What medication is recommended for chronic pruritus due to uremia in a patient on Hemodialysis (HD)?

Management of Chronic Uremic Pruritus in Hemodialysis Patients

Gabapentin (100-300 mg after each dialysis session, three times weekly) is the most effective medication for treating chronic pruritus due to uremia in hemodialysis patients. 1

First-Line Approach: Optimize Dialysis Parameters

Before initiating pharmacologic therapy, ensure:

• Adequate dialysis (target Kt/V of around 1.6) as pruritus is more common in underdialysed patients 1, 2
• Normalized calcium-phosphate balance and controlled parathyroid hormone levels 1, 2
• Correction of anemia with erythropoietin if present 2
• Regular use of emollients to address xerosis (dry skin), which is the most common cutaneous manifestation in dialysis patients 1, 2

Pharmacologic Treatment Algorithm

First-Line Medication

• Gabapentin 100-300 mg after each dialysis session (three times weekly) 1
  • A multicentre, double-blind, placebo-controlled trial showed good response rates with 100 mg postdialysis, with visual analogue ratings falling by over 50% compared to placebo 1
  • Note that these are lower doses than used in non-ESRD populations due to reduced renal clearance 1
  • Common side effect: mild drowsiness 1

Alternative/Adjunctive Treatments

• Topical capsaicin cream (0.025%) applied to affected areas 1, 2

  • Acts by depleting neuropeptides including substance P in peripheral sensory neurons 1

• Topical calcipotriol for localized areas 1

• Doxepin (10 mg twice daily) for short-term use 1

  • Complete resolution reported in 58% of patients vs. 8% on placebo 1
  • Caution: 50% of patients reported drowsiness 1
  • Avoid long-term use of sedative antihistamines due to potential dementia risk 1, 2

Important Considerations and Pitfalls

• Avoid cetirizine (10 mg daily) as it has been shown ineffective specifically for uremic pruritus 1

• Avoid long-term sedative antihistamines except in palliative situations, as they may predispose to dementia 1, 2

• Ketotifen (1 mg daily) may be as effective as gabapentin according to one RCT, but has less supporting evidence overall 1

• Renal transplantation remains the only definitive treatment for uremic pruritus but is not always feasible 1, 3

• Pruritus severity monitoring is important as it significantly impacts quality of life and is associated with depression and mortality in hemodialysis patients 4

• Despite its high prevalence (affecting 40-90% of hemodialysis patients), uremic pruritus remains underdiagnosed and undertreated, with approximately 17% of severely affected patients not reporting symptoms to healthcare providers 4

Treatment Resistance

For patients with refractory pruritus:

• Consider UVB phototherapy if available 2, 3
• In Japan, nalfurafine (a κ-opioid receptor agonist) has shown efficacy 5, 6
• For suitable candidates with intractable symptoms, consider prioritizing for kidney transplantation 3