Opioids for hemodialysis patients

[specepic]

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For those of you who do opioid management what are your preferred opioids for hemodialysis patients. I have a gentleman that takes 5 mg of oxycodone per day, as needed. Starting to get diminishing returns after a couple years and does get some constipation so does not really want to go up on the strength. I was considering Butrans patch. I think methadone would also be an option although frankly I think I would prefer the Butrans

Other options you think about with these folks. I do not really care for fentanyl patches for multiple reasons, plus I think it is more than he is going to need

Other ideas?

 

[lobelsteve]

Dilaudid 2mg

 

[Snowmen96]

Avoid morphine at all cost, can lead to potentially lethal seizures secondary to metabolite accumulation in ESRD.

 

[clubdeac]

Last I read up on opioids and renal clearance was over 10 yrs ago but from what I remember fentanyl, dilaudid and methadone were the best in ESRD.

 

[specepic]

Any reason that buprenorphine/Butrans would be a bad choice?

 

[Mofasa]

Buprenorphine / Butrans is definitely the best and safest choice (would not start anything higher than 5 mcg/hr patch) for this pt who only uses 7.5 MME in a day.

The only downside is sometimes insurance problems, and they are too expensive to pay for out pocked ($400-600 is what I hear). Good chance that they will need a prior authorization and can be annoying. I have even had prior denials because they want me to start a long acting full agonist opioid, which I can usually successfully appeal, but other than that had good results with buprenorphine / Butrans for pain.

 

[Ducttape]

for acute pain, dilaudid is typically the best choice.

if he is taking 5 mg per day, not sure why you would be considering escalating to methadone.

if he is only on 5 mg a day, but you are worried about tolerance developing (which seems unlikely at that low a dose), consider an opioid holiday for a month. he may find he doesnt need, and when you re-institute, he may find slightly improved benefit.

 

[Agast]

buprenorphine or methadone

Low doses for both

 

[kstarm]

Buprenorphine is easily the best choice here, and the patch is usually the most convenient. Just remember the Flonase for the skin, or hydrocortisone cream. Generally Dilaudid is best tolerated of the full agonist but there is always exceptions to these "rules".