Page 46 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
A systematic review of 18 studies to evaluate the use of opioids in
cancer patients with renal impairment revealed substantial disagreement
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clearance and the clearance of morphine and its metabolites. 51, level I
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patients with renal impairment. Patients with renal impairment (<90 ml/
min/1.73 m ) treated with morphine had higher odds of having severe
2
constipation (OR=1.91, 95 % CI 1.08 to 3.37) compared with those with
normal renal function. Higher serum morphine concentrations were
more likely to lead to severe cognitive dysfunction (OR=1.77, 95 % CI
1.13 to 2.78). 51, level I 7KH VLJQL¿FDQW SUHGLFWRUV RI PRUSKLQH LQWROHUDQFH
were age >78 years, high white cell count and high platelet count on
concomitant poor liver or renal function. 51, level I
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prolonged in renal impairment. Hence, these patients with increased
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fatigue (OR=1.70, 95% CI 1.04 to 2.78). 51, level I

In another systematic review of 15 studies on the use of opioids
for cancer patients with moderate to severe cancer pain and renal
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in the patients. There was also no direct clinical evidence on the use of
any opioids in renal impairment or level of impairment where caution is
needed. 39, level I
Fentanyl is metabolised in the liver and its metabolites have minimal
or no pharmacological effect. It is least likely to cause harm when used
appropriately. 39, level I

Recommendations on the use of opioids in cancer-related pain with
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follows: 39, level I
• assess for any reversible factors
• all opioids that are appropriate for cancer pain can be used with
consideration of a reduced dose or frequency
• monitor for changes in renal function and consider opioid switching
in rapidly deteriorating renal function
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opioid to one considered safer in renal impairment

There was also lack of good clinical data on opioid treatment in cancer
patients with hepatic impairment. In a systematic review of three studies
assessing opioid use in cancer patients with hepatic impairment, there
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