From the Guidelines
Pruritus in dialysis patients can be effectively managed with a stepwise approach, starting with optimizing dialysis adequacy and addressing dry skin, and considering treatments such as emollients, capsaicin cream, and gabapentin, with BB-UVB phototherapy being an effective option for many patients, as recommended by the British Association of Dermatologists' guidelines 1. The management of pruritus in dialysis patients involves a multifaceted approach, considering the various underlying mechanisms and pathways involved.
- Optimizing dialysis adequacy is crucial, as pruritus is more common in underdialysed patients, and increasing the dialysis dose may improve symptoms 1.
- Addressing dry skin with regular application of emollients, such as petroleum jelly or ceramide-containing moisturizers, is also essential 1.
- For persistent symptoms, topical therapies like capsaicin 0.025% cream or pramoxine 1% lotion can provide relief 1.
- If topical treatments fail, oral antihistamines like hydroxyzine or gabapentin, starting at 100mg after each dialysis session and gradually increasing to 300mg per dose as tolerated, can be effective 1.
- For refractory cases, consider UVB phototherapy, specifically BB-UVB, which has been shown to be effective in many patients with uraemic pruritus, with a strength of recommendation A and level of evidence 1+ 1. The pathophysiology of uremic pruritus involves multiple mechanisms, including immune system dysregulation, elevated inflammatory cytokines, imbalance in opioid receptors, and altered calcium-phosphate metabolism, which explains why addressing multiple pathways often yields better results than monotherapy 1. It is also important to note that sedative antihistamines may predispose to dementia and should be avoided, except in palliative care, and cetirizine is not effective in uraemic pruritus 1. Renal transplantation is the only definite treatment for uraemic pruritus, with a strength of recommendation D and level of evidence 3 1. Overall, a comprehensive approach, considering the various treatment options and underlying mechanisms, is necessary for effective management of pruritus in dialysis patients.
From the Research
Treatment Options for Pruritus in Dialysis Patients
- Desloratadine and gabapentin are two treatment options that have been studied for the management of uremic pruritus in dialysis patients 2.
- A study comparing the efficacy and side effects of gabapentin and desloratadine found that desloratadine provided significant relief of uremic pruritus, while gabapentin had marginal efficacy 2.
- Another study found that gabapentin was effective in reducing pruritus scores in hemodialysis patients, with 88.9% of patients responding well to the treatment 3.
Prevalence and Awareness of Pruritus in Dialysis Patients
- The prevalence of pruritus in people on hemodialysis is decreasing but remains underestimated, with 18% of patients reporting being very much or extremely bothered by itching in 2015 4.
- A significant number of patients on hemodialysis with severe pruritus do not receive treatment, with 18% of patients using no treatment for pruritus 4.
- Medical directors often underestimate the prevalence of pruritus in their unit, with 69% of medical directors underestimating the prevalence 4.
Treatment Algorithms and Safety
- Treatment algorithms for pruritus in dialysis patients should be based on the efficacy and safety of the drugs used, with the goal of avoiding adverse effects 5.
- Gabapentin has been found to be efficacious and safe in improving uremic pruritus among dialysis patients, although it may be associated with a higher incidence of adverse drug events such as dizziness and drowsiness 6.
- The use of antihistamines, such as desloratadine, may also be effective in managing pruritus in dialysis patients, with a lower risk of adverse effects compared to gabapentin 2.