What medication is recommended for a patient with End-Stage Renal Disease (ESRD) on dialysis experiencing post-dialysis itching?

Management of Post-Dialysis Itching in ESRD Patients

Gabapentin 100-300 mg administered after each dialysis session (three times weekly) is the most effective first-line medication for uremic pruritus in dialysis patients. 1, 2

Stepwise Treatment Algorithm

Step 1: Optimize Dialysis Parameters and Basic Management

Before initiating pharmacologic therapy, address these foundational issues:

• Ensure adequate dialysis with a target Kt/V of approximately 1.6, as pruritus is more common in underdialyzed patients 1, 2, 3
• Normalize calcium-phosphate balance and control parathyroid hormone levels to accepted ranges 1, 2
• Correct anemia with erythropoietin if present 1, 2
• Provide emollients for xerosis (dry skin), which affects 54-69% of dialysis patients and lowers the threshold for itch 4, 2

Step 2: First-Line Pharmacologic Treatment

Gabapentin is the medication of choice:

• Dose: 100-300 mg after each dialysis session (three times weekly) 1, 2
• This dosing is significantly lower than non-ESRD populations due to reduced renal clearance 1, 2
• Demonstrated superior efficacy in multicentre, double-blind, placebo-controlled trials with significant reduction in visual analogue ratings 2
• Timing is critical: Administer after hemodialysis sessions to avoid premature drug removal 1
• Common side effect: mild drowsiness 2

Step 3: Topical Adjunctive Therapy

Capsaicin 0.025% cream can be added or used as an alternative:

• Apply to affected areas four times daily 1, 2
• Strong evidence shows marked relief in 14 out of 17 patients in randomized trials, with 5 achieving complete remission 2
• Works by depleting neuropeptides including substance P in peripheral sensory neurons 2

Step 4: Alternative Systemic Options

If gabapentin is not tolerated or ineffective:

• Sertraline 25-50 mg daily may be considered, with evidence showing significant improvement in pruritus severity (P = 0.001) 5, 6
• Dose can be titrated up to 200 mg daily as needed 6

Step 5: Non-Pharmacologic Treatment

Broad-band UVB phototherapy is effective for many patients with strong supporting evidence 1, 2

Critical Pitfalls to Avoid

Medications That Are INEFFECTIVE for Uremic Pruritus:

• Cetirizine is specifically ineffective for uremic pruritus despite efficacy in other conditions and should be avoided 1, 2
• Traditional antihistamines have limited efficacy for uremic pruritus and should not be first-line 1, 2, 7
• Ondansetron does not improve pruritus in hemodialysis patients 8
• Calamine lotion has no supporting literature 2
• Crotamiton cream is not effective compared to vehicle control 2

Medications to Use with Extreme Caution:

• Avoid long-term sedating antihistamines (diphenhydramine, hydroxyzine) except in palliative care, as they may predispose to dementia 1, 2
• Avoid cetirizine and levocetirizine in severe renal impairment (CrCl <10 mL/min) 1
• Topical doxepin should be limited to 8 days maximum, 10% body surface area, and 12 g daily if used 2

Special Considerations for True Urticaria (Not Uremic Pruritus)

If the patient has true urticaria rather than uremic pruritus:

• Fexofenadine 180 mg daily is the preferred antihistamine, requiring no dose adjustment in renal impairment 1
• Can be updosed to 720 mg daily if needed, with approximately 75% response rate 1

Definitive Treatment

Renal transplantation remains the only definitive cure for uremic pruritus but is not always feasible 2, 7