Can a patient with end-stage renal disease (ESRD) on hemodialysis, hypertension (Htn), coronary artery disease (CAD) with three blocks managed medically, and heart failure (HF) with an ejection fraction of 35%, use gabapentin (Neurontin) or pregabalin (Lyrica) for itching?

Gabapentin for Uremic Pruritus in ESRD on Hemodialysis

Gabapentin 100-300 mg administered after each hemodialysis session (three times weekly) is the most effective medication for uremic pruritus in your patient and can be safely used despite the cardiac comorbidities. 1, 2

Dosing Protocol for Hemodialysis Patients

Post-dialysis administration is critical:

• Give 100-300 mg after each dialysis session (three times weekly) 1, 2
• These doses are substantially lower than non-ESRD populations due to reduced renal clearance 2
• Administer after hemodialysis to avoid premature drug removal and facilitate adherence 1
• Gabapentin is effectively removed by hemodialysis (approximately 50% in 4 hours), with hemodialysis clearance of 142 mL/min 3, 4

Safety Considerations in This High-Risk Patient

Important cardiac and neurologic precautions:

• The patient's HF with EF 35%, CAD, and hypertension do not contraindicate gabapentin use, as these are not listed contraindications 3
• However, gabapentin carries significant risks in hemodialysis patients: 50% higher hazard of altered mental status, 55% higher hazard of falls, and 38% higher hazard of fractures at doses >300 mg daily 5
• Even lower doses (100-300 mg) are associated with 31-41% higher hazard of altered mental status and 26-30% higher hazard of falls 5
• Common side effects include mild drowsiness, which may increase fall risk 2

Monitoring requirements:

• Watch closely for altered mental status, excessive sedation, and fall risk 5
• Gabapentin can be removed by hemodialysis if toxicity occurs 3
• Symptoms of toxicity include double vision, slurred speech, drowsiness, lethargy, and diarrhea 3

Pregabalin Alternative

Pregabalin is NOT recommended as first-line:

• Less evidence supports its use in uremic pruritus compared to gabapentin 2
• Associated with up to 51% higher hazard of altered mental status and 68% higher hazard of falls in hemodialysis patients 5
• Also requires dose adjustment and post-dialysis administration 6

Comprehensive Treatment Approach Before Gabapentin

Optimize these parameters first: 1, 2

• Ensure adequate dialysis with target Kt/V of approximately 1.6
• Normalize calcium-phosphate balance and control parathyroid hormone levels
• Correct anemia with erythropoietin if present
• Provide emollients for xerosis (dry skin affects 54-69% of hemodialysis patients) 7

Alternative Treatments if Gabapentin Fails or Is Not Tolerated

Second-line options: 1, 2

• Topical capsaicin 0.025% cream applied four times daily (14 of 17 patients reported marked relief in trials)
• Broad-band UVB phototherapy is effective for many patients
• Topical doxepin for severe cases (limited to 8 days, 10% body surface area, maximum 12 g daily)

Avoid these treatments: 1, 2

• Cetirizine is specifically ineffective for uremic pruritus despite efficacy in other conditions
• Long-term sedating antihistamines (diphenhydramine, hydroxyzine) should be avoided except in palliative care due to dementia risk and increased falls

Clinical Pitfalls

• Do not use standard non-ESRD gabapentin dosing (this would cause severe toxicity) 2, 3
• Do not administer gabapentin before dialysis sessions (drug will be removed) 1
• Do not combine with other CNS depressants without careful monitoring 5
• The patient's beta-blocker therapy for HF (which should be continued per guidelines) may compound sedation risk 8