Microsoft word - esrd general symptom mgt.docx

ESRD Symptom Management
Patient Teaching
Medical 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
Patient Teaching
Medical 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
Patient Teaching
Medical 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

Source: http://hciclient.com/pdfs/ESRD_General_Symptom_Mgt_JA.pdf