate or promote pain. Depending on the level of pain the patient is having and the need for titration, I will see the patient again within two weeks and ensure the patient has a way to call for pain concerns.
AJKDBlog: Thank you for these thoughtful responses!
All AJKD In Practice articles are available in this collection.