What are the recommended treatments for pruritus in a hemodialysis patient?

Treatment of Dialysis-Related Pruritus

Gabapentin 100-300 mg administered after each hemodialysis session (three times weekly) is the most effective first-line medication for uremic pruritus, combined with optimization of dialysis adequacy (target Kt/V ~1.6) and regular use of emollients. 1

Stepwise Treatment Algorithm

Step 1: Optimize Dialysis Parameters and Basic Skin Care

Before initiating pharmacologic therapy, address these foundational elements:

• Ensure adequate dialysis with a target Kt/V of approximately 1.6, as pruritus is significantly more common in underdialyzed patients 1
• Normalize calcium-phosphate balance and control parathyroid hormone levels to accepted ranges, as secondary and tertiary hyperparathyroidism frequently accompany end-stage renal disease and contribute to pruritus 1
• Correct anemia with erythropoietin if present 1
• Apply emollients regularly as supportive care to address xerosis (dry skin), which is the most common cutaneous sign in dialysis patients and lowers the threshold for itch 1

The British Journal of Dermatology emphasizes this stepwise approach as the foundation before implementing other treatment strategies 1. This is critical because many cases improve with these measures alone, avoiding unnecessary medication exposure.

Step 2: First-Line Pharmacologic Treatment

Gabapentin is the preferred systemic agent:

• Dosing: 100-300 mg after each dialysis session (three times weekly) 1, 2
• Evidence: Multicentre, double-blind, placebo-controlled trials demonstrate good response rates with significant reduction in visual analogue ratings 1
• Important dosing consideration: These doses are substantially lower than those used in non-ESRD populations due to reduced renal clearance 1
• Common side effect: Mild drowsiness 1
• Administration timing: Give after hemodialysis sessions to avoid premature drug removal and facilitate adherence 2

Caution: If the patient is on beta-blocker therapy for heart failure, monitor carefully as this may compound sedation risk when combined with gabapentin 2

Step 3: Topical Therapy (Can Be Used Concurrently or for Localized Itch)

Capsaicin 0.025% cream is highly effective:

• Application: Four times daily to affected areas 1, 3
• Evidence: In randomized trials, 14 out of 17 patients reported marked relief, and 5 achieved complete remission of pruritus 1
• Mechanism: Depletes neuropeptides including substance P in peripheral sensory neurons 1
• Duration of benefit: Antipruritic effect persists for up to 8 weeks after discontinuation 1
• Patient counseling: Warn patients that initial burning or stinging may occur but typically resolves with continued application 1

For localized pruritus (e.g., around arteriovenous fistula arm, back, or face), capsaicin can be used as primary therapy 1, 3

Step 4: Second-Line Options

If gabapentin and capsaicin provide insufficient relief after 2-4 weeks:

• Broad-band UVB (BB-UVB) phototherapy is effective for many patients with strong supporting evidence 1, 2
• Topical doxepin may be considered for severe cases, but treatment must be strictly limited to 8 days, 10% of body surface area, and maximum 12 g daily 1

Step 5: Alternative Systemic Agent

• Ketotifen 1 mg daily may be as effective as gabapentin but has less overall supporting evidence 1

Critical Pitfalls to Avoid

Ineffective Antihistamines

Do not use cetirizine for uremic pruritus - it has been specifically shown to be ineffective for this condition despite efficacy in other pruritic conditions 1, 2. This is a common mistake in clinical practice.

• Non-sedative antihistamines such as fexofenadine 180 mg or loratadine 10 mg may be tried, though evidence for their efficacy specifically in uremic pruritus is limited 1
• Avoid long-term sedative antihistamines (diphenhydramine, hydroxyzine) except in palliative care settings, as they may predispose to dementia 1, 2

Ineffective Topical Agents to Avoid

• Calamine lotion: No supporting literature for efficacy in uremic pruritus 1, 3
• Crotamiton cream: Shown to be ineffective compared to vehicle control 1, 3
• Menthol: Provides only counter-irritant effect without true antipruritic mechanism 1

Special Considerations

Pattern Recognition

• Pruritus can be generalized (approximately 50% of cases) or localized (commonly affecting back, face, or arteriovenous fistula arm) 1, 3
• Intensity ranges from mild intermittent irritation to intractable itch severely disrupting sleep and quality of life 1
• May worsen during summer or at night, and some patients experience itch during or soon after dialysis treatment 1

Definitive Treatment

Renal transplantation is the only definitive cure for uremic pruritus but is not always feasible 1. In very severe refractory cases, patients suitable for transplantation might be considered for high-urgency status 4.

Monitoring Response

If localized itching spreads to become generalized, this suggests broader uremic pruritus requiring systemic therapy with gabapentin rather than topical treatment alone 3. Severe pruritus not only affects quality of life but is also associated with poor outcomes in chronic hemodialysis patients 5.