BONE PAIN IN CKD: TREATMENT


Bone pain is an inevitable consequence of advanced Chronic Kidney Disease. Our previous article explained why this is the case. We elucidated on the “crosstalk” that exists between kidneys and bones in normal health, and how their “relationship turns painful” when Chronic Kidney Disease hits!

This article serves to cover the treatment principles that help make that debilitating pain go away, literally by acting as “relationship counsellors” for the Kidney & Bones.

Let’s get started then, shall we?

Bone Pain Treatment

 

Bone Pain Treatment PAINKILLERS ARE A BIG NO!

It may appear common sense that when you have pain in any part of the body, take those magic pills called Painkillers (Fancy term: Analgesics)!

But hold on. You’ve got chronic kidney disease (CKD), right? So, is it really safe for you to take those painkiller meds easily available over-the-counter?

Turns out they aren’t. And for good reason.

Bone Pain Treatment

You see, commonly available painkiller medicines are of the type called “Non-Steroidal Anti Inflammatory Drugs” or “NSAID”. These include drugs that contain “Aspirin”, “Ibuprofen”, “Diclofenac”, “Aceclofenac”, “Naproxen sodium” and more.

TIP

How do you know what’s in your medicine? This depends on your country of residence & its healthcare system norms. Your medicine is likely to have the same name as their active ingredient if you get “Generic” medicines, as is the case with the NHS, UK. However, in most countries worldwide, healthcare systems permit pharmaceutical companies to market medicines under a registered “brand name”. Eg: Tylenol for Paracetamol or Cellcept for MMF (a transplant medicine). To know what your medicine contains, check the “Composition” label printed on the medicine packaging

Coming back to NSAIDs, they are pretty effective in reducing pain due to swelling or injury. However, once they are done fighting your pain, they flush-out from the body via your kidneys. In the process, as a side effect, they happen to momentarily reduce blood flow to your kidneys.

Now in good health, kidneys can endure a temporary blood flow reduction, when patients take painkillers in their permissible dose schedule as advised by a doctor. However, for kidneys that are already unwell, such as those during CKD, any disruption in blood flow, unfortunately, perpetrates intense kidney cell damage & speeds-up the process of kidney failure. This is also the case for people who take painkillers at the drop of a hat or on a chronic, long-term basis without prescription even if they have a normal kidney function, to begin with.

So if you are a CKD warrior, it is imperative that you avoid taking any pain-killer medicine without consulting your medical team.

NOTE:

If you have been on NSAID class of medicines for a Heart condition or Arthritis before being diagnosed with Chronic Kidney Disease, talk to your doctor about whether it would be safe for you to continue these drugs. Your doctor may choose to reduce the dose of these drugs or completely stop them and start you on new medicines.

 

Bone Pain Treatment TREAT THE ROOT DEFECT

As the image below and our previous article explains, bone pain in CKD is the result of a cascade of events that arise due to:

Red tick Bone PainPoor active vitamin D levels due to kidney disease and poor absorption of Calcium from the food in the gut.

Red tick Bone PainA fall in overall Blood Calcium levels

Red tick Bone PainAs a consequence, a massive rise in Parathyroid Hormone (PTH) levels

Red tick Bone PainAggressive “Bone loss” by PTH to let more calcium into the bloodstream and restore blood Calcium levels to normalcy.

Bone Pain CKD treatment
Hence working on the initial steps of this cascade, such as improving blood calcium levels and restoring levels of activated Vitamin D in blood should be an effective mediator in smoothing-out the friction in the kidney-bone relationship.

On one hand, this approach would provide “external” support to the kidneys; And on the other, it would slow down or even completely halt the aggressive bone damage brought about by an abnormal rise in PTH levels in CKD patients.

    • CALCIUM SUPPLEMENTATION

The entire “bone-damaging” fiasco by Parathyroid Hormone (PTH) is triggered by low blood calcium levels. So, steps to raise this parameter feature as an important part of treating bone-pain in CKD with high PTH.

Hence, patients are put on Calcium containing tablets (Usually of 500 mg strength) twice a day.

Bone Pain Calcium

NOTE

Always buy these Calcium supplements from a registered pharmacy. Avoid substituting these for calcium pills stocked-up in supermarket shelves. That’s because the latter may not always be tested for how effective they will be in patients with kidney disease.

    • VITAMIN D SUPPLEMENTATION

In CKD patients, blood calcium levels begin to drop because there isn’t enough “Active Vitamin D” in their bloodstream to absorb Calcium from digested food in their intestine. And this is because it is the job of our kidneys to turn Vitamin D into an “active, usable version” – an ability that takes a serious, irreversible hit with CKD.

Active vitamin D deficiency-induced low blood calcium levels are what triggers a massive release of parathyroid hormone and consequent “bone pain” in CKD patients. So, starting them on Vitamin D supplements forms the mainstay of treating bone pain in CKD. This is usually done as soon as the bloodwork of CKD patients indicates a sustained dip in their Active Vitamin D levels.

Such Vitamin D supplements can essentially be of two types:
    • VITAMIN D3 CAPSULES

Vitamin D3 or Chole-calciferol (“kol-kalsi-ferol”) is pro-vitamin D. It requires “activation” by kidneys before it can be diverted for its many useful functions in the body.

In many cases, CKD may be diagnosed when the patient’s kidneys still produce moderate amounts of Vitamin-D activation enzyme.  Such patients are started on high dose Vitamin D3 capsules. Such Vitamin D formulations usually have strengths ranging from 20,000-40,000 IU.

Bone Pain Treatment

The rationale behind prescribing high dose Vitamin D3 to CKD patients is to push for the continuation of the “natural activation process” of Vitamin D3 within the body for as long as is possible.

This is a “prescription only medicine” specially marketed for CKD and other bone conditions. It is necessary that you buy this medicine from registered pharmacies. It MUST NOT be substituted for the usual 2000 IU strength Vitamin D capsules usually populating the supermarket shelves.

    • ACTIVATED VITAMIN D

Pro-vitamin D or Vitamin D3 capsules are not clinically useful when severe renal impairment sets in. This is when the production of the Vitamin D-activating enzyme by kidneys begins to shut down. It refers to the stage when something called your GFR number falls below 30.

To understand what GFR number is, and how is it related to the staging of chronic kidney disease, click here.

When a patient’s bloodwork indicates extremely low levels of Active Vitamin D, Alfacalcidol (pronounced as “Alfa-calsi-dol”) comes at our rescue. This is an “artificially activated” form of Vitamin D available in the form of tablets of 0.25, 0.5 & 1 microgram strength.

Bone Pain Treatment

Alfacalcidol is also a prescription-only medicine marketed especially for CKD patients and must be bought from registered pharmacies.

Here is an information leaflet on Alfacalcidol by the MHRA, UK for your reference.

Doctors often start Alfacalcidol (0.25 microgram) alongside Vitamin D3 capsules. It forms the mainstay of Vitamin D supplementation in advanced stages of CKD and kidney failure.

 

IS IT POSSIBLE THAT THESE MEDICINES ALONE DON’T WORK?

Yes.

CKD patients who have bone pain from a separate condition such as Arthritis will be treated separately for it. Calcium & Vitamin D supplementation in CKD patients is meant to take care of the bone pain solely caused due to bone loss from abnormally high Parathyroid (PTH) Hormone levels in CKD.

In addition in rare cases, it is possible that treating bone pain in CKD patients with Calcium & Vitamin D supplementation fails to contain parathyroid (PTH) Hormone levels to normal limits. As a result, despite all treatment as per approved clinical protocol, CKD patients continue to suffer from Bone Loss & Bone Pain perpetrated by high PTH levels. In such cases, doctors will check for any disease affecting parathyroid glands directly, that may raise PTH hormone levels. Tumour(s) & inflammation in the parathyroid glands could be some such conditions that raise PTH levels independently. If this is the case, your doctor would treat it accordingly. This could either involve new medicines or if required, surgical removal of parathyroid glands.

 

Reference
  1. Medically Refractory Hyperparathyroidism in CKD


 

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