How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis?

Pregabalin is structurally related to gabapentin and is indicated for a variety of neuropathic pain conditions. Pregabalin is 90% excreted unchanged in the urine, and approximately 50% of drug is removed after four hours of hemodialysis. Dose adjustments are required in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.²⁸

Antidepressant options. Amitriptyline, nortryptiline, and desipramine are the tricyclic antidepressants (TCAs) commonly used for neuropathic pain. TCAs are metabolized in the liver to inactive metabolites, with the exception of amitriptyline, which is metabolized to nortryptiline. Common side effects reported with TCAs include postural hypotension and anticholinergic side effects, such as constipation, urinary retention, blurred vision, dry mouth, delirium, and sedation. It is unlikely that the TCAs can be removed by dialysis. It is suggested that the dosage be reduced in renal insufficiency and that anticholinergic side effects be monitored.²⁹

Back to the Case

The patient’s ankle pain was controlled with acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some relief.

A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.

Bottom Line

Pain management in patients with renal insufficiency and dialysis can be challenging, but there are a number of safe non-narcotic and narcotic pain regimens that can be safely used in this patient population.

Dr. Harisingani is a board-certified hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y., and Drs. Saad and Cassagnol are assistant clinical professors at St. Johns University College of Pharmacy and Health Sciences in Jamaica, N.Y., and clinical pharmacy coordinators at Long Island Jewish Medical Center.

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