Evidence for Morphine or Hydromorphone-Induced Neurotoxicity in Renal Impairment: A Systematic Review (S705)

Abstract

•Describe opioid-induced neurotoxicity and its risk in renal impairment.•Summarize evidence for morphine or hydromorphone neurotoxicity in hospice and palliative care patients with renal impairment.•Understand current opioid guidelines in renal impairment. Opioids are the mainstay of symptom control for seriously ill patients with pain. The accumulation of active metabolites, particularly with use of morphine and hydromorphone, is thought to increase risk of neurotoxicity in patients with renal impairment exacerbating the high symptom burden of these patients. To identify and assess the quality of evidence for opioid-induced neurotoxicity in patients with renal impairment receiving morphine or hydromorphone. Systematic searches were conducted of the following databases from inception to December 2015: MEDLINE, CINAHL, EMBASE, in addition to hand-searching relevant review articles’ citations. Studies were included if they reported neurotoxic effects of either morphine or hydromorphone for chronic or malignant pain in patients with renal impairment. Review articles and case reports were excluded. Narrative review was undertaken. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess study quality. Six original articles, including three prospective and three retrospective studies were identified and assessed. No relevant randomized clinical trials were identified. Though morphine and hydromorphone may be associated with neurotoxic effects in patients with renal impairment, current evidence is limited to very low-quality studies with conflicting findings. Clinicians may consider using either morphine or hydromorphone in mild to moderate renal impairment, while closely monitoring for neurotoxic effects, particularly when used in high doses and for extended duration.