Abstract
Many analgesics and their metabolites are renally excreted. The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmö revised (LMR) equations are. This observational study investigated differences between creatinine-based eGFR equations and how the choice of equation influences dosage of analgesics in elderly (≥70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations. Standard daily dose for postoperative pain medications ibuprofen, morphine and gabapentin was simulated for each equation according to dosage recommendations in Renbase®. For 118 patients, mean eGFR from the CKD-EPI, BIS, CG, FAS, LMR, and MDRD equations was 67.3 mL/min/1.73 m2, 59.1 mL/min/1.73 m2, 56.9 mL/min/1.73 m2, 60.3 mL/min/1.73 m2, 58.9 mL/min/1.73 m2, and 79.1 mL/min/1.73 m2, respectively (p < 0.0001). Mean difference to CKD-EPI was −10.4 mL/min/1.73 m2 to 11.8 mL/min/1.73 m2. Choice of eGFR equation significantly influenced the recommended dose (p < 0.0001). Shifting to BIS, FAS, or LMR equations led to a lower recommended dose in 20% to 31% of patients. Choice of eGFR equation significantly influenced dosing of ibuprofen, morphine, and gabapentin.
Highlights
Optimization of postoperative pain management in elderly patients is essential for fast-track surgery and patient-related outcomes [1,2]
The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmö revised (LMR) equations are
This observational study investigated differences between creatinine-based estimated glomerular filtration rate (eGFR) equations and how the choice of equation influences dosage of analgesics in elderly (≥70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations
Summary
Optimization of postoperative pain management in elderly patients is essential for fast-track surgery and patient-related outcomes [1,2]. Renal function declines with age, and this decline is further accelerated by co-morbidities such as hypertension, diabetes mellitus, and chronic inflammation [8,9,10] Because of their high age, high comorbidity and reduced kidney function, most acute hip fracture patients are categorized as fragile patients [11,12,13,14,15,16]. Several renally excreted analgesics in particular are known to cause adverse drug reactions when they or their active metabolites accumulate in the body or to cause nephrotoxicity [6,7,18]. These so-called “renal risk medications” include the first line choices in postoperative pain management, such as ibuprofen, morphine, and gabapentin. The adverse reactions of ibuprofen, morphine, and gabapentin are dose-dependent, stressing the importance of prescribing these drugs at doses individually adjusted for the actual kidney function [6,7]
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