Use of both opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) has increased among patients with chronic kidney disease (CKD) aged 65 years and older in the United States, a new study found. These worrisome trends highlight a need for better pain management of this population.

Among 6,260,454 Medicare Part D beneficiaries, 9.6% had CKD. From 2006 to 2015, opioid use increased from 31.2% to 42.4% and NSAID use from 10.7% to 16.6% among patients with CKD, Rajiv Saran, MD, MS, of the Kidney Epidemiology and Cost Center, in Ann Arbor, Michigan, and colleagues reported in JAMA Network Open. Use of these analgesics peaked in 2013 then slightly decreased perhaps due to public health measures to curb misuse, according to the team.

Analgesic use varied by CKD stage. Compared with patients who did not have CKD, patients with CKD stages 1-2, 3, and 4-5 had 21%, 30%, and 35% higher odds of opioid use, respectively, in 2015 after adjusting for demographic characteristics and CKD- and pain-related comorbidities, the investigators reported. However, patients with these CKD stages, respectively, had 16%, 29%, and 45% decreased odds of NSAID use compared with the non-CKD group (all P <.001).

Long-term analgesic use was more prevalent among beneficiaries with CKD. In 2015, more patients with than without CKD used opioids for longer than 90 days: 35.6% vs 29.1%, respectively. Approximately one-third of patients with CKD received prescription NSAIDs for more than 90 days, with lower use at CKD stages 4 to 5 (23.2%) than stages 1 to 2 (33.2%).


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With respect to comorbidities, patients with diabetes, hypertension, depression, cancer, back pain, neck pain, arthritis, headache, HIV, or depression had significantly higher use of opioids, NSAIDs, or both pain relievers, compared with those free of CKD and each of these ailments. Patients with co-existing cardiovascular disease were 22% less likely to use NSAIDs (P <.001), probably due to the cardiovascular risks associated with these medications, according to the investigators.

Dr Saran and his collaborators also observed differences in analgesic use by state, locality, and racial group. Black patients were 4% more likely to use opioids and 22% more likely to use NSAIDs than White patients. Asian patients, however, were 41% less likely to use opioids and 74% more likely to use NSAIDs than White patients.

Importantly, patients who ever used opioids had a 10% greater risk for end-stage kidney disease and a 19% greater risk for death. NSAIDs appeared possibly protective in this study, but previous research findings have been contradictory.

“Special precautions are needed to manage treatment of patients with reduced kidney function, who may be more prone to experiencing drug toxic effects, adverse effects, greater dose adjustment requirements, and drug interactions … Opioids may have extended half-life in patients with advanced CKD, with substantial effects on the central nervous system, resulting in respiratory depression, hypotension, and addiction,” Dr Saran and his colleagues wrote. “Use of NSAIDs in patients with CKD may result in nephrotoxicity, fluid and electrolyte imbalances, hypertension, and other complications.”

According to the team, clear clinical guidelines for chronic pain management in CKD may be warranted.

Reference

Han Y, Balkrishnan R, Hirth RA, et al. Analgesic use in older adults with and without chronic kidney disease and outcomes. JAMA Netw Open. 3(9). Published online September 30, 2020.  doi:10.1001/jamanetworkopen.2020.16839