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Rodrigues R, Costeira C. Pain Assessment in Patients during Hemodialysis Treatment: Quality Improvement Project. NURSING REPORTS 2024; 14:1370-1387. [PMID: 38921713 PMCID: PMC11206322 DOI: 10.3390/nursrep14020103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Pain is a prevalent symptom in patients with chronic kidney disease, related to disease progression, comorbidities, and required immobility during dialysis treatment. Nurses must perform detailed pain assessments to manage pain effectively during hemodialysis treatment. This quality improvement project, reported using SQUIRE 2.0, aims to describe pain characteristics in chronic kidney disease patients in a hemodialysis unit clinic in Portugal, implement strategies to improve the pain assessment process in patients with chronic kidney disease during hemodialysis treatment, and assess nurses' satisfaction with the implemented strategies. The study was conducted in a Portuguese hemodialysis clinic, with patients and nurses, in three phases: diagnostic study, protocol implementation, and a descriptive study to assess nurse satisfaction. Seventy-five patients (mean age 71 ± 12.6 years) participated, with 64% reporting moderate chronic pain daily and 48% during hemodialysis treatment. Thirteen nurses considered the pain assessment protocol important, rating their satisfaction at 7.92 ± 1.32 (0-10). Standardizing practices through protocol implementation is likely to improve care and increase nurse satisfaction.
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Affiliation(s)
- Rita Rodrigues
- School of Health Sciences of Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal;
- Local Unit of Leiria, R. de Santo André, 2410-197 Leiria, Portugal
| | - Cristina Costeira
- School of Health Sciences of Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal;
- Centre for Innovative Care and Health Technology (ciTechCare), Campus 5, Polytechnic of Leiria, Rua das Olhalvas, 2414-016 Leiria, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3004-011 Coimbra, Portugal
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2
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Bonanad C, Buades JM, Leiva JP, De la Espriella R, Marcos MC, Núñez J, García-Llana H, Facila L, Sánchez R, Rodríguez-Osorio L, Alonso-Babarro A, Quiroga B, Bompart Berroteran D, Rodríguez C, Maidana D, Díez J. Consensus document on palliative care in cardiorenal patients. Front Cardiovasc Med 2023; 10:1225823. [PMID: 38179502 PMCID: PMC10766370 DOI: 10.3389/fcvm.2023.1225823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
There is an unmet need to create consensus documents on the management of cardiorenal patients since, due to the aging of the population and the rise of both pathologies, these patients are becoming more prevalent in daily clinical practice. Chronic kidney disease coexists in up to 40%-50% of patients with chronic heart failure cases. There have yet to be consensus documents on how to approach palliative care in cardiorenal patients. There are guidelines for patients with heart failure and chronic kidney disease separately, but they do not specifically address patients with concomitant heart failure and kidney disease. For this reason, our document includes experts from different specialties, who will not only address the justification of palliative care in cardiorenal patients but also how to identify this patient profile, the shared planning of their care, as well as knowledge of their trajectory and the palliative patient management both in the drugs that will help us control symptoms and in advanced measures. Dialysis and its different types will also be addressed, as palliative measures and when the decision to continue or not perform them could be considered. Finally, the psychosocial approach and adapted pharmacotherapy will be discussed.
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Affiliation(s)
- Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Biomedical Research Institute (INCLIVA), Valencia, Spain
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
| | - Juan M. Buades
- Nephrology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Spain
- Institute for Health Research of the Balearic Islands (IdISBa), Palma de Mallorca, Spain
| | - Juan Pablo Leiva
- Support and Palliative Care Team, Hospital Manacor, Palma de Mallorca, Spain
| | - Rafael De la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Biomedical Research Institute (INCLIVA), Valencia, Spain
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
| | - Marta Cobo Marcos
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
- Cardiology Department, Hospital Puerta del Hierro, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Biomedical Research Institute (INCLIVA), Valencia, Spain
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
| | - Helena García-Llana
- Universidad Internacional de La Rioja (UNIR), La Rioja, Spain
- Centro de Estudios Superiores Cardenal Cisneros, Universidad Pontifica de Comillas, Madrid, Spain
| | - Lorenzo Facila
- Cardiology Department, Consorcio Hospital General de Valencia, Valencia, Spain
| | - Rosa Sánchez
- Nephrology Department, Hospital Universitario General de Villalba, Madrid, Spain
| | | | | | - Borja Quiroga
- Cardiology Department, Consorcio Hospital General de Valencia, Valencia, Spain
| | | | - Carmen Rodríguez
- Nephrology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Javier Díez
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
- Center for Applied Medical Research (CIMA), and School of Medicine, Universidad de Navarra, Pamplona, Spain
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3
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Hafez G, Malyszko J, Golenia A, Klimkowicz-Mrowiec A, Ferreira AC, Arıcı M, Bruchfeld A, Nitsch D, Massy ZA, Pépin M, Capasso G, Mani LY, Liabeuf S. Drugs with a negative impact on cognitive functions (Part 2): drug classes to consider while prescribing in CKD patients. Clin Kidney J 2023; 16:2378-2392. [PMID: 38046029 PMCID: PMC10689198 DOI: 10.1093/ckj/sfad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 12/05/2023] Open
Abstract
There is growing evidence that chronic kidney disease (CKD) is an independent risk factor for cognitive impairment, especially due to vascular damage, blood-brain barrier disruption and uremic toxins. Given the presence of multiple comorbidities, the medication regimen of CKD patients often becomes very complex. Several medications such as psychotropic agents, drugs with anticholinergic properties, GABAergic drugs, opioids, corticosteroids, antibiotics and others have been linked to negative effects on cognition. These drugs are frequently included in the treatment regimen of CKD patients. The first review of this series described how CKD could represent a risk factor for adverse drug reactions affecting the central nervous system. This second review will describe some of the most common medications associated with cognitive impairment (in the general population and in CKD) and describe their effects.
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Affiliation(s)
- Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | - Mustafa Arıcı
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
| | - Marion Pépin
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
- Department of Geriatrics, Ambroise Paré University Medical Center, APHP, Boulogne-Billancourt, France
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Biogem Research Institute, Ariano Irpino, Italy
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
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4
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Molnar AO, Bota SE, Naylor K, Nash DM, Smith G, Suri RS, Sood MM, Gomes T, Garg AX. Opioid prescribing practices in chronic kidney disease: a population-based cohort study. Nephrol Dial Transplant 2022; 37:2408-2417. [PMID: 34888696 DOI: 10.1093/ndt/gfab343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic pain is common, and its management is complex in patients with chronic kidney disease (CKD), but limited data are available on opioid prescribing. We examined opioid prescribing for non-cancer and non-end-of-life care in patients with CKD. METHODS This was a population-based retrospective cohort study using administrative databases in Ontario, Canada which included adults with CKD defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 from 1 November 2012 to 31 December 2018 and estimated the proportion of opioid prescriptions (type, duration, dose, potentially inappropriate prescribing, etc.) within 1 year of cohort entry. Prescriptions had to precede dialysis, kidney transplant or death. RESULTS We included 680 445 adults with CKD, and 198 063 (29.1%) were prescribed opioids. Codeine (14.9%) and hydromorphone (7.2%) were the most common opioids. Among opioid users, 24.3% had repeated or long-term use, 26.1% were prescribed high doses and 56.8% were new users. Opioid users were more likely to be female, had cardiac disease or a mental health diagnosis, and had more healthcare visits. The proportions for potentially inappropriate prescribing indicators varied (e.g. 50.1% with eGFR <30 were prescribed codeine, and 20.6% of opioid users were concurrently prescribed benzodiazepines, while 7.2% with eGFR <30 mL/min/1.73 m2 were prescribed morphine, and 7.0% were received more than one opioid concurrently). Opioid prescriptions declined with time (2013 cohort: 31.1% versus 2018 cohort: 24.5%; p <0.0001), as did indicators of potentially inappropriate prescribing. CONCLUSIONS Opioid use was common in patients with CKD. While opioid prescriptions and potentially inappropriate prescribing have declined in recent years, interventions to improve pain management without the use of opioids and education on safer prescribing practices are needed.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,ICES, ON, Canada
| | | | | | | | | | - Rita S Suri
- Research Institute of the McGill University Health Center (MUHC), and Division of Nephrology, Department of Medicine, MUHC, Montreal, QC, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Manish M Sood
- ICES, ON, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tara Gomes
- ICES, ON, Canada.,Unity Health, Toronto, ON, Canada
| | - Amit X Garg
- ICES, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
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5
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Ethical Challenges When Caring for African American Older Adults Requesting to Withdraw From Dialysis. J Hosp Palliat Nurs 2022; 24:209-217. [PMID: 35488364 DOI: 10.1097/njh.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The number of African American adults 65 years and older with end-stage kidney disease receiving maintenance hemodialysis is increasing. The high symptom burden (ie, pain, fatigue, depression) can make it challenging for many to continue dialysis, which can lead to request to withdraw from dialysis. This can present ethical challenges when someone has diminished decision-making capacity and no advance directives or family to assist with this complex decision. This article will provide a brief overview of ethical issues to consider when responding to an older adult's request to withdraw from a life-sustaining treatment such as dialysis. Suggestions for research to address the gaps in knowledge will be presented.
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6
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Howk A, McAdams C, Heidel E, Grandas O. Pain after Arteriovenous Access Creation. South Med J 2022; 115:262-265. [PMID: 35365842 DOI: 10.14423/smj.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively. METHODS We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm3 of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control. RESULTS In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (P = 0.04). CONCLUSIONS Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.
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Affiliation(s)
- Amy Howk
- From the Department of Surgery, University of Tennessee, Knoxville
| | - Callie McAdams
- From the Department of Surgery, University of Tennessee, Knoxville
| | - Eric Heidel
- From the Department of Surgery, University of Tennessee, Knoxville
| | - Oscar Grandas
- From the Department of Surgery, University of Tennessee, Knoxville
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7
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Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol 2022; 18:113-128. [PMID: 34621058 PMCID: PMC8792317 DOI: 10.1038/s41581-021-00484-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/30/2022]
Abstract
Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.
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8
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Boukhira I, Jidane S, Kharbach A, Belyamani L. Chronic Pain Assessment in Moroccan Hemodialysis Population. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2021. [DOI: 10.29333/ejgm/11312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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9
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Hayward S, Hole B, Denholm R, Duncan P, Morris JE, Fraser SDS, Payne RA, Roderick P, Chesnaye NC, Wanner C, Drechsler C, Postorino M, Porto G, Szymczak M, Evans M, Dekker FW, Jager KJ, Caskey FJ. International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study. Nephrol Dial Transplant 2021; 36:503-511. [PMID: 32543669 DOI: 10.1093/ndt/gfaa064] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. METHODS The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. RESULTS Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021]. CONCLUSIONS Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.
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Affiliation(s)
- Samantha Hayward
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Barnaby Hole
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Rachel Denholm
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Bristol Medical School, University of Bristol, Bristol, UK
| | - James E Morris
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Rupert A Payne
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Christiane Drechsler
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Maurizio Postorino
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Gaetana Porto
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Marie Evans
- Department of Clinical Sciences Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
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10
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Dreiher J, Fleishman TT, Shvartzman P. Pain Management Evaluation in Maintenance Hemodialysis Patients. PAIN MEDICINE 2021; 22:1946-1953. [PMID: 33779735 DOI: 10.1093/pm/pnaa488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTEXT Pain is a common complaint in maintenance hemodialysis (MHD) patients, and it is often inadequately assessed and inappropriately treated. OBJECTIVES The study goal was to preliminarily evaluate pain management in MHD patients. METHODS The study was a cross-sectional study conducted in 2013-2015. A sample of 277 MHD patients who reported pain within the last 24 hours from five hospital hemodialysis units in Israel were interviewed and evaluated. Study tools included the Brief Pain Inventory, the Pain Management Index (PMI), demographic and clinical characteristics. Pharmacy computerized data were reviewed to identify the type of analgesics used. RESULTS Mean pain level was 7.2 ± 2.2 (median: 8). Pain level was mild in 17 (6.1%), moderate in 120 (43.3%) and severe in 140 (50.5%) of patients. Only 185 participants (66.8%) were treated with analgesics during the year prior to the interview. Of these, 99 (53.5%) received opioids. Using the PMI to preliminarily assess the appropriateness of the treatment, 214 (77.3%) of patients with pain in the last 24 hours were undertreated, and 52 patients (18.8%) were appropriately treated. In a multivariable analysis, factors associated with inappropriate treatment were severe pain intensity and a higher Functional Independent Measure (FIM). A lower FIM was associated with opioid use in a multivariable analysis. CONCLUSIONS According to the PMI, most dialysis patients were found to be inappropriately treated. About one third received opioids, but even among them, inappropriate treatment was common. Pain management in MHD patients needs to be improved.
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Affiliation(s)
- Jacob Dreiher
- Division of Health in the Community, Pain and Palliative Care Unit, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel
| | - Tatiana Talya Fleishman
- Division of Health in the Community, Pain and Palliative Care Unit, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Medical Affairs, Division of General Medicine, Ministry of Health, Jerusalem, Israel
| | - Pesach Shvartzman
- Division of Health in the Community, Pain and Palliative Care Unit, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Soroka University Medical Center, Beer Sheva, Israel.,Clalit Health Services, Southern District, Beer Sheva, Israel
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11
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Hawley CE, Hickey E, Triantafylidis LK. Pharmacologic Considerations for Opioid Use in Kidney Disease. Semin Nephrol 2021; 41:2-10. [PMID: 33896470 DOI: 10.1016/j.semnephrol.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Individuals with kidney disease have a high prevalence of chronic noncancer pain. Although opioids are not a recommended treatment option for chronic noncancer pain in the general population, a higher percentage of individuals with kidney disease receive opioid prescriptions for chronic pain. Individuals with kidney disease have an increased risk for opioid adverse events because of changes related to kidney disease progression, normative aging, and the pharmacology of opioid medications. Despite the frequent prescription of opioids for chronic noncancer pain among those with kidney disease, there are no guidelines for opioid management in this population. This article reviews the pharmacologic challenges of opioid use in relation to the physiologic changes occurring in kidney disease and normative aging. We highlight how understanding opioid pharmacology and human physiology can support safe practices of opioid management in patients with kidney disease who require opioids for chronic noncancer pain.
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Affiliation(s)
- Chelsea E Hawley
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA.
| | - Erin Hickey
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
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12
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Zhuo M, Triantafylidis LK, Li J, Paik JM. Opioid Use in the Nondialysis Chronic Kidney Disease Population. Semin Nephrol 2021; 41:33-41. [PMID: 33896472 DOI: 10.1016/j.semnephrol.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although pain is a common and burdensome condition in patients with chronic kidney disease (CKD), little is known about the use and safety of opioids in this patient population. Recommendations regarding opioid use in patients with CKD are based on pharmacokinetic data, extrapolation from non-CKD studies, and from clinical experience. Given the potential increased risk for opioid-related adverse events in patients with reduced kidney function, health care providers may be hesitant to prescribe opioids, resulting in inadequate pain control. This review summarizes current studies of opioid use in patients with CKD, highlights special considerations, and proposes an opioid prescribing strategy for this unique patient population. Specifically, oral hydromorphone, transdermal fentanyl, and buprenorphine should be considered as the first-line opioids for patients with CKD if opioid management is indicated. A stepwise approach such as the Screen-Quantify-Use opioids-Adjust-Reassess-Engage prescribing strategy proposed here is critical to ensure optimal pain control while minimizing the side effects and adverse events of opioids. The effects of opioids on clinically relevant outcomes in the CKD population remains to be explored in future studies.
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Affiliation(s)
- Min Zhuo
- Renal Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | | | - Jiahua Li
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Julie M Paik
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA
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13
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Frailty modifies the association between opioid use and mortality in chronic kidney disease patients with diabetes: a population-based cohort study. Aging (Albany NY) 2020; 12:21730-21746. [PMID: 33176279 PMCID: PMC7695426 DOI: 10.18632/aging.103978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023]
Abstract
The prevalence of chronic pain in patients with chronic kidney disease (CKD) and diabetes mellitus is high and correlates with higher frailty risk, but satisfactory pain control frequently fails, necessitating opioid initiation. We aimed to examine whether opioid use affected their outcomes and whether such a relationship was modified by frailty. From the longitudinal cohort of diabetes patients (n = 840,000), we identified opioid users with CKD (n = 26,029) and propensity score-matched them to opioid-naïve patients in a 1:1 ratio. We analyzed the associations between opioid use and long-term mortality according to baseline frailty status, defined by the modified FRAIL scale. Among all, 20.3% did not have any FRAIL items, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items, respectively. After 4.2 years, 16.4% died. Cox proportional hazard regression showed that opioid users exhibited an 18% higher mortality risk (HR 1.183, 95% CI 1.13-1.24) with a dose- and duration-responsive relationship, compared to opioid-naive ones. Furthermore, the mortality risk posed by opioids was observed only in CKD patients without frailty but not in those with frailty. In conclusion, opioid use increased mortality among patients with CKD, while this negative outcome influence was not observed among frail ones.
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Dolati S, Tarighat F, Pashazadeh F, Shahsavarinia K, Gholipouri S, Soleimanpour H. The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article. Anesth Pain Med 2020; 10:e105754. [PMID: 34150565 PMCID: PMC8207885 DOI: 10.5812/aapm.105754] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.
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Affiliation(s)
- Sanam Dolati
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faezeh Tarighat
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Pashazadeh
- Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kavous Shahsavarinia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saina Gholipouri
- Department of Medical Sciences, University of Western Ontario, Ontario, Canada
| | - Hassan Soleimanpour
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. ,
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Owsiany MT, Hawley CE, Paik JM. Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review. Drugs Aging 2020; 37:875-884. [PMID: 33030671 DOI: 10.1007/s40266-020-00804-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.
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Affiliation(s)
- Montgomery T Owsiany
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA
| | - Chelsea E Hawley
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA
| | - Julie M Paik
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA. .,Renal Section, VA Boston Healthcare System, Boston, MA, USA. .,Renal Division and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Han Y, Balkrishnan R, Hirth RA, Hutton DW, He K, Steffick DE, Saran R. Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes. JAMA Netw Open 2020; 3:e2016839. [PMID: 32997126 PMCID: PMC7527874 DOI: 10.1001/jamanetworkopen.2020.16839] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Pain is a common symptom among patients with kidney disease. However, little is known about use of analgesics among patients aged 65 years or older with chronic kidney disease (CKD) who do not receive dialysis treatment. OBJECTIVE To assess national trends and geographic variations in use of opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults with and without CKD in the US (2006-2015) and examine associations between use of opioids and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the 5% Medicare claims data (2005-2015) to select 10 retrospective annual cohorts of Medicare Part D beneficiaries aged 65 years and older from 2006 to 2015 and a retrospective longitudinal cohort. Data were analyzed in August 2019. EXPOSURES CKD status and other comorbidities identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. MAIN OUTCOMES AND MEASURES Analgesic use was measured by overall use (proportion of ever used opioids/NSAIDs), long-term use (prescribed >90 days), and cumulative use (total annual days' supply). Patient outcomes included progression to end-stage kidney disease (ESKD) and all-cause mortality. RESULTS A total of 6 260 454 beneficiaries (9.6% identified with CKD by claims) were selected in the annual cohorts and 649 339 beneficiaries (8.3% identified with CKD) were selected in the longitudinal cohort. There was significant growth in opioid use (31.2%-42.4%) and NSAID use (10.7%-16.6%) among patients aged 65 years and older with CKD from 2006 to 2015. Long-term use of opioids increased during 2006 to 2014 (25.8%-36.7%) but decreased through 2015 at 35.6%, while long-term use of NSAIDs remained stable. Opioid use was higher in patients with CKD, particularly CKD stages 4 to 5 (odds ratio [OR], 1.35; 95% CI, 1.33-1.37; P < .001) compared with non-CKD. NSAID use was lower in patients with CKD stages 4 to 5 (OR, 0.55; 95% CI, 0.54-0.56; P < .001). Substantial geographic variations in analgesic use were observed across states (opioid use in CKD: 24.7%-54.3%; NSAID use in CKD: 11.2%-20.8%, 2012-2015). Opioid use was associated with progression to ESKD (hazard ratio [HR], 1.10; 95% CI, 1.04-1.16; P = .001) and death (HR, 1.19; 95% CI, 1.18-1.20; P < .001) independent of CKD status and other covariates. There was an inverse association between NSAID use and death (HR, 0.84; 95% CI, 0.83-0.85; P < .001). CONCLUSIONS AND RELEVANCE Among Medicare patients with CKD, use of prescription analgesics, both opioid and NSAID, increased from 2006 to 2015. Optimizing pain management in a complex condition such as kidney disease should remain a priority for clinicians and researchers alike.
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Affiliation(s)
- Yun Han
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Rajesh Balkrishnan
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - Richard A. Hirth
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - David W. Hutton
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - Kevin He
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Diane E. Steffick
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Epidemiology, Ann Arbor
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17
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Krishnan D, Hopman WM, Holden RM. Association Between Sex and Opiate and Benzodiazepine Prescription Among Patients With CKD: Research Letter. Can J Kidney Health Dis 2020; 7:2054358120932673. [PMID: 32637143 PMCID: PMC7323260 DOI: 10.1177/2054358120932673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 04/27/2020] [Indexed: 11/15/2022] Open
Abstract
Background Opiate and benzodiazepine use is associated with increased mortality and poorer transplant outcomes in patients with chronic kidney disease (CKD). Objective To determine the predictors of opiate and benzodiazepine prescription in people with kidney disease. Design Cross-sectional, observational study. Setting Outpatient clinics at Kingston Health Sciences Centre or at affiliated sites as of June 2017. Patients Individuals with CKD being treated at clinics or with various dialysis modalities at Kingston Health Sciences Centre and affiliated sites. Measurements The total number of regular opioid and benzodiazepine prescriptions was recorded for each patient. Patients were stratified based on clinical (eg, dialysis modality) and demographic (sex, age, diabetes mellitus [DM], ethnicity) characteristics, as elicited below. Methods We evaluated opiate and benzodiazepine use by chart review in the following patient groups: conventional hemodialysis (HD) (n = 359), home hemodialysis (HHD) (n = 21), peritoneal dialysis (PD) (n = 95), patients attending the multidisciplinary chronic kidney disease clinic (MCKDC) (n = 322), and kidney transplant (KT) recipients (n = 176). Opiates and benzodiazepines were classified according to the American Hospital Formulary Service system. Patients were also stratified as white (n = 855), indigenous (n = 66), or all others (n = 48). Results The mean age was 66.2 ± 14.9 years, 602 (61.9%) were men, and 439 (45.1%) had DM. Opiates were prescribed to 223 patients (22.9%), most frequently to HD (32.3%), followed by MCKDC (20.8%), HHD (19.0%), PD (14.7%), and KT (12.5%) (P < .001). The independent predictors of opiate prescription included DM (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.6; P < 0.001), conventional HD (vs all other treatment modalities) (OR, 1.8; 95% CI, 1.3-2.5; P < .001), and female sex (OR, 1.4; 95% CI, 1.0-1.9; P = .041) after adjustment for age and ethnicity (R 2 = 0.037, P < .001). Benzodiazepines were prescribed to 106 patients (10.9%), most frequently to HD (15.9%), followed by HHD (9.5%), KT (9.1%), MCKDC (7.5%), and PD (7.4%) (P = .005). The independent predictors of benzodiazepine use included female sex (OR, 2.3; 95% CI, 1.5-3.4; P < .001) and dialysis modality (excluding MCKDC and KT) (OR, 1.8; 95% CI, 1.2-2.8; P = .006) after adjustment for ethnicity, DM, and age (R 2 = 0.027, P < .001). Limitations We were not able to ascertain the indication for prescription of these drugs or patient adherence. Conclusions Women with kidney disease are significantly more likely to be prescribed opiates and benzodiazepines than men with kidney disease. Further research is required to determine whether these medications contribute to increased morbidity and mortality in women with kidney disease. Trial Registration This manuscript does not meet the criteria for requiring registration or a statement of written consent from study participants. The previous submission of this manuscript already made mention of Research Ethics Board approval.
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Affiliation(s)
- Dhruv Krishnan
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Wilma M Hopman
- KGH Research Institute, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Rachel M Holden
- Department of Medicine, Queen's University, Kingston, ON, Canada
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18
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Owsiany MT, Hawley CE, Triantafylidis LK, Paik JM. Opioid Management in Older Adults with Chronic Kidney Disease: A Review. Am J Med 2019; 132:1386-1393. [PMID: 31295441 PMCID: PMC6917891 DOI: 10.1016/j.amjmed.2019.06.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/11/2022]
Abstract
Chronic pain, a common comorbidity of chronic kidney disease, is consistently under-recognized and difficult to treat in older adults with nondialysis chronic kidney disease. Given the decreased kidney function associated with aging and chronic kidney disease, these patients are at increased risk for drug accumulation and adverse events. Emerging research has demonstrated the efficacy of opioids in chronic kidney disease patients, but research specifically focusing on older, nondialysis chronic kidney disease patients is scarce. The primary objective of this review is to determine which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients. We discuss the limited existing evidence on opioid prescription in older, nondialysis chronic kidney disease patients and provide recommendations for the management of oral and transdermal opioids in this patient population. Specifically, transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring; and tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events. Because older adults with nondialysis chronic kidney disease are at increased risk for adverse events, vigilant monitoring of opioid prescription is critical. Lastly, collaboration among an interprofessional clinical team can ensure safe prescription of opioids in older adults with nondialysis chronic kidney disease.
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Affiliation(s)
| | - Chelsea E Hawley
- New England Geriatric Research, Education and Clinical Center; Pharmacy Department, VA Boston Healthcare System, Mass
| | | | - Julie M Paik
- New England Geriatric Research, Education and Clinical Center; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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19
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Belinskaia DA, Belinskaia MA, Barygin OI, Vanchakova NP, Shestakova NN. Psychotropic Drugs for the Management of Chronic Pain and Itch. Pharmaceuticals (Basel) 2019; 12:ph12020099. [PMID: 31238561 PMCID: PMC6631469 DOI: 10.3390/ph12020099] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022] Open
Abstract
Clinical observations have shown that patients with chronic neuropathic pain or itch exhibit symptoms of increased anxiety, depression and cognitive impairment. Such patients need corrective therapy with antidepressants, antipsychotics or anticonvulsants. It is known that some psychotropic drugs are also effective for the treatment of neuropathic pain and pruritus syndromes due to interaction with the secondary molecular targets. Our own clinical studies have identified antipruritic and/or analgesic efficacy of the following compounds: tianeptine (atypical tricyclic antidepressant), citalopram (selective serotonin reuptake inhibitor), mianserin (tetracyclic antidepressant), carbamazepine (anticonvulsant), trazodone (serotonin antagonist and reuptake inhibitor), and chlorprothixene (antipsychotic). Venlafaxine (serotonin-norepinephrine reuptake inhibitor) is known to have an analgesic effect too. The mechanism of such effect of these drugs is not fully understood. Herein we review and correlate the literature data on analgesic/antipruritic activity with pharmacological profile of these compounds.
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Affiliation(s)
- Daria A Belinskaia
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
| | - Mariia A Belinskaia
- International Centre for Neurotherapeutics, Dublin City University, Glasnevin, Dublin 9, Ireland.
| | - Oleg I Barygin
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
| | - Nina P Vanchakova
- Department of Pedagogy and Psychology, Faculty of Postgraduate Education, First Pavlov State Medical University, L'va Tolstogo str. 6-8, St. Petersburg 197022, Russia.
| | - Natalia N Shestakova
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
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Davison SN. Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure. Clin J Am Soc Nephrol 2019; 14:917-931. [PMID: 30833302 PMCID: PMC6556722 DOI: 10.2215/cjn.05180418] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pain is common and poorly managed in patients with advanced CKD, likely due to both under and over prescription of appropriate analgesics. Poorly managed pain contributes to patients' poor quality of life and excessive health care use. There is tremendous variability within and between countries in prescribing patterns of analgesics, suggesting that factors other than patient characteristics account for these differences. This article discusses the pharmacologic management of acute and chronic pain in patients with advanced CKD, and the role analgesics, including opioids, play in the overall approach to pain management.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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21
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Ishida JH, McCulloch CE, Steinman MA, Grimes BA, Johansen KL. Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients. Clin J Am Soc Nephrol 2018; 13:746-753. [PMID: 29674340 PMCID: PMC5969477 DOI: 10.2215/cjn.09910917] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/24/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment). RESULTS The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture. CONCLUSIONS Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.
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Affiliation(s)
- Julie H. Ishida
- Departments of Medicine and
- Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and
| | - Charles E. McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Barbara A. Grimes
- Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Kirsten L. Johansen
- Departments of Medicine and
- Epidemiology and Biostatistics, University of California, San Francisco, California
- Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and
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