What medications can be prescribed for a dialysis patient experiencing pruritus?

Management of Pruritus in Dialysis Patients

Start with gabapentin 100-300 mg administered after each dialysis session (three times weekly), as this is the most effective medication for uremic pruritus in hemodialysis patients. 1

Stepwise Treatment Algorithm

Step 1: Optimize Dialysis and Metabolic Parameters (Essential Foundation)

Before initiating pharmacologic therapy, address these fundamental issues:

• Ensure adequate dialysis with a target Kt/V of approximately 1.6, as pruritus is significantly more common in underdialyzed patients 1
• Normalize calcium-phosphate balance and control parathyroid hormone levels, as secondary and tertiary hyperparathyroidism frequently accompany end-stage renal disease and contribute to pruritus 1
• Correct anemia with erythropoietin if present 1
• Provide emollients as essential supportive care to address xerosis (dry skin), which is the most common cutaneous manifestation in dialysis patients and lowers the threshold for itch 2, 1

Step 2: First-Line Pharmacologic Treatment

Gabapentin is the medication of choice:

• Dose: 100-300 mg after each dialysis session (three times weekly) 1
• These doses are substantially lower than those used in non-ESRD populations due to reduced renal clearance 1
• Gabapentin demonstrates the greatest reduction in itch scores among all studied interventions, with high certainty evidence 3
• Common side effect is mild drowsiness 1

Step 3: Alternative or Adjunctive Treatments

If gabapentin is insufficient or not tolerated, consider these options:

Topical therapies:

• Capsaicin 0.025% cream applied four times daily has shown significant efficacy, with 14 out of 17 patients reporting marked relief and 5 achieving complete remission 2, 1
• The antipruritic effect can persist up to 8 weeks after cessation of treatment 2

Systemic alternatives:

• Ketotifen 1 mg daily may be as effective as gabapentin but has less supporting evidence 1
• Kappa-opioid agonists (nalfurafine) reduce itch but show a more modest effect compared to gabapentin 3

Phototherapy:

• Broad-band UVB (BB-UVB) phototherapy is effective for many patients with uremic pruritus 1

Step 4: Short-Term Options for Severe Cases

• Doxepin 10 mg twice daily can be used for short-term treatment, with complete resolution reported in 58% of patients versus 8% on placebo 1
• Treatment must be limited to 8 days, 10% of body surface area, and 12 g daily 1
• Caution is advised due to potential drowsiness 1

Critical Pitfalls to Avoid

Do NOT use these medications:

• Cetirizine is ineffective specifically for uremic pruritus despite its use in other pruritic conditions 1, 4
• Ondansetron has little or no effect on itch scores in dialysis patients 1, 3
• Long-term sedative antihistamines should be avoided except in palliative care settings, as they may predispose to dementia 1, 4
• Loratadine should be used with extreme caution in severe renal impairment 4
• Cetirizine and levocetirizine should be avoided in severe renal impairment (creatinine clearance < 10 mL/min) 4

Important Clinical Considerations

Pruritus characteristics in dialysis patients:

• Can be generalized (approximately 50% of cases) or localized to the back, face, or arteriovenous fistula arm 1
• Intensity ranges from mild intermittent irritation to intractable itch that severely disrupts sleep and quality of life 1
• May worsen during summer or at night 1
• Some patients experience itch during or soon after dialysis treatment 1

Definitive treatment:

• Renal transplantation is the only definitive cure for uremic pruritus but is not always feasible 1, 4