Microsoft word - esrd general symptom mgt.docx
ESRD Symptom Management
• Begin with opioids for pain control and sedation
Alprazolam (Xanax) 0.25-1 mg po tid, qid
Lorazepam (Ativan) 1-2 mg po q 4 hrs PRN
Haloperidol (Haldol) 0.5 – 5 mg po q 6-12 hrs (max dose 20 mg per day)
Chlorpromazine (Thorazine) 12.5-50 mg q 4-12 hrs
Lorazepam 2 mg / haloperidol 5m IM; repeat in 15-30 min if needed
Midazolam (Versed) 5-10mg SC stat. if needed and 20-30mg/24h by CSCI; increase by 10-30mg increments; if 60-100mg/24h not working, add
25mg SC stat. if needed and 50-100mg/24h by CSCI; increase by 50-100mg increments to 250mg/24h as required.
Phenobarbital 200mg stat. SC and 600-2400mg/24h by CSCI; Note: a second syringe driver is needed as phenobarbital is incompatible with most other drugs
• Erythropoietin (Epogen) 50 to 100 Units/kg TIW;
• Megestrol (Megace) 40-400 mg suspension po
• Nandrolone (anabolic steroid) injection
• Dronabinol (Marinol) 2.5-5 mg po 2-3 times a
Nystatin: 4-6 ml; 4 times daily swish/swallow; continue 48 hrs after symptoms resolve
Clotrimazole (Mycelex) troche: dissolve 1 troche 5 times daily for 14 days
Diflucan suspension: 200mg po on the first day, followed by 100 mg once daily; continue for 2 weeks
• Cholinergic therapy for increased saliva
ESRD Symptom Management
• Severe constipation: bisacodyl 10 mg
suppositories per rectum (usually effective in 15 minutes to 1 hour) or a high soapsuds enemas
• Avoid laxatives containing magnesium, citrate,
or phosphate in patients with end-stage renal disease
• Amitriptyline (Elavil) 50-150 mg po q hs
• Fatigue and Weakness • Manage underlying contributors: anorexia,
• Temazepam (Restoril) 7.5-30 mg po qhs
• Flurazepam (Dalmane) 15-30 mg po qhs
• Triazolam (Halcion) 0.125-0.25 mg po qhs
• Morphine, codeine and meperidine are not
recommended for long-term use in patients with renal insufficiency and a GFR less 30 mL/min due to the rapid accumulation of active, nondialyzable metabolites that are neurotoxic. If morphine must be used, long-acting preparations should be avoided and the patient monitored closely for toxicity.
• Oxycodone and hydromorphone should be used
with caution unless the patient is receiving hemodialysis, since accumulation may cause neurotoxicity and sedation. Metabolites of these drugs are removed through dialysis.
• The safest pain medications to use in patients
with renal failure are fentanyl and methadone, since these drugs have no active metabolites and limited drug accumulation. Although neither of these drugs are readily dializable, they are removed via the feces.
• Transdermal fentanyl – start with a 25 μg/hr
patch and increase as necessary up to a 100 μg/hr patch. Change every 48 hours. Treat with a fast acting opioid (i.e., transmucosal/IV fentanyl) until desired long-acting relief is achieved.
• Methadone – start with 2.5 mg to 10 mg po
every 4 to 12 hours; titrate to effect with maximum dose 80 to 120 mg/day. Treat with a fast acting opioid (i.e., transmucosal/IV fentanyl)
ESRD Symptom Management
until desired long-acting relief is achieved. Takes 5-6 days to achieve steady state. Long half life.
• Initial treatment should include erythropoietin
(Epogen), with maximum effects occurring in 3-4 weeks. Starting dose: 50 to 100 Units/kg TIW; IV or SC
• Antihistamine therapy: diphenhydramine
(Benadryl) 25-50 mg po q 8-12 hours, hydroxyzine (Vistaril) 25-50 mg po q 6 hours, Atarax 25-50 mg po q 6-12 hours, Periactin 2-4 mg po q 8-12 hours, Tavist 2 mg po bid, Hismanal 10 mg po daily
• If erythropoietin and antihistamine therapy are
ineffective, consider a 3-week trial of phototherapy with UVB light three times weekly
• If phototherapy ineffective, consider Naltrexone
(narcan) Hcl 50mg, 1/2 pill po qhs (note: this is an opioid antagonist)
• If the Naltrexone interferes with opioids for pain
or is not tolerated by patient, try Capsaicin cream topical bid-qid
• If Capsaicin cream is ineffective, try Ketotifen 2
• If Ketotifen or Ondanstron is ineffective, try
cholestyramine 5 mg po bid or activated charcoal 6g po per day in 4-6 divided doses for 8 weeks
Should echinacea be taken on a daily basis?The question whether echinacea should be used on along-term or continual basis has not been adequatelyanswered. The usual recommendation with long-termuse is 8 weeks on followed by one week off. Researchsuggests that the people most likely to benefit fromusing echinacea for prevention are those with weakerimmune systems who are more prone to infection.
Subject Bill Index 1998 Regular Session Prepared by the David R. Poynter Legislative Research Library SUBJECT HEADINGS USED IN INDEX ABBREVIATIONS USED IN INDEX assn./assns. hwy./hwys. co./cos. dept./depts. DPS&C Department of Public Safety & Corrections R.S. (+citation) Rep. Representative rules/regs rules & regulations Sen. Senator St. S