Pain is a common symptom in patients with ESKD, and impacts significantly on quality of life and function.
Pathogenesis can be
- pain relating to the underlying kidney disease such as polycystic kidney disease, renal bone disease, amyloid deposition (carpal tunnel syndrome), and calciphylaxis;
- pain related to management of ESKD, such as steal syndrome, intradialytic cramps, intradialytic headaches, abdominal pain with peritoneal dialysis; and
- pain related to co-morbidities such as musculoskeletal disease, peripheral neuropathy, peripheral vascular disease, ischaemic heart disease, gouty arthropathy
Take a detailed pain history. Patients may have multiple causes of pain.
Treat the underlying cause if possible.
For specific pain syndrome such as diabetic peripheral neuropathy or osteoarthritis, follow evidence-based guidelines. If certain medications are relatively contraindicated in renal failure, check pharmacokinetics and adjust doses according to renal function.
For musculoskeletal pain, use non-pharmacological strategies as the mainstay of treatment: for example, heat packs or cold packs, joint splinting, gentle exercises, and hydrotherapy.
Treat co-morbid depression and/or anxiety.
For chronic non-cancer pain, consider referral to a multidisciplinary pain clinic.
Nociceptive/soft tissue pain
For localised pain, consider topical therapies. Commonly available agents include:
- Zen liniment
- Ice3 Gel (Menthol)
- Topical NSAIDs
Systemic treatment should follow WHO analgesic ladder
Step 1: Non-opioid analgesia
Regular paracetamol is safe is renal failure, use 1g qid if needed
Systemic NSAIDs are contraindicated
Step 2: weak opioids
Codeine and tramadol are not routinely used in this population
Step 3: Strong opioids
Preferred short acting strong opioids are:
- Hydromorphone, start with 0.25mg-0.5mg q4h, and titrate slowly to effect
- Oxycodone, start with 2.5mg q6h, and titrate up to effect
- Fentanyl lozenge or sublingual preparations, start 100-200mcg qid (not PBS subsidized for non-cancer pain)
Preferred long acting strong opioids are
- Buprenorphine patch, starting at 5mcg/h
- Fentanyl patch (NB should not be initiated in opioid naïve patients, even at the lowest dose of 12mcg – instead, begin with short acting opioids)
- Oxycontin (starting doses based on oxycodone requirement)
- Palexia XR up to 50mg BD
- Faecally excreted and not dialysed
- Palliative guidance is usually required due to complex pharmacokinetics.
Morphine should avoided in renal failure.
Paracetamol should be maintained as background treatment.
The following medications can be used, either
- as first line for neuropathic pain, OR
- as an adjunct in nociceptive pain, according to WHO analgesic ladder
- Gabapentinoids (gabapentin or pregabalin)
- Commence gabapentin 100mg or pregabalin 25mg alternate nights for non-dialysis (eGFR<15ml/min) and peritoneal dialysis patients, or 3x weekly post-dialysis for haemodialysis patients. Additional dose post APD if pain control suboptimal during daytime.
- Up-titration if limited efficacy without side effects: to gabapentin 100mg nocte and then 100mg bd or pregabalin 25mg nocte and then 25mg bd. Higher doses can be used if well tolerated
- Main side effects include drowsiness, ataxia, clumsiness, blurred vision
- These drugs are used in restless legs syndrome and uraemic pruritus
- Tricyclic antidepressants
- Amitriptyline 10mg nocte. Titrate up to 25mg nocte after 3-7 days, and to 50mg nocte after 1-2 weeks. If no efficacy at 50mg nocte, consider other alternatives.
- Common side effects include drowsiness, dry mouth, and constipation
- Duloxetine (SNRI) has evidence for efficacy in painful diabetic peripheral neuropathy. Use 30mg daily.
- Other medications useful for neuropathic pain include: lignocaine, mexiletine, and methadone, with pain team or palliative care guidance.
Neuropathic creams can trialled in localised neuropathic pain, but requires use of a compounding pharmacy. Example: Lignocaine/tetracaine/prilocaine.
Lignocaine 5% patches (Versatis) can be used for post-herpetic neuralgia on the involved dermatome.