www.mcpcil.org.uk

Renal Impairment is an increasingly common problem within an ageing

population, and constitutes a major source of morbidity and mortality1,2.

Prescribing for patients with renal impairment can be complex due to the

altered pharmacokinetic properties of many medications; this is further

complicated for those receiving Renal Replacement Therapy (RRT)3.

In addition there is a lack of robust evidence regarding the use of many drugs

in renal impairment, and variability exists in prescribing practice, including

in the use of opiates. Pharmacokinetically it is suggested that Alfentanil and

Fentanyl are the safest opiates to use in renal impairment, as their metabolites

are inactive; however their short half-life is a limitation of their use as PRN

analgesics4.

Within the framework of a regional audit programme, we aimed to:

professionals (HCPs) concerning prescribing in renal impairment.

with the ultimate aim of providing higher quality patient care.

Following a comprehensive literature review, three data collection tools were

developed and distributed.

in prescribing for patients receiving RRT.

specialists in patients with renal impairment.

patients with renal impairment. We asked about prescribing practice, including

the prescription of PRN opiates at differing levels of renal impairment:

We also asked HCPs about the usual starting doses of PRN opiates they would

prescribe for patients with differing levels of renal impairment. Generally

lower initial starting doses were suggested as the severity of renal impairment

increased.

In the second survey of practice, 50 case notes of patients with renal

impairment were reviewed. There was a range of severity of renal impairment

amongst patients included in the survey, with a mean urea of 17mmol/l (4.2

– 63.2mmol/l) and mean creatinine of 239μmol/l (51-2041μmol/l). 86% of

patients were prescribed a PRN opiate; of which 72% (26/36) were prescribed

Oxycodone, 22% (8/36) were prescribed Morphine, 3% (1/36) were prescribed

Diamorphine and 3% (1/36) were prescribed Alfentanil.

We also conducted a third small survey of the prescribing practice of 9 renal

specialists, including renal physicians, specialist renal nurses and a specialist

renal pharmacist. Although a small sample, the use of Morphine as a PRN

analgesic even in severe renal impairment was more commonly reported:

The literature reveals a lack of robust evidence regarding the use of palliative

care drugs such as opiates in patients with renal impairment. In this study

Oxycodone was prescribed most frequently as a PRN analgesic for those with

renal impairment. However, variability in prescribing practice is seen, both within

palliative care HCPs as a group, and also in comparison with renal specialists.

It is recommended that patients with renal impairment should be closely

monitored for evidence of drug toxicity, and drugs used with a lower risk

of toxicity. When prescribing opiates for patients with renal impairment, it

is suggested reduced starting doses should be used, and increased dosing

intervals considered. Further research is needed to clarify the PRN opiate of

choice in palliative care patients with renal impairment.

Increased education from clinicians experienced in caring for patients

palliative care HCPs. Following the results of the audit, regional

guidelines for Prescribing in Renal Impairment have subsequently

been revised.

P, Saunders Y. Comparative pilot study of symptoms

and quality of life in cancer patients and patients with

end stage renal disease. Palliative Medicine 2006;

20(6): 631-6.

org/guidelines .

3. Ashley C, Currie A. The Renal Drug

of the use of opioid medication

for those with moderate

to severe cancer pain & renal

Palliative Care Research

Collaborative Opioid

Guidelines Project. Pall

Med 2011; 25(5):

525-52

BACKGROUND

AIMS

REFERENCES

METHODS

CONCLUSION

Prescribing for Palliative Care Patients with Renal Impairment

Horlick C1, Raj J2, Sharma A2, Mack H3, Waddington A2, Sandham J4, Telfer R5.

1. Wirral St John’s Hospice, 2. Aintree University Hospital NHS Foundation Trust, 3. 5 Boroughs Partnership NHS Trust, 4. Marie Curie Hospice, Liverpool, 5. St Helens & Knowsley Teaching Hospitals NHS Trust.

RESULTS

We asked HCPs what level of renal impairment would prompt a review of the

type and dose of opioid prescribed in the absence of toxicity. 3% would review

opiate type and dose in patients with an eGFR 60-89ml/min, 59% for those

with an eGFR of 30-59ml/min, and 65% for those with an eGFR of <30ml/min.

14% wouldn’t review opiate type and dose in renal impairment in the absence of

toxicity, regardless of the level of impairment.

which generally was low:

987654

0123

60-90 30-59 <30

eGFR ml/min

Figure 3: In opiate naive patients with renal impairment

which PRN opiate would you prescribe or recommend

first line for PRN analgesia?

Alfentanil Fentanyl Hydromorphone Oxycodone Morphine

0 5 10 15 20 25 30

Very confident

Confident

Neither

Unconfident

Figure 2: HCP's confidence in prescribing for patients

receiving RRT

Very Unconfident

Table 1: Average PRN oral opiate doses in opiate naïve patients.

eGFR Average PO PRN Morphine Dose

Average PO PRN Oxycodone dose

60-90 ml/min

4.8mg 2.6mg

30-59 ml/min

4.1mg 2.3mg

<30 ml/min

3.1mg 1.9mg

0

10

20

30

40

50

60-90 30-59 <30

eGFR ml/min

Figure 1: In opiate naive patients with Renal Impairment,

which drug would you suggest first line for PRN opiate

analgesia in these circumstances

Morphine

Oxycodone

Alfentanil

Fentanyl

Hydromorphone

Other