From the Guidelines
Treatment of pruritus in patients with impaired renal function should prioritize non-pharmacological measures, followed by pharmacological approaches, with gabapentin being a viable option, as evidenced by recent studies 1.
Non-Pharmacological Measures
Non-pharmacological measures should be tried first, including:
- Using mild soaps
- Applying emollients
- Avoiding hot baths
- Wearing loose cotton clothing These measures can help alleviate pruritus symptoms and improve quality of life.
Pharmacological Management
For pharmacological management, the following options can be considered:
- Topical therapies like menthol 1% in aqueous cream or capsaicin 0.025% cream
- Systemic options like gabapentin (100-300mg after dialysis) or pregabalin (25-75mg daily, adjusted for renal function)
- Antihistamines such as diphenhydramine (25-50mg at bedtime) or hydroxyzine (25mg 2-3 times daily), though these should be used cautiously due to potential accumulation in renal failure
- Opioid antagonists like naltrexone (50mg daily) can be useful when other treatments fail
- Mirtazapine (15-30mg at bedtime) may provide dual benefits of itch relief and improved sleep
Recent Developments
Recent studies have shown that difelikefalin, a highly selective kappa opioid receptor agonist, has significant improvement in pruritis in some patients undergoing hemodialysis 1. However, more evidence is needed to fully understand its efficacy and safety in this population.
Considerations
When prescribing medications for patients with impaired renal function, it is essential to consider the potential for adverse effects, such as QT prolongation and altered pharmacokinetics 1. Additionally, caution is warranted when prescribing SSRIs due to their adverse-effect profile and lack of consistent benefit in this population 1.
From the Research
Treatment Options for Pruritus in Patients with Impaired Renal Function
- The treatment of pruritus in patients with impaired renal function is challenging due to limited therapeutic options 2.
- Topical treatment with or without anti-inflammatory compounds and systemic treatment with gabapentin, μ-opioid receptor antagonists, and κ-agonists are commonly used approaches 2.
- Other treatment options include drugs with anti-inflammatory action, phototherapy, and acupuncture 2.
Role of κ-Opioid Receptor Agonists in Treating Uremic Pruritus
- κ-Opioid receptor agonists, such as nalfurafine, difelikefalin, and nalbuphine, have shown promise in reducing itching symptoms in patients with refractory uremic pruritus 3, 4, 5.
- Nalfurafine has been found to be effective and safe in treating uremic pruritus in patients undergoing hemodialysis, with significant reductions in worst itching, itching intensity, and sleep disturbances 4, 5.
Safety and Efficacy of Nalfurafine
- Nalfurafine has been shown to be well-tolerated, with most adverse drug reactions being mild and resolving quickly 5, 6.
- Long-term studies have found no evidence of abuse liability or physical dependence with nalfurafine use in hemodialysis patients 6.
- Nalfurafine has also been found to be effective in treating refractory pruritus in peritoneal dialysis patients and chronic liver disease patients 5.