What is the best oral (PO) medication for a 73-year-old male with pruritus (itchy skin)?

Best Oral Medication for Pruritus in a 73-Year-Old Male

For a 73-year-old male with pruritus, gabapentin is the recommended first-line oral medication due to its efficacy in elderly patients and favorable safety profile. 1

Initial Assessment and Management

• First rule out asteatotic eczema with a 2-week trial of emollients and topical steroids before proceeding to oral therapy 1
• Use moisturizers with high lipid content as they are preferred in elderly patients 1
• Avoid sedative antihistamines in elderly patients due to increased risk of adverse effects including potential cognitive impairment 1

Oral Medication Algorithm

First-Line Therapy:

• Gabapentin - specifically recommended for pruritus in elderly skin 1
  • Start with low doses and titrate gradually to minimize side effects
  • Effective for neuropathic and central itch components common in elderly patients 1

Second-Line Options:

• Non-sedating antihistamines:
  • Fexofenadine 180 mg daily 1
  • Loratadine 10 mg daily 1
  • Cetirizine 10 mg daily (mildly sedating but better tolerated than first-generation antihistamines) 1

Third-Line Options:

• H1 and H2 antagonist combination (e.g., fexofenadine and cimetidine) 1
• Other oral agents to consider if above treatments fail:
  • Mirtazapine 1
  • Paroxetine 1
  • Ondansetron 1
  • Pregabalin 1

Important Considerations for Elderly Patients

• Avoid sedative antihistamines (strength of recommendation C) as they may increase risk of falls and cognitive impairment 1
• Hydroxyzine, while FDA-approved for pruritus 2, should be avoided in elderly patients due to anticholinergic and sedative effects 1, 3
• Monitor for drug interactions as elderly patients often take multiple medications 1
• Start with lower doses and titrate slowly to minimize adverse effects 1

If Initial Treatment Fails

• Reassess the patient if initial treatment does not provide relief 1
• Consider referral to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1
• Consider laboratory workup to rule out underlying systemic causes (CBC, liver function, renal function, thyroid function, etc.) 1

Adjunctive Measures

• Continue emollients and topical therapies alongside oral medication 1
• Topical options that may complement oral therapy include:
  • Menthol-containing preparations 1, 4
  • Topical clobetasone butyrate 1
  • Pramoxine-containing products 5, 4
• Avoid topical crotamiton cream (strength of recommendation B), capsaicin, or calamine lotion as they are not recommended 1

Monitoring and Follow-up

• Evaluate response to therapy within 2-4 weeks
• If inadequate response, consider advancing to next line of therapy or referral 1
• Monitor for side effects, particularly with gabapentin (dizziness, somnolence)
• Consider non-pharmacological approaches like acupuncture as complementary therapy 1