Use of Opioids in Renal Disease

Use of Opioids in Renal Disease

21. What adjustments in analgesic dosing would be required if T.J. had an estimated creatinine clearance of 30 mL/minute?

Uremia can produce CNS changes, which can cause patients with renal disease to be more sensitive to the CNS depressant effects of opioids. As discussed in Question 6, some opioids have active metabolites that are renally excreted, and uremia or significant renal disease can lead to their accumulation. For example, the active metabolites of meperidine and morphine (normeperidine and morphine-6-glucuronide, respectively) are renally excreted. Both of these active metabolites can cause CNS excitation; in particular, normeperidine can precipitate tonic-clonic seizures. Therefore, meperidine should be avoided in uremic patients, but other opioids can be used as long as the clinician is aware of the potential toxicities, the patient is closely monitored, and the dosage is properly titrated. For T.J., hydromorphone PCA could still be a reasonable choice for the management of her acute pain; however, a continuous basal infusion would be unnecessary in a patient with significant renal dysfunction. As with all patients receiving opioid analgesics, close monitoring and follow-up care are essential.

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