Opioid choice in renal impairment — RACP Adult Medicine MCQ
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Correct answer: D — Reduce or stop morphine, treat reversible contributors and rotate under expert supervision to an opioid with a safer renal metabolite profile
The best answer is “Reduce or stop morphine, treat reversible contributors and rotate under expert supervision to an opioid with a safer renal metabolite profile”. Morphine glucuronides accumulate in advanced kidney impairment and can cause sedation and myoclonus. Management includes hydration or other reversible factors where appropriate, dose reduction or cessation, and carefully calculated rotation—often to fentanyl or another renal-safer option—with close palliative review. Codeine also accumulates, naloxone may reverse dangerous acute toxicity but abolishes analgesia, and untreated severe cancer pain is unacceptable.
Reference: Australian Prescriber: Rational prescribing in community palliative care: https://australianprescriber.tg.org.au/articles/rational-prescribing-in-community-palliative-care.html Kidney Health Australia: CKD Management in Primary Care, 5th edition: https://kidney.org.au/health-professionals/ckd-management-handbook/