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Neuropathic Pain

 

Neuropathic pain is commonly described as numbness, tingling, burning, stabbing, shooting.

  • Patients with chronic kidney disease may experience pain from a variety of causes. They might have neuropathic and/or nociceptive (musculoskeletal) pain.
  • Consider using the Follow-up Pain Assessment Tool weekly to monitor effect of pain management.
  • See: Pain Patient Handout

1st Line

  • Gabapentin 50-100 mg PO nightly. If not effective, titrate by 100 mg every 7 nights to a maximum of 300 mg PO  nightly, or
  • Pregabalin 25 mg PO nightly. Titrate by 25 mg every 7 nights to a maximum of 75 mg PO nightly (not covered by the Seniors’ or Basic Alberta Blue Cross plans)

2nd Line

  • TCA antidepressant (unless contraindications i.e. conduction abnormalities on ECG, or excess weight gain)
  • Amitriptyline (Elavil) 10-25 mg PO daily (max dose 75 mg daily). Titrate by 10-25 mg every week as required.

Is pain now adequately controlled?

Yes: Reassess at least monthly using the Follow-Up Pain Assessment Tool

No benefit: STOP Adjuvant and START Non-Opioid/Weak Opioid (Step 2)

Some benefit but inadequate: ADD Non-Opioid/Weak Opioid (Step 2)

1st Line

  • Acetaminophen (Tylenol) 500-1000 mg PO q6-8 hours (max 3 grams/24hrs)

2nd Line

  • Tramadol (immediate release) 25-50 mg PO once/twice daily (max 100 mg/day) for a trial period of 4 weeks
  • Note that Tramadol can have serious interactions with amitriptyline (Elavil) – it is not recommended for patients to take both.

Is pain now adequately controlled?

Yes: Reassess at least monthly using the Follow-Up Pain Assessment Tool

Inadequate: ADD Strong opioid (Step 3)

Consider completing an opioid risk tool and order a bowel routine (See: Constipation Guideline). Start with low doses and titrate slowly to effect.

Hydromorphone (Dilaudid)

  • 0.5 mg PO q4h (or 0.2 mg subcutaneously)
  • Due to the accumulation of metabolites, monitor closely for adverse effects.

Fentanyl Transdermal Patch

  • For controlled pain
  • 12 mcg/h q72hours
  • Not recommended in opioid naïve patients (Opioid Conversion Table)
  • Also available sublingually/subcutaneously

Buprenorphine Transdermal Patch

  • For controlled pain
  • 5 mcg/h q7days (Opioid Conversion Table)
  • Is not covered by Alberta Blue Cross
  • Access may be limited

Methadone

  • 1-2 mg/day PO
  • Consider referral to Palliative Care
  • Requires specific education and licensing by CPSA

Considerations for Opioid Titration:

  • Ongoing pain re-assessment is critical.
  • Titrate analgesics every 3-7 days as needed and tolerated. Slower titration may be required.
  • Titrating up the regular Opiod dose:
    1. Add the total amount of opioid used in the last 24 hours (regular and breakthrough doses). Divide the total dose by 6, and prescribe this amount q4H, OR
    2. For ongoing pain exceeding patients pain control targets, adjust as follows:
      • For pain rated 3-6, inrease dose of opioid by 25%
      • For pain rated 7-10, increase dose of opioid by 50%
  • Breakthrough (PRN) dose prescription: 10% of toal 24 hour opioid dose q 1-2 hrs PRN.
  • If the patient is also taking benzodiazepines, consider titrating down the dose, while opiods are being increase. If not, titrate opioids more slowly.

Is pain now adequately controlled?

Yes: Reassess at least monthly using the Follow-Up Pain Assessment Tool

No: Refer to Palliative Care

Considerations at End of Life:

In the last days of life, see the End of Life Pain Algorithm Open Algorithm PDF

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