Rebound Pain after Dialysis...Searching for NON Dialyzable Opioid

Today I was covering the acute pain service...i had a case of 81 y/o female patient with ESRD and Lymphoma...she was maintained on Duragesic patch 25mcg..we are consulted because she is suffering of severe chest and back pain during dialysis.."yes it is Rebound pain"..a well known phenomenon that occurs when opioids get dialyzed ...SO i thought How to manage..and what opioid that will stay in during dialysis...

Here is what I found:

The factors that determine whether or not a drug is filtered during dialysis are

the molecular weight (MW) of the compound and

its degree of protein binding,

volume of distribution (VD),

and solubility (WS)

Molecules less likely to be removed by dialysis have low MW and WS, are highly protein bound, and have a high VD.

 Using these criteria, one would anticipate that morphine, a drug of relatively low protein binding and moderate WS, would be removed by dialysis

 Whereas methadone with its high protein binding, high VD, and low MW would not be removed.

 Fentanyl and sufentanil are highly protein bound, with low WS and a high VD. Therefore, these drugs should not be removed during dialysis.

 This what is written in literature..but as you see in our case although she was maintained on Duragesic patch or Fentanyl patch..the above rule didn’t apply and withdrawal happened..

a very similar case scenario reported Fentanyl withdrawal during and after dialysis !! Click Here

What i want to suggest is, contrary to the published literature, lipophilic opioids may be removed by dialysis and hence may not provide effective pain relief. This may have been the result of the particular dialyzer membrane used, as fentanyl has been shown to be dialyzable with some membranes but not others.

As it takes a finite period of time for serum and central nervous system opioid levels to reach
an efficacious level following dialysis, the only appropriate drug to use in chronic pain is one that is not removed by dialysis. Methadone may have been a more appropriate opioid to use earlier in this case. There is some evidence to suggest that it is poorly removed by dialysis.

Bastani B, Jamal JA. Removal of morphine but not fentanyl during haemodialysis [letter].
Nephrol Dial Transplant 1997;12:2804

Joh J, Sila MK, Bastani B. Nondialyzability of fentanyl with high-efficiency and high-flux membranes. [letter]. Anesth Analg 1998;86:447.

Furlan V, Hafi A, Dessalles MC, et al. Methadone is poorly removed by haemodialysis.
 Nephrol Dial Transplant 1999;14(1):254e255