What oral medications are used to manage pruritus in the elderly?

Oral Medications for Managing Pruritus in the Elderly

Gabapentin is the recommended oral medication for elderly patients with pruritus, while sedative antihistamines should be avoided due to safety concerns. 1

Initial Management Before Oral Medications

Before initiating oral therapy, elderly patients must receive a trial of topical treatment:

• Emollients with high lipid content and topical steroids for at least 2 weeks to exclude asteatotic eczema (the most common cause of elderly pruritus) 1, 2
• Only proceed to oral medications if topical therapy fails after reassessment 1

First-Line Oral Medication

Gabapentin is the preferred oral agent specifically for elderly pruritus:

• This is the only oral medication with a specific recommendation (Strength D) for pruritus in elderly skin 1
• Particularly useful when xerosis and topical treatments have been inadequately effective 3, 4

Second-Line Oral Options (For Generalized Pruritus of Unknown Origin)

If gabapentin is ineffective or the pruritus is generalized without clear etiology, consider:

Non-Sedating Antihistamines

• Fexofenadine 180 mg or loratadine 10 mg orally 1, 2
• Mildly sedative cetirizine 10 mg may be used if non-sedating options fail 1
• Can combine H1 and H2 antagonists (e.g., fexofenadine with cimetidine) for enhanced effect 1

Alternative Systemic Agents

For refractory cases, the following may be considered (all Strength D recommendations):

• Paroxetine or fluvoxamine (SSRIs) 1
• Mirtazapine (antidepressant with antipruritic properties) 1
• Pregabalin (alternative to gabapentin) 1
• Naltrexone (opioid antagonist) 1
• Ondansetron or aprepitant (antiemetics with antipruritic effects) 1

Critical Safety Considerations

Sedative antihistamines (e.g., hydroxyzine) should NOT be prescribed for elderly patients with pruritus (Strength of recommendation C):

• This is an explicit contraindication in the elderly population 1, 2
• Despite FDA approval for pruritus management 5, the fall risk, cognitive impairment, and anticholinergic burden make these agents inappropriate for elderly patients 6, 4
• Only acceptable in short-term or palliative settings for generalized pruritus of unknown origin, not specifically for elderly skin pruritus 1

Important Clinical Pitfalls

Common mistakes to avoid:

• Starting oral medications without adequate topical therapy trial (minimum 2 weeks) 1
• Using sedative antihistamines due to familiarity, despite clear evidence against their use in the elderly 1
• Failing to reassess for underlying systemic causes (thyroid disease, malignancy, renal/hepatic disease) before escalating therapy 6, 7
• Not considering polypharmacy and drug interactions in elderly patients with multiple comorbidities 3, 8, 4

When to Refer

Refer to secondary care if:

• Diagnostic uncertainty exists 1, 2
• Primary care management (topical therapy plus gabapentin) fails to relieve symptoms 1, 2
• Suspicion of underlying dermatological conditions (bullous pemphigoid, mycosis fungoides) that are more common in elderly patients 6