Management of Itching in CKD Stage 5 Patients on Regular Hemodialysis
First-Line Pharmacological Treatment
Gabapentin 100-300 mg administered after each dialysis session (three times weekly) is the most effective medication for uremic pruritus in hemodialysis patients, with significantly lower doses required than in non-ESRD populations due to reduced renal clearance. 1, 2, 3, 4
- A multicentre, double-blind, placebo-controlled trial demonstrated that gabapentin 100 mg post-dialysis three times weekly reduced visual analogue scale scores by more than 50% compared to placebo 1
- The Cochrane systematic review (92 RCTs, 4466 participants) confirmed that GABA analogues including gabapentin and pregabalin reduce itch by 4.95 cm on the 10 cm VAS scale (95% CI 5.46 to 4.44 lower) with high certainty evidence 4
- Common side effects include mild drowsiness, but no severe adverse events have been reported 3
Optimize Dialysis Parameters Before Pharmacotherapy
Before initiating medications, ensure dialysis adequacy with a target Kt/V of approximately 1.6, as pruritus is more common in underdialysed patients. 1, 2, 3
- Normalize calcium-phosphate balance and control parathyroid hormone levels to accepted targets, as secondary and tertiary hyperparathyroidism often accompany ESRD and contribute to pruritus 2, 3
- Correct anemia with erythropoietin if present 2, 3
- Provide emollients for xerosis (dry skin), which is the most common cutaneous sign in dialysis patients and may lower the threshold for itch 2, 3
Alternative Pharmacological Options
Kappa-Opioid Agonists (Nalfurafine/Difelikefalin)
- Kappa-opioid agonists reduce itch by 1.05 cm on VAS (95% CI 1.40 to 0.71 lower) with high certainty evidence, though the effect is more modest compared to gabapentinoids 4
- Consider as an alternative when gabapentin is not tolerated or contraindicated 2, 5
Topical Treatments
- Capsaicin 0.025% cream applied four times daily to affected areas provides marked relief, with 14 out of 17 patients reporting significant improvement and 5 achieving complete remission 1, 2, 3
- Capsaicin acts by depleting neuropeptides including substance P in peripheral sensory neurons 3
- Topical calcipotriol can be considered for localized areas 1, 3
Phototherapy
- Broad-band UVB (BB-UVB) phototherapy is effective for many patients with uremic pruritus and should be considered when pharmacological options are insufficient 2, 3, 6
Critical Pitfalls to Avoid
Do not use cetirizine for uremic pruritus—it is specifically ineffective for this condition despite efficacy in other pruritic disorders. 1, 2, 3
- Avoid long-term sedative antihistamines (diphenhydramine, hydroxyzine) except in palliative care, as they may predispose to dementia 1, 2, 3
- Non-sedative antihistamines (fexofenadine, loratadine) have limited evidence for efficacy specifically in uremic pruritus, though they may be tried 3
- Ondansetron has little or no effect on itch scores (0.38 cm reduction, 95% CI 1.04 lower to 0.29 higher) with high certainty evidence 4
Treatment Algorithm
- Optimize dialysis adequacy (Kt/V ~1.6) and metabolic parameters (calcium, phosphate, PTH) 2, 3
- Provide emollients for all patients to address xerosis 2, 3
- Start gabapentin 100-300 mg post-dialysis three times weekly as first-line pharmacotherapy 1, 2, 3, 4
- Add topical capsaicin 0.025% four times daily to affected areas if gabapentin alone is insufficient 1, 2, 3
- Consider BB-UVB phototherapy if topical and systemic treatments provide inadequate relief after 2-4 weeks 2, 3
- Alternative: kappa-opioid agonists if gabapentin is not tolerated 4, 5
Additional Considerations
- Renal transplantation remains the only definitive treatment for uremic pruritus but is not always feasible 1, 3
- Pruritus may be generalized (50% of cases) or localized (commonly affecting back, face, or arteriovenous fistula arm) 3
- Symptoms often worsen during summer, at night, or during/after dialysis treatment 3
- Monitor for improvement at each dialysis session and adjust treatment accordingly 2, 3