Terminal pain management in patients with advanced kidney disease receiving palliative or hospice care

SubQ: subcutaneously; IV: intravenous.
* First-line analgesics include acetaminophen (for nociceptive pain) and gabapentin or pregabalin (for neuropathic pain).
¶ Patients with advanced kidney disease should not receive morphine. If the patient is prescribed morphine for pain, this agent should be discontinued and replaced with either hydromorphone or fentanyl.
Δ In patients taking oral hydromorphone who have persistent (breakthrough) pain, the route of administration should be changed to subcutaneous.
◊ Patients who are cachetic may not adequately absorb fentanyl via the transdermal route. Such patients who are treated using a fentanyl patch should be converted to subcutaneous hydromorphone. Alternatively, the patient can be treated with fentanyl administered slowly using a subcutaneous infusion system (if available).