Home' Australian Pharmacist : Australian Pharmacist August 2013 Contents 38 Australian Pharmacist August 2013 I ©Pharmaceutical Society of Australia Ltd.
Dr Hanan Khalil is the Director of the Centre for
Chronic Disease Management, a collaborating
centre of the Joanna Briggs Institute, Faculty of
Medicine, Nursing and Health Sciences, Monash
University, and a reviewer for the consumer
group of the Cochrane Collaboration.
Pruritus management in
palliative care patients
By Dr Hanan Khalil
The purpose of this evidence summary is to provide
the best available evidence for the efficacy of the
pharmacological interventions used for the management
of pruritus in palliative care patients. For the full review,
please refer to Xander C, Meerpohl JJ, Galandi D, Buroh
S, Schwarzer G, Antes G, Becker G. Pharmacological
interventions for pruritus in adult palliative care patients.
Cochrane Database of Systematic Reviews 2013, Issue 6.
Art. No.: CD008320. DOI: 10.1002/14651858.CD008320.
Pruritus is associated with many types
of malignancies such as haematological,
Hodgkin's disease, lymphomas and solid
tumours. The underlying pathohysiology of
pruritus is complex. It involves modulations
by serotonergic, enkephalinergic,
histaminic and opioid receptors.
This suggests that the basis of pruritus
involves different mechanisms, making it
difficult to find an effective treatment.2
Pharmacological management of
pruritus involve many classes of drugs
such as antihistamines, opioid receptors
antagonists and partial agonists, SSRIs
and antidepressants, antiepileptics,
rifampicin, colestyramine, cromolyn
sodium, leukotriene antagonists, EPO and
active charcoal. Topical treatments include;
capsaicin, tacrolimus and pramoxine.3
This evidence summary details the current
pharmacological treatment of pruritus in
palliative care patients.
Characteristics of the studies
The studies selected for the systematic
review mentioned above were randomised
controlled trials of adult patients receiving
palliative care or suffering from an incurable
condition such as advanced malignant and
non-malignant disease such as cancer, HIV/
AIDS, renal and liver failure.
Quality of the research
Studies included in the report were of
variable methodological quality. Biases
such as small sample size, study design,
inadequate washout periods between
treatments and allocation concealments
• The following databases were
searched; The Cochrane Library
(CENTRAL,DARE,CDSR) (2012, issue 8 of
12); MEDLINE (1950 to Aug 2012); EMBASE
(1980 to Aug 2012) and three other
databases including PsychINFO, BIOSIS
and CINHAL. Key textbooks, reviews,
and websites, and various investigators
and specialists in pruritus and palliative
care regarding unpublished data were
• The review included 40 studies with a total
of 1,286 participants detailing 30 different
• The following outcomes were assessed
subjective assessments of pruritus using
validated and reliable scales, patient
reported self-assessment and estimates of
patients' conditions by nursing and medical
staff. Secondary outcomes included quality
of life, patient satisfaction, depression and
• The participants included in the review
suffered from a variety of conditions; 947
participants had chronic kidney disease
(CKD)-associated pruritus, 276 participants
had cholestatic pruritus (CP) caused by
hepatobiliary diseases, 23 participants had
pruritus associated with malignancies, and
40 participants had pruritus as a symptom
associated with HIV. The drugs assessed
were psychotropic drugs, antagonistic
drugs, anaesthetics, adsorbent substances
and topical treatments.
• All studies measured pruritus response
and adverse effects. A few studies also
measured quality of life, depression,
and patient satisfaction.
• Results showed that identifying the main
cause of pruritus is important to guide
• Trials show paroxetine, a SSRI, is beneficial
in palliative care patients with pruritus of
different natures. Patients should start with
small doses, such as 5--10 mg nightly to
avoid adverse events. Effects are usually
observed within the first two days.
• For patients suffering from pruritus
associated with HIV infection, indomethacin
was described as the most effective drug,
although the evidence was weak.
• For patients suffering from chronic kidney
disease-associated pruritus, gabapentin may
be an option. An alternative treatment for
this patient group seems to be the opioid
receptor agonist nalfurafine, which has
shown significant amelioration of pruritus
and acceptable adverse effects.
• Rifampicin and flumecinol may be
recommended for patients with cholestatic
pruritus due to their low incidence of
• The opioid antagonist naltrexone has been
shown to offer a therapeutic alternative
for patients suffering from uraemic or
cholestatic pruritus. However, these drugs
are often inappropriate in the palliative
population because of the risk of reducing
analgesia when giving high doses of
• There is weak evidence to support the
efficacy of topical treatment. Capsaicin
has been examined in several studies with
limited quality and has shown some benefit.
Capsaicin is accompanied by initial burning
and stinging and may be useful as additional
treatment in mild or moderate uraemic
Implications for research and practice
A number of therapies used in managing
pruritus with different degrees of success.
Further studies addressing the pathogenesis
of pruritus and its cause will provide more
insight into successful management of
The current evidence supports the benefits
of various treatments for pruritus of
different origins in palliative care patients.
Understanding the origin of pruritus will result
in better managing the patients.
1. Xander C, Meerpohl JJ, Galandi D, et al. Pharmacological interventions
for pruritus in adult palliative care patients. Cochrane Database
of Systematic Reviews 2013, Issue 6. Art. No.: CD008320. DOI:
2. Chaing HC, Huang V, Cornelius LA. Cancer and itch. Seminars in
Cutaneous Medicine and Surgery 2011;30(2):107--12.
3. Weisshaar E, Kucenic MJ, Fleischer AB. Pruritus -- a review. Acta
Dermato-Venereologica 2003 Suppl 213;213:5--32.
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