Treatment of cancer pain : special considerations in patients with renal disease

Pain is a common symptom in patients with cancer, and requires careful assessment and appropriate therapy in order to improve quality of life. Treatment for pain requires modification in the presence of renal disease.NSAIDs should be avoided whenever possible, as they all (including the cyclo-oxygenase-2-specific inhibitors) have detrimental effects on kidney function.Morphine is not the preferred opioid in renal insufficiency and renal failure as it causes retention of active metabolites with subsequent adverse effects. Oxycodone and tramadol cause fewer adverse effects, and fentanyl may be the first choice in this setting as its pharmacokinetics are unaffected by renal function.Of the commonly used co-analgesics, ketamine is not affected by renal disease, while tricyclic antidepressants and gabapentin show increased rates of adverse effects. Co-analgesics commonly used to treat bone pain such as calcitonin and bisphosphonates need to be used with caution in renal disease.Psychological interventions might be particularly useful in patients with renal disease as they effectively address issues of chronic disease management, and have no adverse effects in these patients.The use of interventional techniques requires careful planning in patients with renal disease as co-morbidities may affect outcome and cause adverse effects.