Pharmacotherapy helps palliative care patients with itch

Wednesday 9 October 2024

Vanessa Jordan

PEARLS No.

755

Clinical question

How effective and safe are pharmacological interventions for preventing or treating pruritus in adult palliative care patients?

Bottom line

For the treatment of uraemic pruritus, GABA analogues such as gabapentin and pregabalin had the most significant effect. Kappa-opioid agonists, montelukast, fish oil/omega-3 fatty acids, cromolyn sodium and topical capsaicin showed moderate to minor effects. For cholestatic pruritus, rifampicin and flumecinol could be effective, though evidence is weak.

Naltrexone offers an alternative for uraemic or cholestatic pruritus but may interfere with pain management in palliative care due to its impact on opioid analgesia. Ondansetron, lidocaine, cholestyramine, thalidomide and sertraline showed limited efficacy.

Paroxetine showed promise in palliative care patients with pruritus of a different nature. Evidence for pruritus associated with HIV was inconclusive, with indomethacin being described as effective but not generalisable.

Caveat

Concerning the risk of experiencing at least one adverse event per participant, evidence was sparse, with GABA-analogues, kappa-opioid agonists, ondansetron, rifampicin and cromolyn sodium showing no statistical difference between events with treatment versus control. Paroxetine increased the risk of adverse events such as nausea and sleepiness. Topical capsaicin may cause a transient burning sensation and local erythema with initial application. Naltrexone produced the largest number of adverse events.

Context

Pruritus is a distressing symptom in palliative care. It is often multifactorial in origin, associated with anxiety and deteriorating liver and kidney function, and can also be a side effect of opioid treatment. Pruritus involves complex interactions between the skin, nervous system and various mediators, including histamine and serotonin. As it arises from diverse pathologic mechanisms, it is challenging to find an effective treatment and no universally effective therapeutic approach has been developed.

Cochrane Systematic Review

Boehlke C, et al. Pharmacological interventions for pruritus in adult palliative care patients. Cochrane Database Syst Rev 2024;8:CD008320. This review contains 91 trials, 4652 people.

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