Pharmacological Interventions for Uraemic Pruritus in Adult Palliative Care Patients

Summary

A Cochrane review [Abstract] 1 included 50 studies with a total of 1 916 adult subjects with 39 different treatments for pruritus in 4 different patient groups: uraemic pruritus (n=1 574), cholestatic pruritus caused by hepatobiliary diseases (n=276), pruritus associated with malignancies (n=26), and pruritus as a symptom associated with HIV (n=40). This evidence summary concerns uraemic pruritus (UP).

Gabapentin (VAS from 0 to 10: MD −5.91, 95% CI −6.87 to −4.96; 2 studies, n=118) and cromolyn sodium (MD -2.94, 95% CI −4.04 to −1.83; 2 studies, n=100) were more effective than placebo. The κ-opioid receptor agonist nalfurafine showed a small improvement of UP (VAS 0 to 10: MD −0.95, 95% CI −1.32 to −0.58; 3 studies, n=422) and only few adverse events compared to placebo. One study (n=24) showed complete improvement in 58.3% of participants treated with doxepin, and this was significantly higher than improvements with placebo (P < 0.001). Leukotriene receptor antagonist montelukast reduced pruritus by 35% (95% CI 9.5 to 62.5) compared to a reduction of 7% (95% CI 0.5 to 15.9) with placebo (P = 0.002) according to 1 small study (n=16). Also erythropoietin, thalidomide, and activated oral charcoal seemed to have a positive effect on UP. Three naltrexone studies focused on UP with conflicting results. One study (n=100) compared turmeric (500 mg) and placebo capsules 3 times a day for 8 weeks, and found that reduction of pruritus was greater in the turmeric than the placebo group (P < 0.001).

Seven studies investigated the effect of topical agents on UP. Whereas tacrolimus ointment was not more effective than the vehicle in relieving UP, pramoxine lotion tended to reduce pruritus to a greater degree than the control lotion. Four studies compared the efficacy of topical capsaicin. A meta-analysis was possible for 2 studies, and the mean pruritus in the intervention group was 1.02 standard deviations lower (1.35 lower to 0.68 lower) compared to vehicle ( 2 studies, n=112). A common minor adverse event of topical capsaicin was a transient burning sensation and local erythaema with initial application, and the risk for at least one adverse event per participant was considerably increased.