What is the best medication for pruritus?

From the Guidelines

Rifampicin is the best medication for pruritus, particularly in patients with hepatic pruritus, due to its high efficacy and relatively low side-effect profile 1.

Treatment Options for Pruritus

• Hepatic pruritus:
  • First-line treatment: Rifampicin (300-600 mg/day) 1
  • Second-line treatment: Cholestyramine (4 g/day to a maximum of 16 g/day) 1
  • Third-line treatment: Sertraline (75-100 mg/day) 1
• Uraemic pruritus:
  • Consider Capsaicin cream, Topical calcipotriol, or Oral gabapentin 1
  • BB-UVB is an effective treatment for many patients with uraemic pruritus 1
• Generalized pruritus:
  • Consider Nonsedative antihistamines (e.g., Fexofenadine 180 mg, Loratadine 10 mg) or Mildly sedative agents (e.g., Cetirizine 10 mg) 1
  • Paroxetine, Fluvoxamine, Mirtazapine, Naltrexone, Butorphanol, Gabapentin, Pregabalin, Ondansetron, or Aprepitant may be considered 1

Important Considerations

• Gabapentin should not be used in patients with hepatic pruritus 1
• Sedative antihistamines should be avoided in the long term, except in palliative care, due to the risk of dementia 1
• Naltrexone should be started at a low dose to avoid opiate withdrawal-like reactions 1

From the Research

Treatment Options for Pruritus

The treatment for pruritus depends on the underlying cause and can be categorized into different approaches based on the etiology.

• For inflammatory chronic pruritus, first-line treatment includes topical anti-inflammatory therapies such as:
  • Hydrocortisone (2.5%) 2
  • Triamcinolone (0.1%) 2
  • Tacrolimus ointment 2
• For neuropathic chronic pruritus, effective therapies include:
  • Neuropathic topical treatments such as menthol, pramoxine, or lidocaine 2
  • Gabapentin 2
  • Antidepressants such as sertraline or doxepin 2
  • Opioid receptor agonist/antagonists such as naltrexone or butorphanol 2
• In cases where no underlying systemic disease is identified, patients may have neuropathic chronic pruritus or mixed etiology, and treatment may involve a combination of topical and systemic therapies 2
• Other therapeutic options for pruritus include:
  • Antihistamines, which may be effective for urticaria and drug-induced reactions 3, 4
  • Neurokinin receptor 1 antagonists, which have shown promise in treating chronic pruritus 5
  • Antagonists against the histamine 4 receptor, nerve growth factor receptor, or gastrin-releasing peptide receptor, which are being explored as potential antipruritic drugs 5

Considerations for Treatment

It is essential to identify the underlying cause of pruritus to determine the most effective treatment approach.

• A thorough history, review of symptoms, and laboratory evaluation should be performed to rule out underlying systemic diseases 2
• Topical emollients or short-term therapy with low-potency steroids may be effective in some cases 4
• Avoidance of frequent bathing and maintenance of a humid environment may also be helpful in managing pruritus 4