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Düll MM, Kremer AE. [Recommended diagnostics for pruritus affecting primary non-lesional skin]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:597-605. [PMID: 38940941 PMCID: PMC11300620 DOI: 10.1007/s00105-024-05380-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Chronic pruritus affecting primary non-lesional skin (CPNL) manifests as a common symptom across a spectrum of diseases spanning various medical specialties. Given the diverse etiological factors involved, diagnosing the underlying condition poses a significant challenge. OBJECTIVES To provide a comprehensive overview of clinical, laboratory, and imaging diagnostics for CPNL. MATERIALS AND METHODS A thorough literature search on the diagnostics of chronic pruritus was conducted using PubMed with specific keywords "chronic pruritus AND non-lesional skin", "chronic itch AND non-lesional skin", "chronic pruritus AND diagnostics", "chronic itch AND diagnostics", "CKD-aP", "hepatic pruritus", "cholestatic pruritus", and "myeloproliferative neoplasms AND pruritus". RESULTS A systematic diagnostic approach is recommended for patients with CPNL, guided by the prevalence of pruritus-associated diseases. Initial basic diagnostics facilitate a cost-effective and focused evaluation during the initial medical assessment. Information pertaining to underlying diseases can be further refined through specialized diagnostic procedures. CONCLUSIONS CPNL often presents a diagnostic dilemma. Adopting a stepwise diagnostic strategy facilitates the identification of underlying etiologies, which is crucial for recognizing diseases and administering pruritus-specific pharmacotherapy.
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Affiliation(s)
- M M Düll
- Medizinische Klinik 1, Gastroenterologie, Pneumologie, Endokrinologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - A E Kremer
- Medizinische Klinik 1, Gastroenterologie, Pneumologie, Endokrinologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland.
- Klinik für Gastroenterologie und Hepatologie, UniversitätsSpital Zürich, Universität Zürich, Rämistr. 100, 8091, Zürich, Schweiz.
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Brand M, Kremer AE. [Systemic pruritus: what is new in diagnosis and treatment?]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:600-608. [PMID: 35925235 PMCID: PMC9358966 DOI: 10.1007/s00105-022-05027-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic pruritus is a common symptom of various systemic diseases. In particular, patients with chronic renal failure, hepatobiliary diseases, and myeloproliferative neoplasms are affected. OBJECTIVES The purpose of this review is to provide an overview of laboratory chemistry and imaging diagnostics as well as current and novel therapeutic approaches to pruritus of systemic diseases. MATERIALS AND METHODS An extensive PubMed search was performed. RESULTS To clarify the cause of chronic pruritus, a step-by-step diagnosis is recommended, which is based on the frequency of pruritus-associated diseases. A basic diagnosis enables a cost-effective and targeted clarification at the level of a general practitioner. Current topical and drug therapy recommendations of pruritus in chronic renal failure, hepatobiliary diseases, myeloproliferative neoplasms, and rarer causes are summarized. In addition, novel therapeutic approaches such as the κ‑opioid receptor agonist difelikefalin, bezafibrate, inhibitors of the ileal bile acid transporter (IBAT), and the JAK-STAT pathway are highlighted. CONCLUSIONS Chronic pruritus in systemic diseases can be a diagnostic challenge. A staged diagnostic approach facilitates identification of the underlying disease. Improved pathophysiological understanding has led to the first approved therapeutic options for chronic kidney disease-associated and hepatic pruritus.
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Affiliation(s)
- M Brand
- Medizinische Klinik D, Universitätsklinikum Münster, Münster, Deutschland
| | - A E Kremer
- Klinik für Gastroenterologie und Hepatologie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz.
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Kremer A. [Diagnostic work-up of chronic pruritus]. MMW Fortschr Med 2022; 164:48-55. [PMID: 35585411 DOI: 10.1007/s15006-022-1025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Andreas Kremer
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Rämistrasse 100, 8091, Zürich, Schweiz.
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Roh YS, Choi J, Sutaria N, Kwatra SG. Itch: Epidemiology, clinical presentation, and diagnostic workup. J Am Acad Dermatol 2022; 86:1-14. [PMID: 34428534 PMCID: PMC8678917 DOI: 10.1016/j.jaad.2021.07.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 01/03/2023]
Abstract
Itch, or pruritus, is the uncomfortable sensation underlying the desire to scratch. Itch is a very common complaint in the general population that can result from dermatologic, systemic (eg, renal, hepatobiliary, endocrine), paraneoplastic, neuropathic, and psychogenic etiologies. Chronic itch is associated with significant sleep disturbances and profoundly reduces overall quality of life. Certain populations, including elderly and African Americans, are at increased risk of experiencing heightened burden of itch. Because of the variable clinical presentation and wide-ranging etiologies, itch presents a challenge for clinicians. The initial evaluation should include a complete blood count, with differential, hepatic, renal, and thyroid function testing along with diabetes screening. Further testing should be guided by history and physical examination findings. There should be a heightened concern for underlying malignancy in individuals older than 60 years of age who have a history of liver disease and diffuse itch less than 12 months of duration. For individuals with chronic pruritus of unknown origin, increased blood eosinophils may serve as a biomarker of T helper cell type 2 polarization and response to immunomodulator therapies. In this first part of a 2-part continuing medical education series, we describe the broader epidemiology and specific conditions associated with itch and the clinical presentation and diagnostic workup for patients with itch.
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Affiliation(s)
- Youkyung S. Roh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Affiliation(s)
- Elke Weisshaar
- Occupational Dermatology, Department of Dermatology, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
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Kushnir V, Dmytrenko S, Katilov O, Kushnir N. Itching as the onset of pain (part 1). PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v4i4.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PAIN is a psychophysiological reaction of an organism that occurs with severe irritation of the sensitive nerve endings embedded in organs and tissues. And also pain is the body’s protective reaction. It is signaling about a discomfort and triggers an appropriate response by the body to eliminate the cause of the pain. Pain is one of the earliest symptoms of some diseases [84].
ITCHING – an unpleasant sensation of irritation, heartburn and tingling in any area of the skin caused by various factors (exposure to chemicals, bacteria, parasites). This feeling is often manifested by the urgent need to rub or scratch some areas of the skin (or mucous membrane) [85].
When considering the pathogenesis of these concepts, a sufficiently large resemblance to the realization of mechanisms of origin, or a certain identity thereof is revealed. The question naturally arises whether itching is an early manifestation of pain, especially in those groups of diseases that are not characterized by pain.
Pathology of the hematopoietic system is not accompanied by a symptom such as pain. But for conditions such as iron overload, iron deficiency or polycythemia, itching is a clear symptom.
The unknown etiology of chronic itching of the skin is indicative of histological examination of the skin in order to exclude skin lymphoma. One of the least understood mechanisms of itching is itching associated with malignant solid tumors.
What pain that itching is a subjective sensation that can have an acute or chronic course, a clear intensity and a very significant impact on quality of life, especially in the case of comorbidity.
In addition, the question arises whether itching is an early manifestation of pain, especially in those groups of diseases that are not characterized by pain. How can a doctor manage itching effectively to prevent complications? To these and other questions, we have attempted to systematize the manifestations of itching in pathologies of organs and systems that are not traditionally accompanied by pain.
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Petruse L, Kiesel H, Rampini SK. [CME: Chronic Generalized Pruritus without Dermatological Cause]. PRAXIS 2020; 109:1099-1107. [PMID: 33108994 DOI: 10.1024/1661-8157/a003595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CME: Chronic Generalized Pruritus without Dermatological Cause Abstract. Chronic generalized pruritus is a common symptom. Dermatological causes must be distinguished from non-dermatological causes. Non-dermatological chronic pruritus has many causes, such as systemic, infectious, neurological, psychogenic disorders, and drug-related side effects, some of which may be associated with significant morbidity. The possibility of a systemic disease should be considered in patients with generalized pruritus and no signs of primary skin lesions. In addition to a careful history and physical examination, selected laboratory examinations can be helpful in making a diagnosis. Pruritus can be the first sign of a malignant hematological disease. Pruritus associated with solid tumors is not that rare. This article offers an approach to chronic generalized pruritus in adults without concomitant skin changes with a viable clarification strategy and consideration of the most important differential diagnoses.
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Affiliation(s)
- Liliana Petruse
- Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
| | - Holger Kiesel
- Klinik für Medizinische Onkologie und Hämatologie, Universitätsspital Zürich
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9
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Comment on: “Chronic pruritus of unknown origin (CPUO): Uniform nomenclature and diagnosis as a pathway to standardized understanding and treatment”. J Am Acad Dermatol 2019; 85:e381-e382. [DOI: 10.1016/j.jaad.2019.07.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
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10
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Hegade VS, Mells GF, Fisher H, Kendrick S, DiBello J, Gilchrist K, Alexander GJ, Hirschfield GM, Sandford RN, Jones DEJ. Pruritus Is Common and Undertreated in Patients With Primary Biliary Cholangitis in the United Kingdom. Clin Gastroenterol Hepatol 2019; 17:1379-1387.e3. [PMID: 30557739 DOI: 10.1016/j.cgh.2018.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 11/13/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Little is known about the prevalence or treatment of pruritus associated with primary biliary cholangitis (PBC). We analyzed data from patients with PBC recruited from all clinical centers in the United Kingdom (UK) to characterize the prevalence, severity, progression, and treatment of pruritus. METHODS We performed cross-sectional and longitudinal studies of patients in the UK-PBC cohort to assess trajectories of pruritus. Data on pruritus frequency, severity, and therapy were collected via paper questionnaires completed by 2194 patients at their initial assessment in 2011 and then again in 2014 and 2017. Self-reported treatment data were validated against the prescription record of PBC cohort in the Clinical Practice Research Datalink, a primary care database. We defined persistent pruritus as itch that occurs frequently or all the time and severe pruritus as PBC-40 pruritus domain scores of 12 or more, throughout their disease course. Latent class mixed models were used to study pruritus trajectories and identify factors associated with high pruritus. RESULTS At initial assessment, 1613 (73.5%) patients had experienced pruritus at some point since their development of PBC-persistent pruritus was reported by 34.5% of the patients and severe pruritus by 11.7%. Only 37.4% of patients with persistent pruritus and 50% with severe pruritus reported ever receiving cholestyramine. Frequencies of rifampicin use were 11% in patients with persistent pruritus and 23% in patients with severe pruritus. Comparison of 2011 and 2014 surveys (comprising 1423 patients) showed consistent self-reported data on pruritus. Proportions of patients in the UK-PBC cohort treated with cholestyramine or naltrexone (37.4% and 4.4%) did not differ significantly from proportions treated in the Clinical Practice Research Datalink cohort (30.4% and 4.4%) (P = .07 for cholestyramine and P = .32 for naltrexone). Latent class mixed models (n = 1753) identified 3 different groups of pruritus. Multivariable analysis identified younger age at diagnosis and higher level of alkaline phosphatase at 12 months after diagnosis as factors significantly associated with persistent high pruritus. CONCLUSIONS In a large national cohort study of patients with PBC, we found a high prevalence of pruritus and inadequate guideline-recommended therapy. Patient-reported data used to determine pruritus prevalence and treatment are reliable. Younger age and levels of higher alkaline phosphatase were associated with persistent pruritus. We need to increase awareness and management of pruritus in PBC in the UK.
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Affiliation(s)
- Vinod S Hegade
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - George F Mells
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Holly Fisher
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Stuart Kendrick
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; GlaxoSmithKline, Stevenage, United Kingdom
| | - Julia DiBello
- GlaxoSmithKline Research and Development, Collegeville, Pennsylvania
| | - Kim Gilchrist
- GlaxoSmithKline Research and Development, Collegeville, Pennsylvania
| | - Graeme J Alexander
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Gideon M Hirschfield
- Centre for Liver Research, National Institute for Health Research Biomedical Research Unit, University of Birmingham, Birmingham, United Kingdom
| | - Richard N Sandford
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - David E J Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
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11
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Larson VA, Tang O, Ständer S, Kang S, Kwatra SG. Association between itch and cancer in 16,925 patients with pruritus: Experience at a tertiary care center. J Am Acad Dermatol 2018; 80:931-937. [PMID: 30217520 DOI: 10.1016/j.jaad.2018.08.044] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/25/2018] [Accepted: 08/29/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pruritus has been associated with cancer. However, limited data are available on the types of underlying malignancies associated with pruritus. OBJECTIVE We sought to characterize the association between pruritus and different cancer types, as well as variations by racial group. METHODS Cross-sectional study of patients ≥18 years of age seen at the Johns Hopkins Health System during 2013-2017. Patients with pruritus were compared with patients without pruritus. Analyses were stratified by race. RESULTS Patients with pruritus were more likely to have concomitant malignancy than those without pruritus (odds ratio 5.76, 95% confidence interval 5.53-6.00). Most strongly associated were cancers of the liver, gallbladder and biliary tract, hematopoietic system, and skin. Compared with white patients, black patients more frequently had soft tissue, dermatologic, and hematologic malignancies and less frequently had liver, respiratory, gastrointestinal, and gynecologic malignancies. LIMITATIONS The cross-sectional design precludes analysis of the temporal association between pruritus and malignancy. The study is limited to a single tertiary care center. CONCLUSION Pruritus is most strongly associated with cancers of the liver, skin, and hematopoietic system. Black patients with pruritus have a higher likelihood of skin, soft tissue, and hematologic malignancies than white patients, while whites have higher likelihoods of liver, respiratory, gastrointestinal, and gynecologic malignancies.
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Affiliation(s)
- Valerie A Larson
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olive Tang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sonja Ständer
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Sewon Kang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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12
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Alizadeh N, Mirpour SH, Golmohamadi R, Darjani A, Eftekhari H, Rafiei R, Gharaei Nejad K, Azimi SZ. Chronic generalized pruritus without primary skin lesions: a longitudinal prospective observational study. Int J Dermatol 2018; 58:273-278. [DOI: 10.1111/ijd.14125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/21/2018] [Accepted: 06/08/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Narges Alizadeh
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Seyyed Hossein Mirpour
- Department of Hematology and Oncology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Razieh Golmohamadi
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Abbas Darjani
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Hojat Eftekhari
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Rana Rafiei
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Kaveh Gharaei Nejad
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
| | - Seyyede Zeinab Azimi
- Skin Research Center; Department of Dermatology; Razi hospital; School of Medicine; Guilan University of Medical Sciences; Rasht Iran
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Millington G, Collins A, Lovell C, Leslie T, Yong A, Morgan J, Ajithkumar T, Andrews M, Rushbook S, Coelho R, Catten S, Lee K, Skellett A, Affleck A, Exton L, Mohd Mustapa M, Levell N, McHenry P, Gibbon K, Buckley D, Leslie T, Mallon E, Wakelin S, Ungureanu S, Hunasehally R, Cork M, Johnston G, Chiang N, Natkunarajah J, Worsnop F, Duarte Williamson C, Donnelly J, Towers K, Saunders C, Adbi Salad A, Brain A. British Association of Dermatologists’ guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol 2018; 178:34-60. [DOI: 10.1111/bjd.16117] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2017] [Indexed: 12/20/2022]
Affiliation(s)
- G.W.M. Millington
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A. Collins
- Haematology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - C.R. Lovell
- Dermatology Department Royal United Hospital Combe Park Bath BA1 3NG U.K
| | - T.A. Leslie
- Dermatology Department Royal Free Hospital Pond Street London NW3 2QGU.K
| | - A.S.W. Yong
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - J.D. Morgan
- General Practitioner Chet Valley Medical Practice 40–48 George Lane London NR14 6QH U.K
| | - T. Ajithkumar
- Oncology Department Addenbrooke's Hospital Hills Road Cambridge CB2 2QQ U.K
| | - M.J. Andrews
- Nephrology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - S.M. Rushbook
- Hepatology Unit Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - R.R. Coelho
- Dermatology Department St George's Hospital Blackshaw Road London SW17 0QT U.K
| | - S.J. Catten
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - K.Y.C. Lee
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A.M. Skellett
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A.G. Affleck
- Dermatology Department Ninewells Hospital Dundee DD1 9SY U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - N.J. Levell
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
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How Frequent Is Itch? Facts and Thoughts of a Long Neglected Aspect of Itch. CURRENT DERMATOLOGY REPORTS 2017. [DOI: 10.1007/s13671-017-0197-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Shevchenko A, Valdes-Rodriguez R, Yosipovitch G. Causes, pathophysiology, and treatment of pruritus in the mature patient. Clin Dermatol 2017; 36:140-151. [PMID: 29566918 DOI: 10.1016/j.clindermatol.2017.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic itch is a common and debilitating health condition in the elderly. There are several common causes of itch in the mature population, such as skin xerosis, immunosenescence, and neuropathic changes. In addition, skin diseases, such as seborrheic dermatitis and stasis dermatitis, systemic conditions (end-stage renal disease and diabetes), or psychogenic derailments, such as depression, anxiety, and dementia, can all serve as triggers of pruritus. Polypharmacy, a common occurrence among the elderly population, may also serve as a cause of itch that may or may not be accompanied by dermatitis. Such medications as μ opioids and calcium channel blockers have been found to have a connection with pruritus in the advanced aging population. Determining the exact trigger for pruritus in the elderly may be especially challenging, because itch can be idiopathic in many cases. The role of treatments should not only take into account elimination of various underlying cutaneous, systemic, or psychogenic conditions associated with itch but also focus on the skin changes that are characteristic of the aging process. Development of such treatment options can be guided by elucidation of the mechanisms underlying the pathophysiology of itch in the geriatric population.
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Affiliation(s)
- Alina Shevchenko
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Rodrigo Valdes-Rodriguez
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Gil Yosipovitch
- Department of Dermatology & Miami Itch Center at the University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA.
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Lo Re V, Carbonari DM, Saine ME, Newcomb CW, Roy JA, Liu Q, Wu Q, Cardillo S, Haynes K, Kimmel SE, Reese PP, Margolis DJ, Apter AJ, Reddy KR, Hennessy S, Bhullar H, Gallagher AM, Esposito DB, Strom BL. Postauthorization safety study of the DPP-4 inhibitor saxagliptin: a large-scale multinational family of cohort studies of five outcomes. BMJ Open Diabetes Res Care 2017; 5:e000400. [PMID: 28878934 PMCID: PMC5574452 DOI: 10.1136/bmjdrc-2017-000400] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/09/2017] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate the risk of serious adverse events among patients with type 2 diabetes mellitus initiating saxagliptin compared with oral antidiabetic drugs (OADs) in classes other than dipeptidyl peptidase-4 (DPP-4) inhibitors. RESEARCH DESIGN AND METHODS Cohort studies using 2009-2014 data from two UK medical record data sources (Clinical Practice Research Datalink, The Health Improvement Network) and two USA claims-based data sources (HealthCore Integrated Research Database, Medicare). All eligible adult patients newly prescribed saxagliptin (n=110 740) and random samples of up to 10 matched initiators of non-DPP-4 inhibitor OADs within each data source were selected (n=913 384). Outcomes were hospitalized major adverse cardiovascular events (MACE), acute kidney injury (AKI), acute liver failure (ALF), infections, and severe hypersensitivity events, evaluated using diagnostic coding algorithms and medical records. Cox regression was used to determine HRs with 95% CIs for each outcome. Meta-analyses across data sources were performed for each outcome as feasible. RESULTS There were no increased incidence rates or risk of MACE, AKI, ALF, infection, or severe hypersensitivity reactions among saxagliptin initiators compared with other OAD initiators within any data source. Meta-analyses demonstrated a reduced risk of hospitalization/death from MACE (HR 0.91, 95% CI 0.85 to 0.97) and no increased risk of hospitalization for infection (HR 0.97, 95% CI 0.93 to 1.02) or AKI (HR 0.99, 95% CI 0.88 to 1.11) associated with saxagliptin initiation. ALF and hypersensitivity events were too rare to permit meta-analysis. CONCLUSIONS Saxagliptin initiation was not associated with increased risk of MACE, infection, AKI, ALF, or severe hypersensitivity reactions in clinical practice settings. TRIAL REGISTRATION NUMBER NCT01086280, NCT01086293, NCT01086319, NCT01086306, and NCT01377935; Results.
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Affiliation(s)
- Vincent Lo Re
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dena M Carbonari
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Elle Saine
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig W Newcomb
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Qing Liu
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Serena Cardillo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Haynes
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- HealthCore Inc., Wilmington, Delaware, USA
| | - Stephen E Kimmel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Margolis
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea J Apter
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Rajender Reddy
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - Brian L Strom
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rutgers Biomedical & Health Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
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Wirth TC, Vogel A. Surveillance in cholangiocellular carcinoma. Best Pract Res Clin Gastroenterol 2016; 30:987-999. [PMID: 27938792 DOI: 10.1016/j.bpg.2016.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/28/2016] [Accepted: 11/04/2016] [Indexed: 01/31/2023]
Abstract
Cholangiocellular carcinoma is the most frequent malignant neoplasm originating from the epithelium of intra- or extrahepatic bile ducts. In the past decades, the incidence of cholangiocarcinoma has been shown to increase while overall mortality has remained high with an approximate 5-year overall survival below 20%. Surgery remains the only curative option while systemic treatment is limited to palliative chemotherapy. Therefore, surveillance strategies for patients at risk of developing cholangiocarcinoma are urgently needed, particularly in patients with primary sclerosing cholangitis and patients infected with liver flukes. Here we summarize the currently available data on surveillance of risk populations and methods for the detection of cholangiocarcinoma.
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Affiliation(s)
- Thomas C Wirth
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, 30625 Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, 30625 Hannover, Germany.
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18
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Fett N, Haynes K, Propert KJ, Margolis DJ. Predictors of malignancy development in patients with chronic pruritus. J Dermatol Sci 2016; 82:123-8. [DOI: 10.1016/j.jdermsci.2016.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/14/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
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Abstract
Chronic itch in the elderly is a common problem, with a significant impact on quality of life and sleep in elderly patients. Chronic itch may be attributable to several causes, including dry skin, immunosenescence and neural degeneration. Itch may also be caused by skin diseases, such as seborrhoeic dermatitis and stasis dermatitis; systemic conditions, such as end-stage renal disease and diabetes; and psychogenic conditions, such as depression and anxiety. The use of polypharmacy may also cause itch, with or without a rash. Specifically, thiazides and calcium channel blockers have been known to cause itch in elderly patients. Management should be tailored according to the underlying dermatological or systemic aetiology of itch. Topical treatment is the mainstay of therapy, providing special emphasis on skin hydration and barrier repair. In addition, topical and oral medications that target the nervous system and reduce neuronal hypersensitization, such as gabapentin and selective antidepressants, have a role in treating patients with severe chronic itch. Furthermore, management must account for changes in metabolism and pharmacokinetics of drugs in the aging population in order to prevent the occurrence of adverse effects.
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20
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Rowe B, Yosipovitch G. Malignancy-associated pruritus. Eur J Pain 2015; 20:19-23. [DOI: 10.1002/ejp.760] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2015] [Indexed: 12/26/2022]
Affiliation(s)
- B. Rowe
- Department of Dermatology and Temple Itch Center; Temple University School of Medicine; Philadelphia Pennsylvania
| | - G. Yosipovitch
- Department of Dermatology and Temple Itch Center; Temple University School of Medicine; Philadelphia Pennsylvania
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21
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Skin Manifestations of Internal Disease in Older Adults. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Langan E. Pruritus and underlying cancer: is targeted screening feasible? Br J Dermatol 2015; 172:1685-1686. [DOI: 10.1111/bjd.13686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- E.A. Langan
- Department of Dermatology; University of Lübeck; Lübeck Germany
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23
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Saine ME, Carbonari DM, Newcomb CW, Nezamzadeh MS, Haynes K, Roy JA, Cardillo S, Hennessy S, Holick CN, Esposito DB, Gallagher AM, Bhullar H, Strom BL, Lo Re V. Determinants of saxagliptin use among patients with type 2 diabetes mellitus treated with oral anti-diabetic drugs. BMC Pharmacol Toxicol 2015; 16:8. [PMID: 25889498 PMCID: PMC4404079 DOI: 10.1186/s40360-015-0007-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/16/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The patterns and determinants of saxagliptin use among patients with type 2 diabetes mellitus (T2DM) are unknown in real-world settings. We compared the characteristics of T2DM patients who were new initiators of saxagliptin to those who were new initiators of non-dipeptidyl peptidase-4 (DPP-4) inhibitor oral anti-diabetic drugs (OADs) and identified factors associated with saxagliptin use. METHODS We conducted a cross-sectional study within the Clinical Practice Research Datalink (CPRD), The Health Improvement Network (THIN), US Medicare, and the HealthCore Integrated Research Database (HIRD(SM)) across the first 36 months of saxagliptin availability (29 months for US Medicare). Patients were included if they were: 1) ≥18 years old, 2) newly prescribed saxagliptin or a non-DPP-4 inhibitor OAD, and 3) enrolled in their respective database for 180 days. For each saxagliptin initiator, we randomly selected up to ten non-DPP-4 inhibitor OAD initiators matched on age, sex, and geographic region. Conditional logistic regression was used to identify determinants of saxagliptin use. RESULTS We identified 64,079 saxagliptin initiators (CPRD: 1,962; THIN: 2,084; US Medicare: 51,976; HIRD(SM): 8,057) and 610,660 non-DPP-4 inhibitor OAD initiators (CPRD: 19,484; THIN: 19,936; US Medicare: 493,432; HIRD(SM): 77,808). Across all four data sources, prior OAD use, hypertension, and hyperlipidemia were associated with saxagliptin use. Saxagliptin initiation was also associated with hemoglobin A1c results >8% within the UK data sources, and a greater number of hemoglobin A1c measurements in the US data sources. CONCLUSIONS In these UK and US data sources, initiation of saxagliptin was associated with prior poor glycemic control, prior OAD use, and diagnoses of hypertension and hyperlipidemia. TRIAL REGISTRATION ClinicalTrials.gov identifiers NCT01086280 , NCT01086293 , NCT01086319 , NCT01086306 , and NCT01377935.
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Affiliation(s)
- M Elle Saine
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Dena M Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Craig W Newcomb
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
| | - Melissa S Nezamzadeh
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Kevin Haynes
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- HealthCore, Inc, Wilmington, DE, USA.
| | - Jason A Roy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Serena Cardillo
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | - Arlene M Gallagher
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK.
| | | | - Brian L Strom
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Rutgers Biomedical & Health Sciences, Rutgers, the State University of New Jersey, Newark, NJ, USA.
| | - Vincent Lo Re
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA.
- Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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