Zhuo Min, Triantafylidis Laura K, Li Jiahua, Paik Julie M
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.
Pharmacy Department, VA Boston Healthcare System, Boston, MA.
Semin Nephrol. 2021 Jan;41(1):33-41. doi: 10.1016/j.semnephrol.2021.02.004.
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.
尽管疼痛在慢性肾脏病（CKD）患者中是一种常见且负担沉重的病症，但对于该患者群体中阿片类药物的使用及安全性却知之甚少。关于CKD患者使用阿片类药物的建议基于药代动力学数据、非CKD研究的推断以及临床经验。鉴于肾功能减退患者发生阿片类药物相关不良事件的潜在风险增加，医疗保健提供者可能会对开具阿片类药物犹豫不决，从而导致疼痛控制不足。本综述总结了目前关于CKD患者使用阿片类药物的研究，强调了特殊注意事项，并为这一独特患者群体提出了阿片类药物处方策略。具体而言，如果需要进行阿片类药物管理，口服氢吗啡酮、透皮芬太尼和丁丙诺啡应被视为CKD患者的一线阿片类药物。这里提出的逐步方法，如筛查-量化-使用阿片类药物-调整-重新评估-参与处方策略，对于确保最佳疼痛控制同时将阿片类药物的副作用和不良事件降至最低至关重要。阿片类药物对CKD人群临床相关结局的影响仍有待未来研究探索。
