Oxycodone Use in Dialysis Patients

Introduction to Oxycodone Accumulation

• The American College of Physicians recommends that oxycodone should be used with caution in patients with GFR <30 mL/min and end-stage renal disease, requiring careful titration, more frequent clinical observation, and increased dosing intervals 1
• The American Society of Nephrology recommends preferentially using opioids with no active metabolites, such as fentanyl, sufentanil, and methadone, for patients with renal insufficiency 1

Safer Alternative Opioids

• Fentanyl is the safest option due to predominantly hepatic metabolism with no active metabolites and minimal renal clearance 1, 3
• Methadone is appropriate due to fecal excretion, making it safe in renal impairment 1
• Buprenorphine can be administered at normal doses without adjustment due to predominantly hepatic metabolism 3, 4

Opioids to Avoid

• Morphine, codeine, meperidine, and tramadol should be avoided due to accumulation of potentially toxic metabolites 1, 4

Practical Management

• If a dialysis patient is currently on oxycodone, assess for signs of toxicity, reduce the dose by 50%, and extend dosing intervals, and consider rotating to fentanyl or methadone 1, 3
• Have naloxone readily available for patients at higher risk of opioid toxicity 1, 4

Monitoring Parameters

• Monitor for opioid toxicity including excessive sedation 4, respiratory depression 3, myoclonus 1, and hypotension 1