Thread by @jrkott27

(1/n) Pain management is far from easy, and having chronic kidney disease only complicates things. Let’s take a quick look at the effects pain has on the kidney population, and what we can do about it!

#tweetorial #NephTwitter #pallcare

(2/n) Pain has a prevalence of 60% in the CKD population, 2-3x that of the general population!
It leads to:
⬆️ Depression and Insomnia
⬆️ Withdrawal From Dialysis
⬆️ Hospital Visits
⬇️ Health Related QOL
⬇️ Social Support
⬇️ Life Satisfaction

(3/n) A H&P qualifies pain and chronicity, but every pain discussion should discuss expectations. To set expectations you need to
🔴 Determine a pain level that would be tolerable
🔴 Come up with a tentative duration of treatment
🔴 Discuss risk and benefits of treatment

(4/n) So, where do we start for treatment? There are several proposed treatment ladders which can help guide us.

(5/n)Let’s look a little deeper into our options, focusing on data in the CKD population. General categories are:
▶️ Non-pharmacologic Strategies
▶️ Non-Systemic Pharmacotherapy
▶️ Non-Opioid Systemic Pharmacotherapy
▶️ Opioids

(6/n) Non-pharmacologic Strategies include:
▶️ Exercise Therapy
▶️ Cognitive Behavioral Therapy
▶️ Massage Therapy/Acupuncture.

Pros:
🟢 Few Side Effects
Cons:
🔴 Minimal Data in the CKD Population (significant variability of practice)
🔴 Limited accessibility/affordability

(7/n) Non-Systemic Pharmacotherapy
▶️Topical Lidocaine
▶️Topical NSAIDS
▶️Topical Capsaicin

These Medications Have
🟢 Low systemic absorption
🟢 Efficacy in the CKD population
🔴 Local site reaction is possible
🔴 Capsaicin should be avoided in those with Cardiac event <3 Mo

(8/n) Now let's turn to systemic pharmacotherapy, here we have many options!

1️⃣ Acetaminophen/Paracetamol
2️⃣ NSAIDS
3️⃣ Gabapentinoids
4️⃣ Muscle Relaxants
5️⃣ Antidepressants
6️⃣ Cannabinoids
7️⃣ Ketamine

(9/n)
👉Acetaminophen/Paracetamol remain safe, but may not have the efficacy we would hope for them to!
👉Unfortunately, Ketamine, Antidepressants, and Cannabinoids, have little to no data in the CKD population in the treatment of pain, and side effects may limit their use.

(10/n) 👉As for the muscle relaxants? I’ll let @Baclofen10mg do the talking there.
Unfortunately there is little data on other muscle relaxants in the CKD/ESKD population

(11/n) Gabapentinoids are increasingly prescribed despite few FDA approved indications:
▶️ Postherpetic Neuralgia
▶️ Fibromyalgia
▶️ Neuropathic pain from Spinal Cord Injuries or Diabetes
🟢 They do effectively treat neuropathic pain the the ESKD population

(12/n) Gabapentionoids have significant neurologic side effects, which have been seen in anywhere between 20-50% of the late stage kidney disease population *Even at appropriate dosing!
🛑 Coprescription with other CNS depressants seriously increases risk of adverse events

(13/n) Now onto NSAIDS, one of the biggest pharmacologic villains to the nephrologist given their role in the development of both acute and chronic kidney disease

But should they be?

(14/n) NSAIDS certainly have adverse effects:
🔴 Hypertension (not responsive to RAASi)
🔴 Fluid Retention (⬇️ prostaglandin mediated natriuresis)
🔴 Hyperkalemia
🔴 GI Bleeding (especially in the ESKD population)

However they are very effective at treating nociceptive pain!

(15/n) We’re a long way from the 1970s when the incidence of analgesic nephropathy was high. Recent reviews have demonstrated populations that should avoid NSAIDs, but there may be populations who would benefit from NSAID use without increased risk!

(16/n) And finally, let’s talk about Opioids, whose issues have been well documented over the last decade.
🔴 Shared Decision Making should be utilized when considering initiation
🔴 Initiation in CKD generally requires dose and frequency adjustments

(16/n) While addiction is the most feared risk of opioids, in the ESKD population they have demonstrated an increased risk of:
🔴 Altered Mental Status
🔴 Hip Fractures
🔴 Falls

(17/n) What are our main takeaways?
1️⃣ Pain is common in those with CKD and has many negative effects
2️⃣ Topical NSAIDs are great!
3️⃣ Almost all meds have side effects and require dose adjustments/monitoring
4️⃣ NSAIDs may be used in the right population with monitoring

18/18
Thank you! I hope this helps tackle the complicated task of pain management! Please reach out if you’d like additional sources!

#Nephtwitter #pallcare