Chronic pain and inappropriate use of pain medications are common in people with early-stage chronic kidney disease (CKD), according to a study published in the Clinical Journal of the American Society of Nephrology.
“We demonstrated that there is a link between pain and patient safety in CKD and that the CKD population warrants closer attention to their pain management such that practitioners can avert clinically significant adverse safety events,” lead author Jeffrey Fink, MD, from the Department of Medicine, University of Maryland School, Baltimore, said in a news release.
Although chronic pain is common in end-stage renal disease, less is known about pain in predialysis CKD, and safety may be an issue. Some prescription and over-the-counter analgesics require renal dosing. In addition, nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic but may be frequently used for pain in CKD, the authors note.
Dr Fink and colleagues analyzed data from 308 predialysis patients enrolled between 2011 and 2013 in the Safe Kidney Care cohort in Baltimore, Maryland. They assessed pain and analgesic use over the course of 12 months, using self-reported questionnaires. Analgesics were categorized as “drug-related problems” on the basis of their potential for nephrotoxicity and whether the dose was appropriate to the participants’ estimated glomerular filtration rate. NSAIDs were considered drug-related problems regardless of estimated glomerular filtration rate.
Analyses revealed that 60.7% (n=187) of participants reported chronic pain, the majority of whom (72.1%) had pain three to four times per week. Patients with arthritis were more likely to report severe pain (odds ratio [OR], 8.22; 95% confidence interval [CI], 3.95 – 17.13), as were patients taking 12 or more medications (OR, 5.02; 95% CI, 2.38 – 10.60) or those who had lower physical function (OR, 1.96; 95% CI, 1.02 – 3.74). In contrast, patients aged 65 years and older had lower odds of reporting severe pain (OR, 0.32; 95% CI, 0.15 – 0.66).
Across the population, the adjusted per patient rate for use of an analgesics with a drug-related problem increased with increasing pain (no chronic pain, 0.07 [95% CI, 0.04 – 0.13]; mild chronic pain, 0.12 [95% CI, 0.07 – 0.20]; P = .17; severe chronic pain, 0.15 [95% CI, 0.09 – 0.27]; P = .04, respectively).
Similarly, the likelihood a patient would use an analgesic with a drug-related problem increased as pain increased. Specifically, patients with mild chronic pain were more than three times as likely to receive an inappropriate analgesic as were patients with no pain (OR, 3.04; 95% CI, 1.12 – 8.29; P = .03). Among participants with severe chronic pain, these odds rose to 5.46 (95% CI, 1.85 – 16.10; P = .002).
Participants most commonly used acetaminophen (34%), tramadol (15%), strong opioids (12%), NSAIDs (5%), and codeine (3%). Ibuprofen was the most commonly used NSAID.
The use of self-reported questionnaires could have limited the study by introducing recall bias. In addition, analgesic prescriptions and over-the-counter purchases may not accurately estimate real usage. Finally, the sample size was small and taken from an academic setting, which could have further limited the study.
“The severity of chronic pain is linked to both proper and potentially hazardous analgesic use,” Dr Fink and colleagues conclude. “Given the prevalence of chronic pain and analgesic use in CKD patients, greater attention should be given to devising optimal pain management strategies as a means to improve medication safety and effectively address the health needs of this population.”
An editorial by Sara Davison, MD, professor, Department of Medicine, University of Alberta, Edmonton, Canada, supports these conclusions. “Currently little is known about the use and safety of analgesics, including opioids, in CKD and the impact of analgesic use on clinically relevant outcomes such as analgesic effect, [health-related quality of life], physical function or adverse events is essentially unexplored,” she notes.
“[T]his work is an important step in understanding the patterns of analgesic use and misuse [in CKD],” Dr Davison writes.
Pain control in CKD should be handled with a comprehensive approach that includes physical, psychological, and behavioral therapies, according to Dr Davison. Further research on the effectiveness of analgesics for chronic pain in CKD is also needed.
“The nephrology community clearly needs to develop effective clinical strategies to optimize outcomes most relevant to the patient while minimizing analgesic-related harms,” Dr Davison emphasizes. “We need to be able to identify patients who may benefit from long-term analgesic use and patients who may be particularly vulnerable to possible analgesic-related harms.”
Leave a Reply
You must be logged in to post a comment.