Wednesday, October 21, 2020

New Ways Of Managing Pain In Patients With kidney Disease

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Pain, both acute and chronic, is commonly prevalent in patients with chronic kidney disease (CKD). This is due to the myriad diseases that often coexist in kidney disease patients (like arthritis, diabetes, obesity, etc). I had earlier written a post on how certain painkillers adversely affect the function of the kidneys. So we know that many pain medications are bad for your kidneys.Few human maladies affect the quality of life as much as pain does. The World Health Organization has recommended a so called “Three Step Approach” to treat escalating levels of pain in the general population:
Step 1: Acetaminophen (Tylenol) or Non Steroidal Anti-inflammatory Drugs (NSAIDS, like ibuprofen,Motrin, Aleve, etc)
Step 2: Tramadol or low potency opioids like oxycodone (eg. in Percocet), or codeine (something that is found in Tylenol #3)
Step 3: More powerful opioids like morphine, fentanyl, methadone, etc
The above approach needs to be modified for patients with kidney disease. As we discussed earlier, given the damaging effects of NSAIDS on the kidneys and the risk of accumulation of some opioids in the body in patients with kidney disease, there are certain nuances that have to be kept in mind when recommending a safer pain regimen in CKD patients.
IS ASPIRIN SAFE FOR PATIENTS WITH KIDNEY DISEASE?
 
Aspirin is also an NSAID, just like ibuprofen. However, it has certain unique effects. In general (as we discussed earlier), at this time there is no medical evidence to support that regular use of low dose aspirin (as might be recommended for patients with heart disease) is harmful, even in patients with underlying kidney disease. Of course, patients taking aspirin need to be cautious about the risk of bleeding; even more so if they have kidney disease.
ARE ALL NON-ASPIRIN NSAIDS EQUALLY HARMFUL TO THE KIDNEYS?
 
NSAIDS affect the kidneys in multiple ways. They can temporarily reduce the blood supply to the kidneys, and cause scarring and permanent kidney damage over the long term. They also elevate your blood pressure and cause swelling/edema. But are all NSAIDS created equally? Not really. And it is important to appreciate this fact because for some patients, nothing else might work. In that situation, it is prudent to “pick the least toxic poison”. For instance, sulindac might be less toxic to the kidneys than ibuprofen.
WHICH OPIOIDS ARE RELATIVELY SAFER?
Just like tramadol, we are worried about the accumulation of opioids (eg. morphine) that could occur when taken by patients with kidney disease. Hence, we tend to prefer drugs that are not as dependent on the kidney’s function for excretion from the body. These include opioids like methadone which can also be excreted in the feces in patients with kidney disease.

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