Problems in treating pain in patients with chronic kidney disease
Patients who have chronic kidney disease (CKD) often suffer from pain, both acute and chronic. Kidney disease patients usually have many other diseases, such as arthritis, diabetes, obesity, etc, that cause pain as well. Unrelieved pain is a serious problem in patients with kidney disease because doctors usually tell their patients that painkillers are harmful for kidney disease. Even though certain medications are not dangerous for kidney, they still can accrue in your body and harm other organs, and therefore harm kidney.
It can be challenging to find an appropriate pain medication for patients with kidney disease due to these factors. However, leaving pain untreated is definitely not a good choice. So, what could patients with kidney disease do to manage their pain conditions? What could be some feasible options?
Three Step Pain Relief Ladder
The Who (World Health Organization) has introduced “Three Step Pain Relief Ladder” to treat intensified levels of pain in the majority of people.
- 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)
- Step 3: More powerful opioids like morphine, fentanyl, methadone, etc
Solutions for Pain Relief in Patients with CKD: Adjusting Three Step Approach
The “Three Step Pain Relief Ladder” approach doesn’t suit completely for patients with CKD. Thus, you will need to adjust it to avoid NSAIDS harmful effects and accumulating of some opioids in your body, and as result not to injure your kidneys. Below you can see a modified approach with a safer program for pain relief in patients with CKD.
- Try non-medication ways to relieve your pain, e.g. massage, heat therapy or cryotherapy.
- Stick to Tylenol as much as possible because it is rather safe for kidneys compared to NSAIDs.
- There are different causes of pain and according to the type of pain you have you should take an appropriate pain medication. For example, to manage neuropathic pain there is a gabapentin (Neurontin); for fibromyalgia patients there is a Cyclobenzaprine (Flexeril) that might help. Your doctor will prescribe you a right medication and a right dose depending on your particular situation.
- If you take aspirin, it is better to take aspirin for kids with the dose of 81mg. The lower dose is better for patients with CKD. Moreover, if aspirin is combined with other meds such as phenacetin or acetaminophen it can lead to the damaging effects of them. However, most medical studies did not indicate that aspirin is dangerous for CKD.
- If you take an NSAID, you have to be aware about the fact that different NSAIDs inflict different levels of harm on kidney disease. Therefore, they all are not the same. But for some patients nothing else might work, so they need to take NSAIDs anyway. In this case, it is important to choose the safest and least toxic option, e.g. sulindac is safer for kidneys than ibuprofen.
NSAIDs are available in short-acting and long-acting forms. For kidneys, short-acting NSAIDs (like ibuprofen and diclofenac) are less harmful than long-acting ones (like naproxen). Also, keep in mind that the latest produced COX-2 inhibitors (like Celebrex or Mobic) can be as detrimental for kidneys as the older NSDAIDs.
- Next step is Tramadol and other low potency opioids that are controlled substances. Tramadol is not known to be harmful for kidneys; however you should be aware of some important points. Tramadol’s metabolites can accumulate in patients with CKD and then lead to muscle spasms and breathing issues. Therefore, the dosage of Tramadol should be the lowest possible and you will need to take it only under careful doctor’s monitoring.
- If above described drugs do not work for you, you will probably need stronger painkillers. These include strong opioids, such as morphine or methadone. They do not interfere with kidney’s blood supply unlike NSAIDs. But, it still can be detrimental for patients with kidney disease because opioids can accumulate in the body and affect kidney’s function. For that reason it is better to choose those kinds of drugs that do not directly affect kidney’s function for excretion from the body, for example, methadone which can be excreted in the feces.
For CKD patients managing any kind of pain can be challenging. Your nephrologist together with pain management doctor should closely monitor your treatment and recommend you an appropriate medication. You should not leave your pain un-treated because it will bring a lot of inconveniences and problems to your life.