| General principle | Specific consideration in CKD |
| "By mouth" | Hemodialysis patients have easy IV access. However, this is to be avoided as the route of administration for analgesics for chronic pain management. Oral or transdermal routes are preferred. |
| "By the clock" | Some patients with mild pain may achieve adequate pain relief with analgesic dosing post-hemodialysis only. An example would be mild neuropathic pain dosed with gabapentin postdialysis. |
| "By the ladder" | Careful selection of analgesics for each step of the ladder, taking into account degree of kidney failure, is critical. Sustained-release preparations are generally not recommended in patients with advanced CKD*. |
| "For the individual" | Chronic pain is often experienced in the context of numerous other physical, psychosocial, and spiritual concerns, including end-of-life issues. Close attention to these other issues must not be forgotten as part of the pain management strategy. |
| "Attention to detail" | There are no studies on the long-term use of analgesics in patients with CKD. Careful attention must be paid to efficacy and safety. The impact on overall symptom burden, physical function, emotional state, cognition, and QOL should be assessed routinely. |
