Specific opioid issues in renal failure
This step describes some specific opioid issues which you may encounter in clinical practice.
Dihydrocodeine has not been studied in renal failure, so should be avoided. The clearance of codeine and its metabolites is significantly reduced in moderate to severe renal impairment. Tramadol is sometimes prescribed with caution by renal units but modified-release formulations should be avoided and safer alternatives considered.
Although buprenorphine and its metabolites are, in theory, safe in renal failure, the evidence base is limited. Like fentanyl, the transdermal route of delivery means it is only suitable for stable pain. Patients with renal impairment should only be converted to a buprenorphine patch from another opioid with the advice of a specialist.
The safety profile of hydromorphone in renal failure is poorly understood and it should therefore only be prescribed with specialist advice.
Pethidine must not be prescribed in renal impairment because its metabolite, norpethidine, is highly neurotoxic and not reversed by naloxone. Other, safer alternatives are available.
Methadone is safe in renal failure because it is not excreted renally. However it should only be prescribed under specialist supervision, ideally as an inpatient, due to wide pharmacokinetic variation between individuals.
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