Douleurs, insuffisance rénale chronique et opioïdes : lesquels choisir ? Comment adapter le traitement ?

Chronic renal failure is a frequent affection, which concerns 10% of the population. It can modify the pharmacology of opioids, their efficacy and their side-effects profile. Many clinical situations (geriatry, oncology, rheumatology…) impose that pain management takes in account the stage of chronic renal failure. The literature on the subject remains poor and the few guidelines do not guarantee a completely safe use of an opioid over another. Following a short review of chronic renal failure classification, we have proposed lines of thought through a review of opioids pharmacology. Clinical consequences may variate depending the elimination pathway of the different opioids and the presence of active or inactive metabolites. Absence or mild chronic renal failure allow the use of nearly all the opioids without dosage adjustment. However, the most advanced stages (severe and end-stage renal failure) seem to reduce the choice of opioids, integrating the limits of their marketing authorizations and their modality of use. Nevertheless, to guarantee safety and effective pain management, the choice of treatment cannot only be based on the presence of chronic renal failure and must integrate a broad set of other factors.