Opioids in liver or renal failure?

[anbuitachi]

What is the general consensus for which opioid to use for pain control when patient has renal or liver failure or both? Seems like somewhat everything is metabolized by liver

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[dozitgetchahi]

Fentanyl.

Oxycodone is a possible option too.

 

[anbuitachi]

Fentanyl.

Oxycodone is a possible option too.

In liver? Wat about renal failure?

 

[Gastrapathy]

What do you mean by liver failure? ALF or cirrhosis? Opioids are a bad idea in ALF, used all the time in cirrhotics.

 

[Nivakia]

The list of the ok drugs you are thinking of are for renal failure. If you have liver failure too then you are out of luck, think of hospice patients where you just do it to alleviate their suffering. Toxicity isnt your concern right now.

 

[LovelyBRass]

What is the general consensus for which opioid to use for pain control when patient has renal or liver failure or both? Seems like somewhat everything is metabolized by liver

Tough question. This is how I think about it:

Renal failure:
Fentanyl and methadone safest
Dilaudid and oxycodone are ok with monitoring and does reduction (should probably avoid oxy in ESRD)
Avoid: codeine, meperidine, and morphine

Liver failure:
Avoid: meperidine, codeine, methadone
Fentanyl safest
Use with caution: morphine, Dilaudid, oxy, hydrocodone

The short of it (especially inpatient) is:
Liver failure: morphine and Dilaudid ok
Renal failure: fentanyl, methadone, Dilaudid ok
And no matter what you use, it should be dose-reduced and dosing should be spread out. Uptitrate as tolerated.

 

[anbuitachi]

Tough question. This is how I think about it:

Renal failure:
Fentanyl and methadone safest
Dilaudid and oxycodone are ok with monitoring and does reduction (should probably avoid oxy in ESRD)
Avoid: codeine, meperidine, and morphine

Liver failure:
Avoid: meperidine, codeine, methadone
Fentanyl safest
Use with caution: morphine, Dilaudid, oxy, hydrocodone

The short of it (especially inpatient) is:
Liver failure: morphine and Dilaudid ok
Renal failure: fentanyl, methadone, Dilaudid ok
And no matter what you use, it should be dose-reduced and dosing should be spread out. Uptitrate as tolerated.

Thanks. Any reason why dilaudid is super popular and not fentanyl? It seems to be safest in both cases. Or why is dilaudid used more than oxycodone when both seem good

 

[Raryn]

Thanks. Any reason why dilaudid is super popular and not fentanyl? It seems to be safest in both cases. Or why is dilaudid used more than oxycodone when both seem good

For IV, Dilaudid lasts longer than fentanyl and is more potent for a given commonly used dose (1mg of dilaudid is roughly equianalgesic to 75mcg of fentanyl). The downside is anecdotal evidence that dilaudid causes more euphoria than fentanyl.

For PO, oxycodone tablets are much more readily available and commonly used, because they are available in different forms (immediate release, immediate release in combination with acetaminophen, extended release) and because providers generally have more experience with them compared to PO dilaudid.

edit: fixed a mistake in the #s above

 

[visari]

Or why is dilaudid used more than oxycodone when both seem good

I don't think PO dilaudid is used more than oxy. I like the combination of methadone as a long acting and morphine as a short acting. I try to avoid the ones that have high street value.

 

[Crayola227]

YOU DO NOT NEED TO AVOID MORPHINE IN RENAL FAILURE

dose adjust

you can do up to 24 mg/24 hr if the patient is not opiate naive from a metabolite clearance standpoint

MORPHINE AND ITS METABOLITES ARE NOT INTRINSICALLY RENOTOXIC

avoiding morphine has to do with avoiding build up of its nasty side effect-y (including sz so I'm not saying go crazy) metabolites, it is not actually hurting the kidneys
equianalgesic doses of fentanyl and dilaudid are preferred becuase there is less concurrent metabolite build up issues

keep in mind the magic power that other opiates do not have compared to morphine: REDUCING AIR HUNGER
because it suppresses respiratory drive as they all do, this one just feels better, yes, balance that with respiratory drive in your COPD'ers etc

Why does this matter?
You can give the CKD patient dilaudid or fentanyl for pain control, and if everyone's happy, great

but if that CKD'er is air hungry or just begging for morphine because it works better (yes, newer opiates did not supplant the older ones because they are unique and people react uniquely to them, it is not just about duration of action etc) then barring other factors their kidneys can have morphine as long as it is dose adjusted

every one will say you are wrong, even palliative maybe, call pharm, they'll back you

 

[Raryn]

YOU DO NOT NEED TO AVOID MORPHINE IN RENAL FAILURE

dose adjust

you can do up to 24 mg/24 hr if the patient is not opiate naive from a metabolite clearance standpoint

MORPHINE AND ITS METABOLITES ARE NOT INTRINSICALLY RENOTOXIC

avoiding morphine has to do with avoiding build up of its nasty side effect-y (including sz so I'm not saying go crazy) metabolites, it is not actually hurting the kidneys
equianalgesic doses of fentanyl and dilaudid are preferred becuase there is less concurrent metabolite build up issues

keep in mind the magic power that other opiates do not have compared to morphine: REDUCING AIR HUNGER
because it suppresses respiratory drive as they all do, this one just feels better, yes, balance that with respiratory drive in your COPD'ers etc

Why does this matter?
You can give the CKD patient dilaudid or fentanyl for pain control, and if everyone's happy, great

but if that CKD'er is air hungry or just begging for morphine because it works better (yes, newer opiates did not supplant the older ones because they are unique and people react uniquely to them, it is not just about duration of action etc) then barring other factors their kidneys can have morphine as long as it is dose adjusted

every one will say you are wrong, even palliative maybe, call pharm, they'll back you

And then your patient will start twitching from the toxic metabolites.