New England Geriatric Research, Education and Clinical Center.
New England Geriatric Research, Education and Clinical Center; Pharmacy Department, VA Boston Healthcare System, Mass.
Am J Med. 2019 Dec;132(12):1386-1393. doi: 10.1016/j.amjmed.2019.06.014. Epub 2019 Jul 8.
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.
慢性疼痛是慢性肾脏病的常见合并症，在非透析慢性肾脏病的老年患者中常常被低估和难以治疗。由于与衰老和慢性肾脏病相关的肾功能下降，这些患者有药物蓄积和不良事件的风险增加。新出现的研究表明阿片类药物在慢性肾脏病患者中的疗效，但专门针对老年非透析慢性肾脏病患者的研究很少。本综述的主要目的是确定哪些口服和透皮阿片类药物对老年非透析慢性肾脏病患者最安全。我们讨论了关于老年非透析慢性肾脏病患者阿片类药物处方的有限证据，并为该患者人群中口服和透皮阿片类药物的管理提供建议。具体而言，在这些患者中，透皮丁丙诺啡、透皮芬太尼和口服氢吗啡酮是最耐受的阿片类药物；氢可酮、羟考酮和美沙酮虽然有用，但需要仔细监测；而曲马多、可待因、吗啡和哌替啶由于有蓄积和不良事件的风险，应避免使用。由于非透析慢性肾脏病的老年患者发生不良事件的风险增加，因此密切监测阿片类药物的处方至关重要。最后，跨专业临床团队之间的合作可以确保安全地为老年非透析慢性肾脏病患者开具阿片类药物。
