Clinical Pathway and Drug Choices for Chronic Pain in Patients on Dialysis – FHA Renal Program
Before selecting drug therapy below, determine current and previously tried analgesics and document on page 2
Neuropathic Pain Component (DN4 score > 4)
►Gabapentin: 200 to 300 mg x 1 HS then 100 mg po QHS and
increase weekly to a maximum of 300 mg QHS.
►Acetaminophen to a maximum of 4 g/day, including acetaminophen in ►Capsaicin Cream 0.025% or 0.075% applied BID to QID for
other products (caution if Hx of EtOH or other liver enzyme inducers e.g.
rifampin and in heart failure). Follow GGT & ALT at least q 3 months if dose
May take 2 weeks or more for full onset of effect of these agents
is over 2.6 g/day) ►Topical NSAIDs localized pain. Apply TID to QID – no association with GI bleeding. (e.g. diclofenac 1.5% in DMSO (Pensaid® or 5 to 25% in Phlogel®. Add an opioid: (AVOID MEPERIDINE & MORPHINE) Complete opioid abuse risk assessment scale on page 2. Titrate dosage each dialysis run based on pain assessment flowsheet.scores (note: neuropathic pain may require higher target doses)
►Nortriptylline 10 mg po QHS & titrate by 10 mg to max 50 mg QHS
►Venlafaxine 37.5 mg po QAM and increase in a week to 75 mg QAM
►Nabilone 0.25 to 0.5 mg po QHS and increase by 0.25 to 0.5 mg QHS
►Oxycodone (generic tablets and Percocet).
every week to a maximum of 2 mg QHS (caution in elderly: start with
Initial dose in opiate naïve pts: 2.5 to 5 mg PO q3-4 hours.
0.25 mg dose – compound in simple syrup 5 mg/50mL since current capsules 0.5 or 1 mg only). Nabilone is also a strong antiemetic.
Once analgesic requirements are stable (allow a few days) consider
►Pregabalin: start at 25 mg po QHS and increase every few days to a
conversion to long-acting agents (refer to opioid conversion chart below)
maximum of 75 mg QHS (not currently covered by drug plans)
Continue to provide short-acting opioid & acetaminophen for breakthrough pain (approx. 1/10th total daily narcotic dose Q2H prn)
►Hydromorphone SR capsules PO Q12H (available in 3 mg increments).
Titrate dosage every 2 to 3 days. (note: neurotoxic metabolite H3G
accumulates if HD is d/c). ►Oxycodone SR tablets PO Q12H (available in 10 or 20 mg increments) Alternative Agents in select cases Vitamin E 400 units or Quinine SO4 300 mg po Daily. Both ►Fentanyl Transdermal Patches Useful choice if non-adherance to
effective in about 1/3 pts. Vitamin E has less adverse effects
Rx a concern (may apply in the HD unit 3x/week) . Apply to new area q2-3 days. Increase dose to next patch size every 2nd run as required.
Restess Legs ►Analgesic Methadone (for opioid allergy or adverse effects/refractory
May be associated with inadequately treated neuropathic pain
pain not controlled by other opioids & adjuvant drugs or if pt taken off HD
Choose from the following (switch if ineffective after a week at
– no toxic metabolites). Baseline QTc and repeat EKG if daily dose > 40
mg. Many drug interactions (e.g. macrolides, quinolones, fluconazole).
►Carbidopa/Levodopa 100/25 CR or IR: ½ to 1 tab QPM or BID
MD needs approval from BCCP&S to Rx.
►Low dose opioid in late afternoon/evening or BID. Consider SR
Initial dose: 1 or 2 mg PO or SL TID and titrate dose gradually Q dialyisis
formulations if short-acting version wears off.
run (available as: 1 mg. 5 mg, 10 mg & 25 mg tabs or 1mg/mL liquid).
►Clonazepam (if not on another benzodiazepine) 0.25 mg to max 1 mg QHS ►Ropinirole (Requip) 0.25 mg QPM or BID & increase q 2-3 days (max 4 mg per day; expensive) Management of opioid adverse effects.
Excessive sedation, low respiratory rate etc. Small doses of naloxone 0.1 mg SC or IV every 1or 2 minutes unless severe respiratory depression in which case 0.4 mg SC or IV should be used OPIOID CONVERSION TABLE (for patients on chronic opioids) initially (along with other supportive measures such as resp. support). Effective dose may need to be repeated every 1-2 hours over several hours Morphine for long-acting narcotics (consider continuous infusion). Hydromorphone
Drugs of choice: prochlorperazine (Stemetil) 2.5 to 10 mg PO, SC or PR QID
PRN or haloperidol (Haldol) 0.5 to 1 mg po PO, SL, IV, SC BID prn (Haldol soln Fentanyl Patch 12 mcg/h = 12 mcg/h =
is flavourless) or metoclopramide (Maxeran) 5 to 10 mg PO, SC, IV QID prn. 10 to 30 mg/day 20 to 60 mg/day Dimenhydrinate (Gravol) may be used 25 to 50 mg PO, SC, IV but is less IV/SC morphine PO morphine
effective, except if secondary to motion/dizziness.
Constipation (monitor on the pain flowsheet)
BCPRA covers several laxatives. Use combinations of these per pt. preference.
Give pt. a handout on constipation when starting opiates.
BLange PharmD, KMahoney MSN, JMarin PharmD
for FHA renal pain working group Sept 2, 2009
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