Symptom control in end-stage renal failure

ESRF, apart from being fairly imminently fatal (approx 8 – 11 days on average without dialysis), can give rise to fairly unpleasant symptoms – nausea/vomiting, itching, weight loss, & intractable fluid overload. A difficulty in treatment is that many drugs need to be avoided. Common no-nos include NSAIDs (nephrotoxic), morphine/oxycodone (toxic metabolites), metoclopramide (extrapyramidal SEs), and cyclizine (risk of arrhythmias/hypotension).

Options include:


  • Paracetamol – if eGFR <10, increase interval to 8 hours.
  • Tramadol up to 50 mg/day maximum.
  • Fentanyl/alfentanil – starting subcut with careful monitoring (as response to the drug is very variable), and considering transdermal patch once stable.
  • If there is particular reason to need an NSAID, best bet is aspirin, with dosing interval not more than 6-hourly. Be cautious.
  • Specialist teams can use methadone.


  • Haloperidol at half normal dose (great for biochemical causes of nausea)
  • Levomepromazine 2nd-line

(BMJ learning module on palliative care in non-malignant disease)


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Nephrology, Palliative care. Bookmark the permalink.

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