#2901 PAIN MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: BEWARE OF INERTIA!
Authors: Messaoud Faiza Ben , Sellami Nada , Saïed Salah , Miladi Saoussen , Abderrahim Ezzeddine 
Published: June 2023

Abstract

Background and Aims
Pain and pain management are major concerns when facing patients with chronic kidney disease (CKD), and it can be more challenging for practitioners other than nephrologists. In practice, one of the aspects of this challenge is the reluctance to initiate or adapt a treatment for this particular group of patients. With this in mind, we proposed to study pain management in patients with CKD by primary care givers by identifying the causes of therapeutic inertia.

Method
A survey, self-administered via internet and elaborated via Google-Forms (including multiple and unique choice questions) was carried out among primary care physicians in November 2022.

Results
Sixty primary care physicians answered our survey with a male-to-female gender-ratio of 0.36 and a mean age of 30.65 years [18-57]. Most of the practitioners enrolled in our survey worked in urban areas (98%). Half of them worked in university hospitals, 20% in regional hospitals, 23% in local community clinics and 6.7% in private offices. When asked about their immediate feeling when managing a patient with CKD for a reason other than their kidney disease, anxiety was mostly cited (55%), with indifference, fear and confidence reported respectively in 23%, 8% and 3% of practitioners. Forty-three (71%) of the participants admitted to have difficulties initiating treatment in CKD patients. The main reasons were lack of knowledge about dose adjustments (45%), fear of adverse effects (71%), unavailability of recommended treatments for CKD patient (13%) and lack of access to nephrologist's opinion (26%). When asked about pain management in CKD patients, one out of three doctors did not prescribe the maximum dose of paracetamol for CKD patients when it was necessary. This was due to a fear of overdose (61%), fear of adverse effects (42%) and fear of interactions with other treatments (14%). Forty percent of the participants admitted delaying the increase of paracetamol doses if the initial dose is ineffective. Ninety per cent of participants did not prescribe non-steroidal anti-inflammatory drugs to CKD patients even if indicated. In this case, 61% preferred to use another therapeutic alternative, 55% feared the risk of long-term nephrotoxicity, 16% feared interactions with other treatments and 9.3% did not know how to monitor the tolerance of the treatment. Concerning not relieved by level 1 analgesic treatment pain, 55% did not reach the permitted dose of Tramadol when necessary. As for codeine, 60% of practitioners did not reach the maximum doses if indicated. In 94% of the cases, this was due to apprehension about side effects. Fifty-five per cent of the participants did not seek for a nephrologist's opinion when initiating or modifying analgesic treatment in these patients. Practitioners did not feel the need to do so in 39% of the cases. One out of four participants did not ask for a specialist's opinion because of heavy workload, absence of a nephrologist nearby or in order not to delay pain management.

Conclusion
Managing patients with CKD calls for great caution when prescribing treatments. However, it is necessary to avoid therapeutic inertia. Our survey illustrates an example regarding a common symptom (pain) that might worsen their quality of life. We suggest that regular seminars on the topic of analgesics prescription for CKD patients should be proposed in order to improve their management.