Conservative Kidney Management

Nociceptive Pain

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Nociceptive pain is most commonly described as aching, dull, gnawing, throbbing, cramping.

Determine cause for pain and consider appropriate investigations.
Step 1 analgesics at full dose can be added to Step 2 & 3. Adjuvants may be added to all 3 steps. For severe pain, start both non-opioid & opioid agents simultaneously.
Consider using the Follow-up Pain Assessment Tool weekly to monitor effect of pain management
See: Pain Patient Handout

Step 1: Mild Pain (1-3/10)

Start non-opioid

Acetaminophen (Tylenol)

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

If pain localized to small joint:

Consider a topical NSAID (e.g. Diclofenac (5% or 10%) gel)
Apply to affected area BID to TID

Is pain now adequately controlled?

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

No: Proceed to Step 2

Step 2: Moderate Pain (4-6/10)

Due to the pharmacokinetics and pharmacodynamics, there are no recommended weak opioid agents for the treatment of nociceptive pain.

Step 3: Severe Pain (7-10/10)

CHANGE weak opioid to a strong opioid, can continue with Step 1

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 - 1.0 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

For special considerations in the last days of life, see End of Life Pain Algorithm.