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Opioid Replacement Options in Kidney
or Liver Disease: Buprenorphine is
Superior to Methadone

Individuals who have used legal or illegal medications in excess often injure their liver or kidney. Often this damage or weakness is not found on routine organ failure labs. For example, the use or Percocet with high doses of Tylenol or acetaminophen depletes the liver of glutathione and makes it hard for the body to remove daily toxic substances -- no liver function test is going to show that problem. This study below shows that buprenorphine, the active agent in Suboxone, is gentle on the liver and kidneys and superior to methadone in this respect.

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The clinical utility of most analgesic drugs is altered in the presence of patients with impaired renal [kidney] or hepatic [liver] function not simply because of altered clearance of the parent drug, but also through production and accumulation of toxic or therapeutically active metabolites. Some analgesic agents may also aggravate pre-existing renal and hepatic disease. A search was performed, taking in published articles and pharmaceutical data to determine available evidence for managing acute pain effectively and safely in these two patient groups. The resulting information consisted mainly of small group pharmacokinetic studies or case reports, which included a large variation in degree of organ dysfunction.

In the presence of renal [kidney] impairment, those drugs which exhibit the safest pharmacological profile are alfentanil, buprenorphine, fentanyl, ketamine, paracetamol (except with compound analgesics), remifentanil and sufentanil. none of these deliver a high active metabolite load, or suffer from significantly prolonged clearance. Amitriptyline, bupivacaine, clonidine, gabapentin, hydromorphone, levobupivacaine, lignocaine, methadone, mexiletine, morphine, oxycodone and tramadol have been used in the presence of renal failure, but do require specific precautions, usually dose reduction. Aspirin, dextropropoxyphene, non-steroidal anti-inflammatory drugs and pethidine, should not be used in the presence of chronic renal failure due to the risk of significant toxicity.

In the presence of hepatic [liver] impairment, most drugs are subject to significantly impaired clearance and increased oral bioavailability, but are poorly studied in the clinical setting. The agent least subject to alteration in this context is remifentanil; however the drugs' potency has other inherent dangers. Other agents must only be used with caution and close patient monitoring. Amitriptyline, carbamazepine and valproate should be avoided as the risk of fulminant hepatic failure is higher in this population, and methadone is contraindicated in the presence of severe liver disease.

Murphy EJ. Acute pain management pharmacology for the patient with concurrent renal or hepatic disease. Anaesth Intensive Care. 2005 Jun;33(3):311-22.



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