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Acute Pain Management in Renal Impairment

Renal impairment reduces the clearance of drugs and their metabolites excreted via the kidney. These effects can have an impact on clinical practice if the drug itself is excreted unchanged and/or has active metabolites. Some drugs can also cause or worsen renal impairment. ANZCA chapter 11.6.1. p 414.

Condition specific perioperative analgesic issues:

The following analgesics do usually not require dose adjustment in renal impairment as they neither show significantly decreased clearance nor have relevant active metabolites ANZCA chapter 11.6.1., p 414:

  • Alfentanil
  • Buprenorphine
  • Fentanyl
  • Ketamine
  • Oxycodone
  • Paracetamol (except compound analgesics).
  • Sufentanil

The following analgesics require caution ANZCA Table 11.5, p 415-429.

  • Codeine: Dose adjustment
  • Clonidine: Dose adjustment
  • Dextropropoxyphene: NOT recommended
  • Dihydrocodeine: NOT recommended
  • Gabapentin: Reduced clearance requires dose adjustment
  • Hydromorphone: Dose adjustment or switch opioid
  • Methadone: Dose adjustment in severe renal impairment
  • Morphine: Dose adjustment or switch opioid see French, section 5.4
  • Paracetamol: Decrease dose interval in severe impairment
  • Pethidine: Increase toxicity; NOT recommended
  • Pregabalin: Reduced clearance requires dose adjustment
  • Tramadol: Dose adjustment or switch opioid
  • Local anaesthetics (amides) may require dose reduction with prolonged or repeated use.
  • Levobupivacaine and ropivacaine may be safer than bupivacaine because of a higher therapeutic ratio.
  • NSAIDs and Coxibs can cause renal impairment and should be used with caution in mild and not at all in severe renal impairment see also French section 6.1.1.


Based on the available evidence, consideration should be given to choice and dose of analgesics administered to patients with renal impairment.

Supplementary reading:

  1. Miller A, Price G. Gabapentin toxicity in renal failure: the importance of dose adjustment. Pain Med. 2009 Jan;10(1):190-2.