Consistently low creatinine on UDS??

[PainBrain78]

I have a patient who was referred by a retiring rheumatologist on 90 MMES morphine. She was consistently short on her morphine and I transitioned to buprenorphine. Since starting buprenorphine every UDS (three times now) has reported abnormal creatinine (“dilute urine. May result in false negative. Possible deliberate diluation.”) Her UDS on her initial visit did not show abnormal creatinine.

Could there a physiological reason for this or is she being facitious? I felt I couldn’t definitely discontinue buprenorphine based on that.

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[specepic]

Okay, am I missing something? I do not see the buprenorphine on the report? That would be the most important thing

 

[Agast]

Did she say the buprenorphine is helping? I’m assuming you mean like SL suboxone not a patch

Buprenorphine actually does have street value. People use it to avoid heroin withdrawals.

 

[PainBrain78]

Yes she says it helps. It does show negative buprenorphine but she’s on a low sublingual dose and I’ve grown accustomed to negative buprenorphine on UDS—even on GCMS. What’s strange to me is the negative buprenorphine and the abnormal creatinine. 🤷🏻‍♀️

 

[Agast]

If you really think she's being honest then maybe she's developed renal dysfunction in the interim and needs updated labs for that

 

[Ducttape]

dilute urine is an marker of diversion.

if GCMS is negative, and creatinine is so low, then they are diverting. doubt it is due to severe renal insufficiency - would probably be in abject renal failure for creatinine to be so low (id take a peek at the labs the PCP has done, including GFR to confirm she isnt in ARF).

if in doubt, do an impromptu pill count - stop in office today with their pills for actual count or discontinue therapy.

 

[Agast]

dilute urine is an marker of diversion.

if GCMS is negative, and creatinine is so low, then they are diverting. doubt it is due to severe renal insufficiency - would probably be in abject renal failure for creatinine to be so low (id take a peek at the labs the PCP has done, including GFR to confirm she isnt in ARF).

if in doubt, do an impromptu pill count - stop in office today with their pills for actual count or discontinue therapy.

She’s taking the gabapentin though. That’s interesting.

 

[lobelsteve]

I have a patient who was referred by a retiring rheumatologist on 90 MMES morphine. She was consistently short on her morphine and I transitioned to buprenorphine. Since starting buprenorphine every UDS (three times now) has reported abnormal creatinine (“dilute urine. May result in false negative. Possible deliberate diluation.”) Her UDS on her initial visit did not show abnormal creatinine.

Could there a physiological reason for this or is she being facitious? I felt I couldn’t definitely discontinue buprenorphine based on that.

Tell her to quit smoking. As the drug prescribed is not in UDS, don’t give her more. Refer for counseling. Put down the pen.

 

[soccrwz]

To be fair the buprenorphine looks like it wasn't tested, so hard to say inconsistent if you didn't test for it. I'm assuming this it he mg buprenorphine not the patch or buccal as the thresholds on those may be too low to detect. Also validity testing usually have specific gravity which would be helpful in a dilutional case with the creatinine being low. renal issues and liver dysfunction can cause hypoproteinuria. You could also do an ODS to confirm, pill count etc

 

[lobelsteve]

To be fair the buprenorphine looks like it wasn't tested, so hard to say inconsistent if you didn't test for it. I'm assuming this it he mg buprenorphine not the patch or buccal as the thresholds on those may be too low to detect. Also validity testing usually have specific gravity which would be helpful in a dilutional case with the creatinine being low. renal issues and liver dysfunction can cause hypoproteinuria. You could also do an ODS to confirm, pill count etc

Lets assume he tested for more than gabapentin and cigarettes.

 

[namethatsmell]

Is the patient cachectic? Low muscle mass is another potential cause of low creatinine.
And as others have mentioned, I've also had a few patients on low doses of bup not have detectable levels and then test as expected if their dose was increased.

One of these two things being present is possible, but both happening at the same time seems suspect. Occam's Razor and what not.

Edit: Just realize you wrote about her Cr being normal when she was on morphine...unless that was along time ago and/or she's had a major change in her health status, that doesn't jive. If you really want to believe her you could give her the option to present for observed dosing M-Th and then a chaperoned UDS on Friday.

 

[soccrwz]

Lets assume he tested for more than gabapentin and cigarettes.

the rest of the doc needs to be posted, better to know than assume

 

[Baron Samedi]

Order a urine specific gravity with the next UDS

 

[Ducttape]

Bup will show up unless you are ordering only qualitative testing, which it doesn't appear you are doing.

Make sure you are asking for levels (GS/LC), and if a level is ZERO, she is not using. Yes it might be low like <10, but there will be a positive number if she is using.

The beauty of the patch if you can visibly see it. In the patients that I have had, a qualitative will be negative (<10) but you can see it and the quantitative will be positive.

 

[Ferrismonk]

If you're prescribing milligrams of buprenorphine, it should be in the UDS. My 10mcg butrans shows up in the UDS I collect. Creatinine is slow likely because she's drinking too much water before her appointment (planning to give a UDS for potentially reasonable or potentially nefarious reasons, either way that's bad) or adding water to her cup before she gives it to you.

If you really want to continue meds, do a random mid-month pill count and/or have her do an oral or blood test to prove herself. Otherwise, stop giving her meds.

 

[specepic]

Was the dose and route of the buprenorphine posted or did I miss that, that would seem important

 

[BobBarker]

Bupe patches in big people don’t show up sometimes on gc/Ms.

 

[PainBrain78]

Lets assume he tested for more than gabapentin and cigarettes.

Yes this is a GCMS full testing. The first page was only the summary. It tests for all opioids, illicit substances, even anti depressants, anticonvulsants and muscle relaxers.

 

[PainBrain78]

Was the dose and route of the buprenorphine posted or did I miss that, that would seem important

It’s 1 mg BID

 

[Ducttape]

what have her pill counts been?

do a random pill count.

dose is low but seems that it should be showing up.

 

[GorillaPanic]

Absolutely would detect bupe 1mg BID…

 

[MitchLevi]

Diversion until proven otherwise. Obviously. This pt is fired by me.

 

[lobelsteve]

Diversion until proven otherwise. Obviously. This pt is fired by me.

You mean the drugs are fired.

 

[MitchLevi]

You mean the drugs are fired.

No, the pt is fired.

Here's what happens - I say the drugs are gone and I offer nonopiate options. The pt gets pissed and never comes back.

Maybe a bad review on Google to go along with her negative reviews of McDonald's, Applebee's and Sonic.

Whether I fire her outright like I'm Donald J Trump or document my offering nonopiate options and try to keep her results in the same outcome.

 

[lobelsteve]

No, the pt is fired.

Here's what happens - I say the drugs are gone and I offer nonopiate options. The pt gets pissed and never comes back.

Maybe a bad review on Google to go along with her negative reviews of McDonald's, Applebee's and Sonic.

Whether I fire her outright like I'm Donald J Trump or document my offering nonopiate options and try to keep her results in the same outcome.

Stop the drug. Let the patient go elsewhere. We are on same page. “Fired” means I am not abandoning you, I am just not writing any prescriptions for you.

 

[Agast]

fired patients don’t always write negative reviews. The people who write negative reviews are the ones you try to help and they freak out on you because they’re not any better after an injection and you didn’t cry in the room with them a week later.