Chronic Kidney Disease
Table 2: Management of Opioid-related Adverse Effects Adverse Effects
Drowsiness Constipation Management Strategies for Adverse Side Effects
• Frequent when opioid first started and can lessen with on-going therapy. • If persistent, try reducing the dose of the prescribed opioid.
• Initiate bowel regimen when starting any opioid: docusate sodium and lactulose 15–30 ml PO OD–BID ± senna glycosides.
• If no bowel movement in 48–72 hours, check for impaction; may require manual removal: administer bisacodyl suppository ± glycerin suppository; increase docusate, lactulose, and senna glycosides as tolerated.
Vomiting and nausea • Symptoms frequently resolve as opioid tolerance develops, and when doses of opioids are titrated slowly. It may help to reduce current opioid dose and titrate more slowly or to switch opioids.
• Ensure patient is not constipated. • Symptoms due to central stimulation may respond to: prochlorperazine 2.5–10 mg PO/PR/IV/SC QID prn; metoclopramide 5–10 mg PO/IV/SC QID prn; haldol 1–2 mg PO/IV/SC q8h prn especially if altered mental status is evident.
• Symptoms from gastric stasis or delayed emptying may respond to: metoclopramide 5–10 mg PO/IV/SC QID; domperidone 5–20 mg PO TID–QID.
• Symptoms due to vestibular stimulation may respond to: dimenhydrinate 25–50 mg PO/PR/IV/SC q4–6h prn.
Hyperalgesia
• Repeated opioid exposure may cause sensitization and worsening pain despite high opioid doses. Optimal treatment options include: decrease in the opioid dose; rotating to a different opioid (e.g. switching hydromorphone to fentanyl or methadone).
Neurotoxicity including • Symptoms include: anxiety, agitation, confusion, restlessness, hallucinations, myoclonus, sleep disturbances, inability to localize pain, delirium and altered mental status
or hyperalgesia.
• Symptoms may occur suddenly or over time and fluctuate. Close clinical monitoring when opioids are initiated and titrated is encouraged. Rule out dehydration and hypercalcemia (corrected serum Ca++ ≥2.65 mmol/l). If applicable, stop non-recommended opioids such as morphine or codeine (both extended release and short acting), and switch to an opioid such a fentanyl or methadone that does not accumulated in CKD. This may require consultation with a pain management expert.
Consider a neuroleptic (e.g. haloperidol 1–2.5 mg q6h and q1h prn for agitation). Avoid benzodiazepines except for severe or dangerous agitation. If needed, use short-acting agents e.g. Midazolam 1–2 mg SC q15 minutes prn.
• It may take days to weeks for patients with CKD to recover from opioid neurotoxicity. Minimize stimulation to patient. Re-orient them. Encourage oral fluids up to their daily maximum.
• **Naloxone does not reverse opioid neurotoxicity. It only reverses opioid narcosis (respiratory depression and excessive sedation).
Respiratory depression • Refer to your facility’s parenteral drug monograph for naloxone. (respiratory rate < 8/minute), or
excessive sedation
Known or suspected opioid overdose
• Naloxone 0.1–0.2 mg IV q3 minutes **OR** 0.2 mg IM/SC q5 minutes.
• Aim for a respiratory rate >10/minute. If no response at 2–10 minutes, repeat naloxone q2 minutes IV or q5 minutes SC/IM up to a total 0.8 mg.
• Monitor respiratory rate q15 minutes up to 1 hour. If opioid half-life exceeds that of naloxone, repeated naloxone doses or an infusion may be required.
• Refer to your facility’s parenteral drug monograph for naloxone.
• Naloxone 0.4–2 mg IV q3 minutes as needed if no response up to 10 mg. • Continuous infusion (monitored setting): 0.4 mg/hour after loading dose of 0.4 mg. • In cases of a large narcotic dose, or a fentanyl or methadone overdose, higher naloxone doses may be needed. • If no response after 10 mg of naloxone, reassess diagnosis.
BID = twice daily, CKD = chronic kidney disease, IM = intramuscular, IV = intravenous, OD = once daily, PO = oral, prn = as needed, PR = rectal, QID = four times daily, qnh = every n hours, SC = subcutaneous, TID = three times daily.
chronic pain is acutely relieved, for example with amputation of an ischemic limb, the opioid antagonism related to the pain itself is relieved. Anticipating toxicity can minimize prolonged consequences such as protracted delirium. The constellation of baseline symptoms that affect patients with CKD can mimic or deteriorate with opioid toxicity. Table 2 outlines common opioid-related complications and effective management strategies. Constipation is near universal, so laxatives are indicated
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whenever opioids are prescribed. Respiratory depression is unusual when titrating with short-acting oral preparations. Nausea affects approximately 50 % of patients but typically resolves due to tolerance and responds to anti-emetics. Delirium is less common; it should be managed with opioid dose reduction, transition to an alternative opioid, and/or low-dose haloperidol. There are associative data suggesting increased falls and fractures among CKD patients on opioids.92,93
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