Palliative Care Guidelines - NHS Lanarkshire

© NHS Lothian Issue date: January 2009 Review date: March 2012Prescribing advice for palliative care patients with chronic kidney disease/renal impairment – Part 1For further information see: other Palliative Care Guidelines & Last days of life (renal) guidelineDrugMild:GFR 60-89 ml/minRenal Impairment Dialysis Clearance CommentsModerate:Severe:HDPDGFR 30-59 ml/min GFR 15-29ml/minParacetamol Normal starting dose 6 hourly dosing 6-8 hourly dosing Cleared No Safe non-opioidNSAIDs50-75% normal doseCAUTIONAVOID AVOID No No Nephrotoxic, ↑ risk of GI bleed (plateletdysfunction). Only used when patient isdying.Codeine/dihydrocodeineNormal starting dose(monitor closely)AVOID or use smalldose and titrate slowlyTramadol Normal starting dose 50 -100mg, 12 hourly(Max 200 mg / 24 hrs)AVOID codeineDihydrocodeine: vsmall dose, slowlytitratedUnknown Unknown Metabolites accumulate. Reports of severetoxicity in CKD stage 4/5.CAUTION Yes Unknown Use 50mg, 12 hourly for dialysis patients.Risk of confusion/ delirium.Nefopam 30-60mg, 8 hourly 30mg, 6-8 hourly 30mg, 8 hourly Unlikely Unknown Can accumulate if on dialysis.Full dose ≈ fentanyl 12 microgram patch.Morphine/ diamorphine 75% normal dose 50% normal dose,6 hourlyOxycodone(see: guideline)Fentanyl(see: guideline)Alfentanil(see: guideline)LevomepromazineOndansetron/GranisetronNormal starting dose50-75% normaldose, reduce dosefrequency to 8 hourlyAVOID or use verysmall doses andmonitor closely– seek adviceAVOID or use verylow dose & monitorYesOccasionallyused as postdialysis dosing.NoCNS depot clears slowly in HD. Metabolitesaccumulate in PD. Single dose post HDcan be used. Monitor closely.Unknown Unknown ↑ half life, and ↓ excretion of metabolites.Avoid modified release preparation.Normal starting dose 75% normal dose 50% normal dose No No Can accumulate after longer term use;monitor and adjust dose.Normal starting dose Normal starting dose Normal or reduced No No Short acting.starting doseMethadone Normal starting dose Normal starting dose 50% normal dose No No Seek specialist advice re dose and titration.Metoclopramide Starting dose(10mg, 8 hourly)75% dose, 8 hourly 50% dose, 8 hourly YesNoReduced clearance; more risk ofextrapyramidal side effects.DomperidoneStarting dose(10mg, 6-8 hourly)Normal starting dose Normal starting dose Unknown UnknownCyclizineStarting dose(25mg, 8 hourly)Normal starting dose Normal starting dose Unknown Unknown Dry mouth. More CNS side effects.Hypotension, tachyarrhythmias reported.HaloperidolStarting dose Normal starting dose 50% normal dose NoNoLowers seizure threshold, ↑risk cardiac(1mg, nocte)arrhythmias, may accumulate.Starting dose(3mg, nocte)Normal starting doseStart low & titrateNormal starting doseStart low & titrateNormal starting doseUnknownNoUnknownUnknownSedation at higher doses. Causeshypotension. Lowers seizure threshold.May help itch, constipating.Palliative Care Guidelines: Renal Palliative CareAnalgesics Antiemetics3