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Uremic Pruritus

 

Guiding Priniciple:

Treat the patient's daily pruritus if it is impairing their sleep or quality of life.

  • Correct iron deficiency (See: Anemia Guideline).
  • Other: xerosis, drug hypersensitivities, allergies, infestations, contact dermatitis, or inflammation.
  • Good skin care and moisturizers are considered first line treatment. Some general principles to follow:
    • Baths are better than showers (daily in lukewarm water for at least 15 minutes).
    • Avoid harsh soaps, body washes, bubble baths, etc. Try gentle cleansers (eg. Cerave, Cetaphil), and only in limited places such as the axilla and groin areas.
    • Post bath: pat dry and moisturize skin within two minutes of getting out. Skin will still be damp. Ideally, use hypoallergenic moisturizers with ceramides (eg. Cerave) that are free from fragrance and additives. Do not use the moisturizers on areas of broken skin.
  • Other skin care strategies include the following:
    • Keep skin cool by wearing light and cool clothing.
    • Avoid scratching – keep fingernails short, encourage massaging rather than scratching, wear gloves at night.
    • Maintain a humid home environment, especially in the winter.
  • See: Itch Patient Handout

Pramoxine

  • Gold Bond Medicated Anti-Itch products (OTC) – contain pramoxine, dimethicone, menthol
  • Pramox HC (hydrocortisone 1%/pramoxine 1%) - apply two times a day for 4 weeks

Capsaicin 0.025% or 0.03% ointment

  • Zostrix 0.025% and Zostrix Hp 0.075%
  • Can be applied 2-4 times a day to affected areas.
  • It may initially cause burning to the area.

Menthol, Camphor and Phenol

  • Separate products that can be added to most creams, typically in the range of 0.3-1.0%
  • All three may be added together, commonly with a 0.3% concentration for each.
  • Must be compounded by pharmacy.

Gamma-Linolenic acid (GLA) 2.2% cream

  • Apply cream twice daily to identified dry skin.
  • May not be easily accessible in Alberta.

Many of the following medications have been dose-adjusted for the end-stage kidney disease patient and some are being used off-label for pruritus. Medications such as gabapentin and pregabalin should be tapered down as kidney function deteriorates.

Note that gabapentin is not commercially available in 50 mg capsules, but can be compounded for patients if the recommended low starting dose is desired.

Antihistamines are not recommended in the treatment of uremic pruritus.

Gabapentin

  • A recommended starting dose is 50 -100 mg* nightly. If not effective, it can be further titrated by 100mg every 7 nights to a maximum of 300 mg PO qhs. It should be taken 1-2 hours before bedtime.
  • The most common side effects are drowsiness, dizziness, confusion, and fatigue. Peripheral edema may also be a side effect.

Pregabalin

  • Similar to gabapentin, but more expensive and not covered by Seniors’ or Basic Alberta Blue Cross plans. Other private plans may cover the cost. Pregabalin can be initiated at 25 mg PO nightly and titrated by 25 mg every 7 nights to a maximum of 75 mg PO qhs. It should be taken 1-2 hours before bedtime. Potential side effects are similar to those of gabapentin.

Doxepin

  • Doxepin 10 mg PO qhs as tolerated.
  • Doxepin is a tricyclic antidepressant. A randomized control trial found that it may be effective.
  • Potential adverse effects: dizziness, blurred vision, constipation, urinary retention. Particularly in older adults, there is an increased risk of confusion and sedation.

Phototherapy

  • Not much is known about the long term effects of UVB, but a trial of three times a week for 3 weeks may provide some relief for a period of time. Requires referral to Dermatology.

Acupuncture

  • Although there is a lack of good evidence about its efficacy, patients may wish to consider this as an alternative or complementary treatment option.

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