Clinical condition

Most frequently used treatments

Other available treatments

Renal pruritusa

– Emollients ± menthol 0.25% + camphor 0.25% tid

– Optimization of RRT and increasing dialysis dose

– Activated charcoal 6 g/d

– UVB phototherapy

– Topical 0.03% tacrolimus ointment bid

– Capsaicin cream 0.025%-0.075% up to tid

– Oral antihistamines (eg, hydroxyzine 10-25 mg PO qid as needed or diphenhydramine 25 mg PO qid as needed)

– Gabapentin (eg, 100-300 mg after hemodialysis or at bedtime)

– Pregabalin (eg, 25-50 mg after dialysis or at bedtime)

– Sertraline 25-200 mg/d

– Thalidomide 100 mg at night

– Naltrexone 50 mg/d

– Cholestyramine 5 g bid

– Montelukast 10 mg/d PO

– Ondansetron 4-8 mg PO, once daily to bid

– Doxepin 25-50 mg at bedtime

– Nalfurafineb 5 microg IV after hemodialysis

Cholestasis

– Bile duct stenting

– Bile acid sequestrants (eg, cholestyramine [4-16 g/d PO; advise patients to take other drugs ≥1 h before or 4-6 h after each cholestyramine dose] or colesevelam (1875 mg bid in case of intolerable adverse effects secondary to cholestyramine)

– UDCA 12-15 mg/kg/d PO in 3 divided doses

– Rifampin 150-300 PO bid (monitor LFTs regularly due to risk of hepatitis)

– SSRIs (eg, sertraline 50-100 mg/d, paroxetine 5-20 mg/d, fluvoxamine 25-100 mg/d)

– Mu-opioid receptor antagonists (eg, naltrexone 12.5-50 mg/d PO or naloxone 0.4 mg IV bolus followed by 0.2 microg/kg/min for 24 h)

– UVB phototherapy

– Transdermal buprenorphine 5-10 microg/h (if patient has received another opioid for pain, try switching to buprenorphine using dose conversion for opioid rotation; see Pain Management: Basic Principles)

– Androgens

– Tropisetronb

– Propofol

Polycythemia vera

– Emollients

– Low-dose aspirin

– Phototherapy (eg, narrow-band UVB or PUVA)

– SSRIs (eg, sertraline 25-100 mg/d)

– Paroxetine 5-20 mg/d, fluvoxamine 25-100 mg/d, or fluoxetine

– Sedative H1 antihistamines (hydroxyzine)

– H2 antihistamines (cimetidine)

– Hydroxyurea or interferon alpha (if cytoreduction is indicated)

– JAK inhibitors (ruxolitinib)

– Thalidomide

Hodgkin lymphoma

– Topical and systemic glucocorticoids

– H1 antihistamines (eg, cetirizine up to 20 mg bid)

– Cimetidine 800 mg/d

– Mirtazapine 7.5-30 mg at bedtime

– Sertraline 25-100 mg/d

– Carbamazepine 200 mg bid

Paraneoplastic pruritus in patients with solid tumors

Paroxetine 5-20 mg/d, sertraline 25-100 mg/d, or fluvoxamine 25-100 mg/d

Mirtazapine 7.5-30 mg at bedtime

Epidural or subarachnoid opioids

Intrathecal bupivacaine, prophylactic ondansetron 4 mg IV, gabapentin, mirtazapine

NSAIDs, antihistamines, ondansetron 4-8 mg IV, nalbuphine hydrochloride, butorphanol, naloxone or naltrexone, propofol, promethazine

Systemic morphine or other opioids

Emollients, lowering ambient temperature, benzodiazepines, first-generation H1-receptor antagonists

Switching to another opioid (especially in the case of morphine) if pruritus does not resolve within a few days and is very uncomfortable; ondansetron, paroxetine

Neuropathic pruritus

– Topical capsaicin

– TCAs (eg, amitriptyline 10-50 mg PO at bedtime)

– Antiepileptic drugs (eg, gabapentin 300-900 mg/d divided in 2-3 doses and pregabalin 75-150 mg/d PO)

– Mirtazapine 15-30 mg PO at bedtime

NSAIDs

Other causes or idiopathic pruritus

Sertraline or paroxetine

Mirtazapine, gabapentin, aprepitant

a Exclude hyperparathyroidism.

b Not available in Canada.