Open Access Open Access  Restricted Access Subscription or Fee Access

Prescribing opioids in renal failure

Joanne Droney, MB, BCh, MRCP(I), Jeremy Levy, PhD, FRCP, Columba Quigley, FRCP


Opioids are commonly used in both cancer and noncancer pain. Many patients who require opioids have renal impairment. This can adversely influence the safety of opioids in these patients.
Objectives: The objectives of this study were to (1) determine which opioids are most commonly prescribed in patients with renal impairment, (2) to identify differences in prescribing practices between two groups of physicians, and (3) to determine how renal impairment was recognized in this setting.
Design and participants: A questionnaire postal survey was sent out to renal and palliative medicine consultants in UK and Ireland. One hundred and seventyeight (30.5 percent) questionnaires were completed.
Results: A larger proportion of renal than palliative medicine physicians prescribed morphine in patients with renal impairment. A significant number of physicians did not adjust doses of morphine or codeine. Palliative medicine physicians were more likely to prescribe opioids other than morphine, with the exception of fentanyl which was widely used by both groups. Renal physicians were more likely to base their choice of opioid on glomerular filtration rate while palliative medicine physicians were more likely to be influenced by serum creatinine.
Conclusions: Consensus guidelines drawing on expertise from both palliative and renal physicians are needed to promote safer use of opioids in this vulnerable patient group.


renal impairment, opioid, morphine, glomerular filtration rate, creatinine

Full Text:



Vainio A, Auvinen A: Prevalence of symptoms among patients with advanced cancer: An international collaborative study. Symptom Prevalence Group. J Pain Symptom Manage. 1996; 12(1): 3-10.

Murtagh FE, Ddington-Hall J, Higginson IJ: The prevalence of symptoms in end-stage renal disease: A systematic review. Adv Chronic Kidney Dis. 2007; 14(1): 82-99.

Humphreys BD, Soiffer RJ, Magee CC: Renal failure associated with cancer and its treatment: An update. J Am Soc Nephrol. 2005; 16(1): 151-161.

Kanuk L, Berenson C: Mail surveys and response rates: A literature review. J Market Res. 1975; XII: 440-453.

Maltoni M, Scarpi E, Modonesi C, et al.: A validation study of the WHO analgesic ladder: A two-step vs three-step strategy. Support Care Cancer. 2005; 13(11): 888-894.

Conway BR, Fogarty DG, Nelson WE, et al.: Opiate toxicity in patients with renal failure. BMJ. 2006; 332: 345-346.

Reid C, Gibbins J, Hanks G: Pain is an issue in renal impairment. BMJ. 2006; 332: 488-489.

Gibson TP: Renal disease and drug metabolism: An overview. Am J Kidney Dis. 1986; 8(1): 7-17.

Chan GL, Matzke GR: Effects of renal insufficiency on the pharmacokinetics and pharmacodynamics of opioid analgesics. Drug Intell Clin Pharm. 1987; 21: 773-783.

Mercadante S, Arcuri E: Opioids and renal function. J Pain. 2004; 5(1): 2-19.

Kurella M, Bennett WM, Chertow GM: Analgesia in patients with ESRD: A review of available evidence. Am J Kidney Dis. 2003; 42(2): 217-228.

Ashley C, Currie A: The Renal Drug Handbook. 2nd ed. Oxford: Radcliffe Medical, 2004.

Murphy EJ: Acute pain management pharmacology for the patient with concurrent renal or hepatic disease. Anaesth Intensive Care. 2005; 33(3): 311-322.

Murtagh FE, Ddington-Hall JM, Donohoe P, et al.: Symptom management in patients with established renal failure managed without dialysis. EDTNA ERCA J 2006; 32(2): 93-98.

Angst MS, Buhrer M, Lotsch J: Insidious intoxication after morphine treatment in renal failure: Delayed onset of morphine- 6-glucuronide action. Anesthesiology. 2000; 92(5): 1473-1476.

Bickel U, Schumacher OP, Kang YS, et al. Poor permeability of morphine 3-glucuronide and morphine 6-glucuronide through the blood-brain barrier in the rat. J Pharmacol Exp Ther. 1996; 278(1): 107-113.

Osborne R, Joel S, Slevin M: Morphine intoxication in renal failure: The role of morphine-6-glucuronide. Br Med J (Clin Res Ed). 1986; 293: 1101.

Talbott GA, Lynn AM, Levy FH, et al.: Respiratory arrest precipitated by codeine in a child with chronic renal failure. Clin Pediatr (Phila). 1997; 36(3): 171-173.

Barnes JN, Williams AJ, Tomson MJ, et al.: Dihydrocodeine in renal failure: Further evidence for an important role of the kidney in the handling of opioid drugs. Br Med J (Clin Res Ed). 1985; 290: 740-742.

Meuldermans W, Van PA, Hendrickx J, et al.: Alfentanil pharmacokinetics and metabolism in humans. Anesthesiology. 1988; 69(4): 527-534.

Chauvin M, Lebrault C, Levron JC, et al.: Pharmacokinetics of alfentanil in chronic renal failure. Anesth Analg. 1987; 66(1): 53-56.

Van PA, Vercauteren M, Noorduin H, et al.: Alfentanil kinetics in renal insufficiency. Eur J Clin Pharmacol. 1986; 30(2): 245-247.

Baselt RC, Casarett LJ: Biliary and urinary elimination of methadone and its metabolites in the rat. Biochem Pharmacol. 1972; 21: 2704-2712.

Kreek MJ, Schecter AJ, Gutjahr CL, et al.: Methadone use in patients with chronic renal disease. Drug Alcohol Depend. 1980; 5(3): 197-205.

Inturrisi CE, Colburn WA, Kaiko RF, et al.: Pharmacokinetics and pharmacodynamics of methadone in patients with chronic pain. Clin Pharmacol Ther. 1987; 41(4): 392-401.

Klepstad P, Kaasa S, Cherny N, et al.: Pain and pain treatments in European palliative care units. A cross sectional survey from the European Association for Palliative Care Research Network. Palliat Med. 2005; 19(6): 477-484.

McClain DA, Hug CC Jr: Intravenous fentanyl kinetics. Clin Pharmacol Ther. 1980; 28(1): 106-114.

Koehntop DE, Rodman JH: Fentanyl pharmacokinetics in patients undergoing renal transplantation. Pharmacotherapy. 1997; 17(4): 746-752.

Chambers EJ, Germain M, Brown E: Supportive Care for the Renal Patient. Oxford: Oxford University Press, 2007.

Lintz W, Erlacin S, Frankus E, et al.: [Biotransformation of tramadol in man and animal (author’s transl)]. Arzneimittelforschung. 1981; 31: 1932-1943.

Lotsch J: Opioid metabolites. J Pain Symptom Manage. 2005; 29(5 suppl): S10-S24.

Gibson TP: Pharmacokinetics, efficacy, and safety of analgesia with a focus on tramadol HCl. Am J Med. 1996; 101(1A): 47S- 53S.

Kaiko RF, Benziger DP, Fitzmartin RD, et al.: Pharmacokineticpharmacodynamic relationships of controlled-release oxycodone. Clin Pharmacol Ther. 1996; 59(1): 52-61.

Kirvela M, Lindgren L, Seppala T, et al.: The pharmacokinetics of oxycodone in uremic patients undergoing renal transplantation. J Clin Anesth. 1996; 8(1): 13-18.

Hand CW, Sear JW, Uppington J, et al.: Buprenorphine disposition in patients with renal impairment: Single and continuous dosing, with special reference to metabolites. Br J Anaesth. 1990; 64(3): 276-282.

Ohtani M, Kotaki H, Sawada Y, et al.: Comparative analysis of buprenorphine- and norbuprenorphine-induced analgesic effects based on pharmacokinetic-pharmacodynamic modeling. J Pharmacol Exp Ther. 1995; 272(2): 505-510.

Ohtani M, Kotaki H, Nishitateno K, et al.: Kinetics of respiratory depression in rats induced by buprenorphine and its metabolite, norbuprenorphine. J Pharmacol Exp Ther. 1997; 281(1): 428-433.

Filitz J, Griessinger N, Sittl R, et al.: Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine. Eur J Pain. 2006; 10(8): 743-748.

Boger RH: Renal impairment: A challenge for opioid treatment? The role of buprenorphine. Palliat Med. 2006; 20 (suppl 1): s17-s23.

Durnin C, Hind ID, Wickens MM, et al.: Pharmacokinetics of oral immediate-release hydromorphone (Dilaudid IR) in subjects with renal impairment. Proc West Pharmacol Soc. 2001; 44: 81-82.

Babul N, Darke AC, Hagen N: Hydromorphone metabolite accumulation in renal failure. J Pain Symptom Manage. 1995; 10(3): 184-186.

Lee MA, Leng ME, Tiernan EJ: Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med. 2001; 15(1): 26-34.

Perrone RD, Madias NE, Levey AS: Serum creatinine as an index of renal function: New insights into old concepts. Clin Chem. 1992; 38(10): 1933-1953.

Holweger K, Bokemeyer C, Lipp HP: Accurate measurement of individual glomerular filtration rate in cancer patients: An ongoing challenge. J Cancer Res Clin Oncol. 2005; 131: 559-567.



  • There are currently no refbacks.