1
|
Okutani H, Lo Vecchio S, Arendt-Nielsen L. Mechanisms and treatment of opioid-induced pruritus: Peripheral and central pathways. Eur J Pain 2024; 28:214-230. [PMID: 37650457 DOI: 10.1002/ejp.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/08/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Pruritus (also known as itch) is defined as an unpleasant and irritating sensation of the skin that provokes an urge to scratch or rub. It is well known that opioid administration can cause pruritus, which is paradoxical as itch and pain share overlapping sensory pathways. Because opioids inhibit pain but can cause itching. Significant progress has been made to improve our understanding of the fundamental neurobiology of itch; however, much remains unknown about the mechanisms of opioid-induced pruritus. The prevention and treatment of opioid-induced pruritus remains a challenge in the field of pain management. The objective of this narrative review is to present and discuss the current body of literature and summarize the current understanding of the mechanisms underlying opioid-induced pruritus, and its relationship to analgesia, and possible treatment options. RESULTS The incidence of opioid-induced pruritus differs with different opioids and routes of administration, and the various mechanisms can be broadly divided into peripheral and central. Especially central mechanisms are intricate, even at the level of the spinal dorsal horn. There is evidence that opioid receptor antagonists and mixed agonist and antagonists, especially μ-opioid antagonists and κ-opioid agonists, are effective in relieving opioid-induced pruritus. Various treatments have been used for opioid-induced pruritus; however, most of them are controversial and have conflicting results. CONCLUSION The use of a multimodal analgesic treatment regimen combined with a mixed antagonist and κ agonists, especially μ-opioid antagonists, and κ-opioid agonists, seems to be the current best treatment modality for the management of opioid-induced pruritus and pain. SIGNIFICANCE Opioids remain the gold standard for the treatment of moderate to severe acute pain as well as cancer pain. It is well known that opioid-induced pruritus often does not respond to regular antipruritic treatment, thereby posing a challenge to clinicians in the field of pain management. We believe that our review makes a significant contribution to the literature, as studies on the mechanisms of opioid-induced pruritus and effective management strategies are crucial for the management of these patients.
Collapse
Affiliation(s)
- Hiroai Okutani
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, School of Medicine, Aalborg University, Aalborg, Denmark
- Department of Anesthesiology and Pain Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Silvia Lo Vecchio
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, School of Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, School of Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
2
|
Pala E, Tasar PT, Soguksu AO, Karasahin O, Sevinc C. Dermatological Diseases in Palliative Care Patients in a University Hospital: A Prospective Study. J Palliat Care 2024; 39:75-81. [PMID: 35938193 DOI: 10.1177/08258597221119063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients receiving palliative care are more prone to dermatological disease. The aim of our study was to determine the frequency of dermatological diseases and associated factors in patients receiving palliative care support. METHODS This prospective observational study included inpatients in the palliative care unit of our university hospital in Erzurum/TURKEY. The patients were evaluated by the same dermatologist within the first 48 h of admission and 3 days a week during follow-up. Demographic data, reasons for admission to the palliative care unit, and skin lesions at the time of admission and during follow-up were recorded. RESULTS The median age of the 259 patients included in the study was 77.0 years (min- max, 19-108) and 54.4% were women. Dermatological disease was detected in 246 patients (96.1%) at admission to the palliative care unit and in 185 patients (71.4%) patients during follow-up. The most common dermatological disease at admission was dry skin (n = 175, 67.6%), which was also the most common cause of pruritis (n = 29, 11.2%). The most common skin infection was dermatophytosis (n = 57, 22.0%) and the most common type of dermatitis was contact dermatitis (n = 17, 6.6%). Nearly all tumors were benign (n = 32, 12.4%) and most chronic wounds were pressure ulcers (n = 96, 37.1%). During hospital follow-up, the most frequent dermatitis was contact dermatitis (n = 44, 17.0%), the most frequent skin infection was candidiasis (n = 25, 9.7%), the most common chronic wound was pressure ulcers (n = 25, 9.7%), the most common dermatological disease was urticaria (n = 14, 5.4%), and all cases of pruritus were associated with dry skin (n = 8, 3.1%). CONCLUSIONS The frequency of dermatological findings is high among patients receiving palliative care. Therefore, dermatologists should be included in multidisciplinary palliative care teams and evaluate palliative care patients early and regularly.
Collapse
Affiliation(s)
- Erdal Pala
- Department of Dermatology, Atatürk University Hospital, Erzurum, Turkey
| | - Pınar Tosun Tasar
- Department of Internal Medicine, Division of Geriatrics, Ataturk University Hospital, Erzurum, Turkey
| | | | - Omer Karasahin
- Infectious Diseases Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Can Sevinc
- Department of Internal Medicine, Division of Nephrology, Ataturk University Hospital, Erzurum, Turkey
| |
Collapse
|
3
|
Kolberg C, Doman E, Mignano S, Mullikin D, Vasta L, Wadzinski W, Foster B. Recognizing a Mediastinal Mass: A Case of Primary Mediastinal Large B-Cell Lymphoma With Pruritus in a 23-Year-Old Adult Male Sailor. Mil Med 2023; 188:3687-3691. [PMID: 35932188 DOI: 10.1093/milmed/usac238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/21/2022] [Accepted: 07/28/2022] [Indexed: 11/14/2022] Open
Abstract
Primary mediastinal large B-cell lymphoma (PMBCL) is a rare, non-Hodgkin, B-cell lymphoma thought to originate from thymic B cells, which occurs primarily in young adults such as in the active duty population. Primary mediastinal large B-cell lymphoma (PMBCL) presents as a large mediastinal mass, posing risks to the cardiopulmonary safety of patients and challenging the routine approach to diagnosis. We describe a case of a 23-year-old male sailor who presented to sick call on his ship while in port with shortness of breath, night sweats, 50-pound weight loss, and pruritic punched-out lesions on all extremities. An initial chest X-ray showed a large consolidation. After being seen in the pulmonary medicine clinic 5 weeks after his initial presentation, the patient was admitted to the intensive care unit after computed tomography of his chest revealed a mediastinal mass, causing compression of both the right bronchus and superior vena cava with a large pericardial effusion. Empiric high-dose dexamethasone was initiated before a formal diagnosis due to his significant risk for cardiopulmonary compromise. Following diagnosis and two cycles of chemotherapy, the patient was transferred to a medical oncology facility in the continental USA. This case demonstrates the need to educate all military providers to recognize the presentation of mediastinal masses in active duty service members and the importance of urgently escalating these patients to higher levels of care in order to avoid life-threatening complications.
Collapse
Affiliation(s)
- Courtney Kolberg
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Elizabeth Doman
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Salvatore Mignano
- Department of Pathology, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Dolores Mullikin
- Department of Pediatric Hematology and Oncology, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Lauren Vasta
- Department of Pediatric Hematology and Oncology, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - William Wadzinski
- Department of Pulmonology and Critical Care, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Brian Foster
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, HI 96859, USA
- Department of Pulmonology and Critical Care, Tripler Army Medical Center, Honolulu, HI 96859, USA
| |
Collapse
|
4
|
Sabah Abdulridha Budair A, Ismail Al Hamdi K, Ali Mansour A. Non-Infectious Dermatological Manifestations among Patients with Diabetes Mellitus in Basrah, Iraq. ARCHIVES OF RAZI INSTITUTE 2022; 77:467-475. [PMID: 35891736 DOI: 10.22092/ari.2021.356588.1874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/04/2021] [Indexed: 09/30/2022]
Abstract
Diabetes mellitus (DM) is a clinical illness usually linked to a wide range of skin manifestations; however, skin, as the greatest organ in the body, has received little attention. As a result, this study aimed to detect the prevalence and pattern of non-infectious skin disorders among patients with diabetes. This study was carried out at the Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah Province, Iraq, from September 2020 to September 2021. The data were collected from 347 patients with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM). The exclusion criteria were patients with skin changes due to some medications, pregnancy, iatrogenic factors, skin infections, established hypo- or hyper-thyroidism, Cushing or adrenal insufficiency, pituitary disorders, end-stage renal impairment, malignancy, and established rheumatological disease and those who were on chemotherapy. Full dermatological examinations and screenings were performed under the supervision of a dermatologist expert and all clinically definable cutaneous lesions were recorded. The prevalence of skin lesions was estimated at 71.5% in patients. Pruritus, xerosis, acrochordon, diabetic dermopathy, acanthosis nigricans, and insulin-related lipohypertrophy were the commonest skin lesions reported among the patients. The occurrence of skin lesions in diabetic patients was proportional to the female gender, duration of disease, obesity, insulin therapy, and worse glycemic control. There was a broad spectrum of skin lesions in both T1DM and T2DM with corresponding prevalence.
Collapse
Affiliation(s)
| | | | - A Ali Mansour
- Faiha Specialized Diabetes, Endocrine, and Metabolism Center, University of Basrah, Basrah, Iraq
| |
Collapse
|
5
|
Shirolkar P, Mishra SK. Role of TRP ion channels in pruritus. Neurosci Lett 2022; 768:136379. [PMID: 34861341 PMCID: PMC8755431 DOI: 10.1016/j.neulet.2021.136379] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 01/21/2023]
Abstract
The transient receptor potential (TRP) channel superfamily responds to various physical, chemical, and environmental stimuli including the detection of sensations both harmful and non-harmful. Among these sensations is pruritus, or itch. There are at least 27 different TRP channels and about six of them are involved in pruriception. The function of these six receptors is primarily seen in the skin and the dorsal root ganglia. Identification and biological insights provided by these receptors in pruriception is important for human health as mutations and activations of many of these channels cause discomfort and disease. This review will focus on involvement of TRP channels in pruriception that may render these channels as the targets of many antagonistic topical medications, which may help patients' better cope with the pruritus that results from various cutaneous and systemic diseases.
Collapse
Affiliation(s)
- Parth Shirolkar
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Santosh K Mishra
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; The WM Keck Behavioral Center, North Carolina State University, Raleigh, NC, USA; Program in Genetics, North Carolina State University, Raleigh, NC, USA.
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Yefet E, Nassar S, Carmeli J, Massalha M, Hasanein J, Zafran N, Rudin M, Nachum Z. Oral analgesia in fixed-time interval administration versus spinal morphine for post-Cesarean pain: a randomised controlled trial. Arch Gynecol Obstet 2021; 305:893-901. [PMID: 34463805 PMCID: PMC8406016 DOI: 10.1007/s00404-021-06196-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Enav Yefet
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.
- Department of Obstetrics and Gynecology, Baruch Padeh Medical Center Poriya, Tiberias, Israel.
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.
| | - Salih Nassar
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Julia Carmeli
- Department of Anesthesiology, Emek Medical Center, Afula, Israel
| | - Manal Massalha
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Jamal Hasanein
- Department of Neonatology, Emek Medical Center, Afula, Israel
| | - Noah Zafran
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Michael Rudin
- Department of Anesthesiology, Emek Medical Center, Afula, Israel
| | - Zohar Nachum
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| |
Collapse
|
8
|
Abstract
Chronic pruritus (itch lasting ≥6 weeks) is a bothersome chief complaint that may present in a broad variety of diseases. Most itch-causing diagnoses fit into 1 of 5 categories (inflammatory, secondary to systemic disease, neuropathic, chronic pruritus of undetermined origin, and psychogenic itch) and this broad differential can be narrowed using key findings in the history and physical. In this article, we discuss which key findings are most pertinent for narrowing this differential and guiding further workup and treatment, as well as how to treat many itchy conditions.
Collapse
Affiliation(s)
- Zoe M Lipman
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Giuseppe Ingrasci
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA.
| |
Collapse
|
9
|
Izci M, Maksoudian C, Manshian BB, Soenen SJ. The Use of Alternative Strategies for Enhanced Nanoparticle Delivery to Solid Tumors. Chem Rev 2021; 121:1746-1803. [PMID: 33445874 PMCID: PMC7883342 DOI: 10.1021/acs.chemrev.0c00779] [Citation(s) in RCA: 216] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Indexed: 02/08/2023]
Abstract
Nanomaterial (NM) delivery to solid tumors has been the focus of intense research for over a decade. Classically, scientists have tried to improve NM delivery by employing passive or active targeting strategies, making use of the so-called enhanced permeability and retention (EPR) effect. This phenomenon is made possible due to the leaky tumor vasculature through which NMs can leave the bloodstream, traverse through the gaps in the endothelial lining of the vessels, and enter the tumor. Recent studies have shown that despite many efforts to employ the EPR effect, this process remains very poor. Furthermore, the role of the EPR effect has been called into question, where it has been suggested that NMs enter the tumor via active mechanisms and not through the endothelial gaps. In this review, we provide a short overview of the EPR and mechanisms to enhance it, after which we focus on alternative delivery strategies that do not solely rely on EPR in itself but can offer interesting pharmacological, physical, and biological solutions for enhanced delivery. We discuss the strengths and shortcomings of these different strategies and suggest combinatorial approaches as the ideal path forward.
Collapse
Affiliation(s)
- Mukaddes Izci
- NanoHealth
and Optical Imaging Group, Translational Cell and Tissue Research
Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Christy Maksoudian
- NanoHealth
and Optical Imaging Group, Translational Cell and Tissue Research
Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Bella B. Manshian
- Translational
Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Stefaan J. Soenen
- NanoHealth
and Optical Imaging Group, Translational Cell and Tissue Research
Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| |
Collapse
|
10
|
Ahn YH, Kang HR. Pathophysiology, diagnosis, and management of chronic pruritus. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.4.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yoon Hae Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| |
Collapse
|
11
|
Meeuwis SH, van Middendorp H, Pacheco-Lopez G, Ninaber MK, Lavrijsen APM, van der Wee N, Veldhuijzen DS, Evers AWM. Antipruritic Placebo Effects by Conditioning H1-antihistamine. Psychosom Med 2020; 81:841-850. [PMID: 31490841 PMCID: PMC6844655 DOI: 10.1097/psy.0000000000000743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/15/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Allergic rhinitis symptoms can be reduced by behaviorally conditioning antihistamine. It is unclear whether these findings extend to histamine-induced itch or work when participants are informed about the conditioning procedure (open-label conditioning). The current study aims to investigate the efficacy of (open-label) antipruritic behavioral conditioning for histamine-induced itch. METHODS Healthy participants (n = 92; 84% female) were randomized to I) an open-label conditioned, II) closed-label conditioned, III) conditioned-not-evoked control, or IV) nonconditioned control group. A two-phase conditioning paradigm was used. During acquisition, a conditioned stimulus (CS; distinctively tasting beverage) was repeatedly paired with the H1-antihistamine levocetirizine (groups I-III). During evocation, the CS was paired with placebo (I, II), or instead of the CS, water was paired with placebo (III). The nonconditioned control group (IV) received CS with placebo in both phases. Itch after histamine iontophoresis and physiological data (i.e., spirometry, heart rate, skin conductance) were assessed. Combined conditioned and combined control groups were first compared, and analyses were repeated for separate groups. RESULTS Marginally lower itch was reported in the combined conditioned compared with the control groups (F(1,88) = 2.10, p = .076, ηpartial = 0.02); no differences between separate groups were found. No effects on physiological data were found, except for heart rate, which reduced significantly and consistently for control groups, and less consistently for conditioned groups (group by time interaction: F(7,80) = 2.35, p = .031, ηpartial = 0.17). CONCLUSION Limited support was found for the efficacy of antipruritic behavioral conditioning, regardless of whether participants were informed about the conditioning procedure. The application of open-label conditioning in patient populations should be further researched. TRIAL REGISTRATION www.trialregister.nl; ID NTR5544.
Collapse
Affiliation(s)
- Stefanie H Meeuwis
- From the Health, Medical and Neuropsychology Unit, Institute Psychology, Faculty of Social and Behavioural Sciences, (Meeuwis, van Middendorp, Pacheco-Lopez, Veldhuijzen, Evers), Leiden University; Leiden Institute for Brain and Cognition (Meeuwis, van Middendorp, Veldhuijzen, Evers), Leiden University Medical Center, Leiden, The Netherlands; Health Sciences Department, Campus Lerma (Pacheco-Lopez), Metropolitan Autonomous University, Lerma, Edo Mex, Mexico; and Departments of Pulmonology (Ninaber), Dermatology (Lavrijsen), and of Psychiatry (van der Wee, Evers), Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Al-Tamimi M, Khan R. Incidence and severity of pruritus in pregnant women undergoing lower-segment cesarean section under spinal anesthesia with fentanyl and bupivacaine. INDIAN JOURNAL OF PAIN 2020. [DOI: 10.4103/ijpn.ijpn_91_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
13
|
|
14
|
Dancker C, MacFarlane P, Love EJ. Pruritus and myoclonus following five consecutive doses of morphine administered through an epidural catheter in a dog. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2019-000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | | | - Emma J Love
- Bristol Veterinary SchoolUniversity of BristolLangfordUK
| |
Collapse
|
15
|
Harrison IP, Spada F. Breaking the Itch-Scratch Cycle: Topical Options for the Management of Chronic Cutaneous Itch in Atopic Dermatitis. MEDICINES (BASEL, SWITZERLAND) 2019; 6:medicines6030076. [PMID: 31323753 PMCID: PMC6789602 DOI: 10.3390/medicines6030076] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 04/13/2023]
Abstract
Chronic itch is an unpleasant sensation that triggers a desire to scratch that lasts for six weeks or more. It is a major diagnostic symptom of myriad diseases, including atopic dermatitis for which it is the most prominent feature. Chronic itch can be hugely debilitating for the sufferer, damaging in terms of both the monetary cost of treatment and its socioeconomic effects, and few treatment options exist that can adequately control it. Corticosteroids remain the first line treatment strategy for atopic dermatitis, but due to the risks associated with long-term use of corticosteroids, and the drawbacks of other topical options such as topical calcineurin inhibitors and capsaicin, topical options for itch management that are efficacious and can be used indefinitely are needed. In this review, we detail the pathophysiology of chronic pruritus, its key features, and the disease most commonly associated with it. We also assess the role of the skin and its components in maintaining a healthy barrier function, thus reducing dryness and the itch sensation. Lastly, we briefly detail examples of topical options for the management of chronic pruritus that can be used indefinitely, overcoming the risk associated with long-term use of corticosteroids.
Collapse
Affiliation(s)
- Ian P Harrison
- Department of Research and Development, Ego Pharmaceuticals Pty Ltd., 21-31 Malcolm Road, Braeside VIC 3195, Australia
| | - Fabrizio Spada
- Department of Research and Development, Ego Pharmaceuticals Pty Ltd., 21-31 Malcolm Road, Braeside VIC 3195, Australia.
| |
Collapse
|
16
|
Fawaz B, Chamseddin BH, Griffin JR. Defining the role of mirtazapine in the treatment of refractory pruritus. J DERMATOL TREAT 2019; 32:132-136. [PMID: 31180795 DOI: 10.1080/09546634.2019.1630702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND/OBJECTIVE Mirtazapine has traditionally been used for the treatment of major depressive disorder, with an added benefit in patients who have comorbid insomnia or anxiety. Recent studies describe its usefulness in treating refractory pruritus of various causes as well. Our goal is to better define the use of mirtazapine in the treatment of refractory pruritus. METHOD Through a thorough literature review of PubMed, we identified all reports of the use of mirtazapine for pruritus. RESULTS Upon examination of 8 supporting articles, we found mirtazapine has quality evidence for the treatment of intra-thecal morphine-induced pruritus. Mirtazapine may also be effective in treating pruritus related to various other conditions, including psoriasis, atopic dermatitis, cutaneous malignancies (primary or metastatic), hematologic malignancies (lymphomas and leukemias), liver failure, renal failure, cholestasis, as well as pruritus of unknown origin. CONCLUSIONS Mirtazapine plays a role in treatment for intra-thecel morphine-induced pruritis yet high-quality trials are needed to confirm its efficacy in other dermatologic conditions.
Collapse
Affiliation(s)
- Bilal Fawaz
- Department of Dermatology, Baylor University Medical Center, Dallas, TX, USA
| | | | - John R Griffin
- Department of Dermatology, Baylor University Medical Center, Dallas, TX, USA
| |
Collapse
|
17
|
Ständer S, Yosipovitch G. Substance P and neurokinin 1 receptor are new targets for the treatment of chronic pruritus. Br J Dermatol 2019; 181:932-938. [PMID: 31016733 DOI: 10.1111/bjd.18025] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pruritus is a distressing symptom associated with various dermatological conditions and systemic diseases. Current treatment options are often inadequate, resulting in impaired quality of life for many patients. An understanding of the underlying mechanisms of itch across pruritic conditions is important for development of effective, targeted treatments for chronic pruritus. OBJECTIVES To provide an overview of the pathogenesis of chronic pruritus, focusing on the role of substance P (SP) and neurokinin 1 receptor (NK1 R) in itch signalling, and to describe data supporting NK1 R antagonism as a potential strategy for the treatment of chronic pruritus. METHODS A PubMed search was conducted to determine what data were available that investigated the role of SP and NK1 R in itch signalling. RESULTS SP is a neuropeptide that is a mediator of itch signalling. One of the target receptors for SP is NK1 R, which is expressed in the central nervous system and on multiple cell types involved in the initiation and transmission of itch. Studies demonstrating that SP and NK1 R are overexpressed across multiple chronic itch-inducing conditions and that NK1 R antagonism disrupts itch signalling and reduces itch provide a rationale for targeting this pathway as a potential treatment of chronic pruritus across multiple diseases. CONCLUSIONS A large and growing body of evidence, including recent phase II clinical studies of NK1 R antagonists, demonstrate that SP and NK1 R play an important role in itch signalling. Additional studies are ongoing to further evaluate the use of NK1 R antagonists for the treatment of chronic pruritus. What's already known about this topic? Chronic pruritus has a significant impact on quality of life. Current treatment options for chronic pruritus are inadequate. Substance P (SP) and neurokinin 1 receptor (NK1 R) have been shown to play a role in itch signalling, and may be a rational target for addressing chronic pruritus. NK1 R antagonists are being evaluated as potential treatment for chronic pruritus. What does this study add? This review provides a compilation of the most up-to-date data elucidating the role of SP and NK1 R in itch signalling, which supports targeting this pathway as a potential treatment of chronic pruritus. NK1 R antagonism disrupts itch signalling and reduces itch. A summary of the latest data on NK1 R antagonists in the treatment of pruritus is provided.
Collapse
Affiliation(s)
- S Ständer
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Münster, Münster, Germany
| | - G Yosipovitch
- Miami Itch Center, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, U.S.A
| |
Collapse
|
18
|
Sukul N, Speyer E, Tu C, Bieber BA, Li Y, Lopes AA, Asahi K, Mariani L, Laville M, Rayner HC, Stengel B, Robinson BM, Pisoni RL. Pruritus and Patient Reported Outcomes in Non-Dialysis CKD. Clin J Am Soc Nephrol 2019; 14:673-681. [PMID: 30975656 PMCID: PMC6500934 DOI: 10.2215/cjn.09600818] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 02/20/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Among patients on hemodialysis, pruritus has been associated with poorer mental and physical quality of life, sleep quality, depression, and mortality. We evaluated patients with nondialysis CKD to describe the prevalence of pruritus, identify associated factors, and investigate associations with patient-reported outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using cross-sectional data from patient questionnaires in the CKD Outcomes and Practice Patterns Study (CKDopps), we asked patients with CKD stages 3-5 (nondialysis) from the United States, Brazil, and France to identify how much they were bothered by pruritus. Response options ranged from "not at all" to "extremely." Log-Poisson regression, yielding prevalence ratios, was used to evaluate associations of moderate-to-extreme pruritus with patient characteristics, CKD stage, self-reported depression symptoms, and restless sleep. Mixed linear regression was used to examine associations between pruritus and physical and mental component summary scores, with lower scores indicating poorer quality of life. RESULTS Of the 5658 CKDopps patients enrolled in the United States, Brazil, and France, 3780 (67%) answered the pruritus question. The prevalence of moderate-to-extreme pruritus was 24%, and more likely in older patients, women, and those with stage 5 CKD, lung disease, diabetes, and physician-diagnosed depression. In adjusted models, patients with moderate pruritus had physical and mental component summary scores 3.5 (95% confidence interval [95% CI], -4.6 to -2.3) and 2.3 (95% CI, -3.2 to -1.5) points lower, respectively, than patients without pruritus, and they also had a higher adjusted prevalence of patient-reported depression (prevalence ratio, 1.83; 95% CI, 1.58 to 2.11) and restless sleep (prevalence ratio, 1.69; 95% CI, 1.49 to 1.91) compared with patients without pruritus. These patient-reported outcomes were progressively worse with increasing severity of pruritus. CONCLUSIONS Our findings demonstrate high prevalence of pruritus in nondialysis CKD, as well as strong associations of pruritus with poor health-related quality of life, self-reported depression symptoms, and self-reported poor sleep.
Collapse
Affiliation(s)
- Nidhi Sukul
- Department of Internal Medicine, Division of Nephrology and
| | - Elodie Speyer
- Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, Université Versailles Saint Quentin, UMRS 1018, Villejuif, France
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Yun Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Antonio A Lopes
- Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | - Koichi Asahi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Laura Mariani
- Department of Internal Medicine, Division of Nephrology and
| | - Maurice Laville
- Nephrology Department, Lyon Sud Hospital, Lyon University, Laboratoire de Recherche en Cardiovasculaire, Métabolisme, diabétologie et Nutrition INSERM U 1060, Pierre Benite, France; and
| | - Hugh C Rayner
- Department of Renal Medicine, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, Université Versailles Saint Quentin, UMRS 1018, Villejuif, France
| | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | |
Collapse
|
19
|
Meeuwis SH, van Middendorp H, van Laarhoven AIM, Veldhuijzen DS, Lavrijsen APM, Evers AWM. Effects of Open- and Closed-Label Nocebo and Placebo Suggestions on Itch and Itch Expectations. Front Psychiatry 2019; 10:436. [PMID: 31293458 PMCID: PMC6598628 DOI: 10.3389/fpsyt.2019.00436] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/03/2019] [Indexed: 12/12/2022] Open
Abstract
Placebo and nocebo effects have been shown to influence subjective symptoms such as itch. These effects can be induced by influencing outcome expectations through, for example, combining the application of an inert substance (e.g., a cream) with verbal suggestions on the anticipated effects of this substance. Interestingly, placebo effects also occur when it is known that a treatment is inert (i.e., open-label placebo). However, no study to date has examined the efficacy of negative and positive verbal suggestions under similar open-label and closed-label (i.e., concealed placebo/nocebo) conditions in itch. A randomized controlled between-subjects study design was applied in which healthy volunteers (n = 92) were randomized to 1) an open-label positive verbal suggestion group, 2) a closed-label positive verbal suggestion group, 3) an open-label negative verbal suggestion group, or 4) a closed-label negative verbal suggestion group. Verbal suggestions were made regarding the topical application of an inert substance. Itch was evoked experimentally by histamine iontophoresis at baseline and again following suggestions. Itch expectations, self-reported itch during and following iontophoresis, and skin response parameters were measured. Positive suggestions were found to result in significantly lower expected itch than were negative suggestions in both open- and closed-label conditions. No effects of the suggestions on itch during iontophoresis were found, but significantly lower itch was reported in the 4 min following iontophoresis in the (combined open- and closed-label) positive compared with negative verbal suggestion groups. In addition, a smaller increase in skin temperature was found in the positive compared with negative suggestion groups. The findings illustrate a potential role of (open- and closed-label) placebo for optimizing expectations and treatment effects for itch in clinical practice. Clinical Trial Registration: Netherlands Trial Register, trial number: NTR6530.
Collapse
Affiliation(s)
- Stefanie H Meeuwis
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands.,Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, Netherlands
| | - Henriët van Middendorp
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands.,Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, Netherlands
| | - Antoinette I M van Laarhoven
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands.,Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| | - Dieuwke S Veldhuijzen
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands.,Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, Netherlands
| | | | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands.,Leiden Institute for Brain and Cognition, Leiden University Medical Center, Leiden, Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
20
|
Aly M, Ibrahim A, Farrag W, Abdelsalam K, Mohamed H, Tawfik A. Pruritus after intrathecal morphine for cesarean delivery: incidence, severity and its relation to serum serotonin level. Int J Obstet Anesth 2018; 35:52-56. [DOI: 10.1016/j.ijoa.2018.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/03/2018] [Accepted: 02/12/2018] [Indexed: 11/26/2022]
|
21
|
Abstract
Chronic pruritus (>6 week's duration) in the geriatric population (≥65 years old), is an increasing health care problem. The pathophysiologic predisposing factors are abnormalities of the epidermal barrier, immune system, and nervous system. Causes can be dichotomized into histaminergic and nonhistaminergic pruritus. Topical treatments are generally safe. Systemic treatments are chosen depending on the condition, comorbid diseases, and drug interactions. Treatment options are limited. Progress has been made in identifying itch-selective mediators over the last decade. Numerous new medications are currently undergoing clinical trials and they are anticipated to enter the clinics in the near future.
Collapse
|
22
|
Kozono H, Yoshitani H, Nakano R. Post-marketing surveillance study of the safety and efficacy of nalfurafine hydrochloride (Remitch ® capsules 2.5 μg) in 3,762 hemodialysis patients with intractable pruritus. Int J Nephrol Renovasc Dis 2018; 11:9-24. [PMID: 29391822 PMCID: PMC5774492 DOI: 10.2147/ijnrd.s145720] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Intractable pruritus in hemodialysis patients can significantly decrease their quality of life and is also associated with poor vital prognosis. Although combined multiple causes of intractable pruritus in these patients have been identified, no existing treatments are proven to be sufficiently effective. We conducted a post-marketing surveillance to follow-up and assess the safety and efficacy of nalfurafine, a selective κ-opioid receptor agonist, for the treatment of intractable pruritus in patients undergoing hemodialysis. Patients and methods Hemodialysis patients with intractable pruritus from institutions in Japan who received oral nalfurafine hydrochloride between January 2010 and December 2013 were enrolled in the surveillance. Surveillance was completed in July 2015. Safety data during 1 year after nalfurafine treatment onset, and efficacy data of nalfurafine evaluating the first 12-week treatment period and the following period until 1 year after the initial dose of nalfurafine (using global assessment of the itch improvement by the physician, Visual Analog Scale, and the Shiratori's severity scores) were collected and analyzed. Results In total, 3,762 patients were analyzed for safety. Adverse drug reactions were experienced by 402/3,762 (10.69%) patients. The most frequent adverse drug reactions were insomnia (127/3,762 [3.38%] patients), constipation (34 [0.90%]), somnolence (32 [0.85%]), dizziness (23 [0.61%]), nausea (13 [0.35%]), and malaise (9 [0.24%]). No patients developed dependence on nalfurafine. Nalfurafine was effective in 82.50% (2,880/3,491) of patients during the first 12 weeks and in 84.95% (2,167/2,551) on treatment during the subsequent period until 1 year after nalfurafine treatment initiation. Statistically significant decreases were reported in the Visual Analog Scale and the Shiratori's severity scores (p<0.001). Conclusion Oral nalfurafine hydrochloride (from 2.5 μg/day to a maximum of 5.0 μg/day) continues to be safe and effective for the treatment of intractable pruritus in hemodialysis patients in real-world clinical settings.
Collapse
Affiliation(s)
- Hideki Kozono
- Pharmaceutical and Medical Device Vigilance Department, Toray Industries, Inc., Tokyo, Japan
| | - Hiroshi Yoshitani
- Pharmaceutical and Medical Device Vigilance Department, Toray Industries, Inc., Tokyo, Japan
| | - Ryoko Nakano
- Pharmaceutical and Medical Device Vigilance Department, Toray Industries, Inc., Tokyo, Japan
| |
Collapse
|
23
|
Nakamoto H, Oh T, Shimamura M, Iida E, Moritake S. Nalfurafine hydrochloride for refractory pruritus in peritoneal dialysis patients: a phase III, multi-institutional, non-controlled, open-label trial. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0133-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
24
|
Gordon R, Kasler MK, Stasi K, Shames Y, Errante M, Ciccolini K, Skripnik Lucas A, Raasch P, Fischer-Cartlidge E. Checkpoint Inhibitors: Common Immune-Related Adverse Events and Their Management
. Clin J Oncol Nurs 2017; 21:45-52. [PMID: 28315555 DOI: 10.1188/17.cjon.s2.45-52] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Immunotherapy, specifically the use of checkpoint inhibitors, offers patients with cancer an alternative to chemotherapy, targeting different pathways to destroy cancer cells. The side effects of immunotherapies, as well as their impact on normal tissue, need to be assessed and managed based on their mechanisms of action. OBJECTIVES This article presents an overview of immune-related adverse events (AEs).
. METHODS Common immune-related toxicities, as well as rare and refractory toxicities, are reviewed.
. FINDINGS Immunotherapy treatment is an option for many patients with cancer, and nurses must understand the distinct side effect profile of these agents. Prompt identification and expert management are the cornerstones of success when dealing with immune-related AEs, and oncology nurses play a key role in improving patient care.
Collapse
|
25
|
Rashid S, Trivedi DD, Al-Shathir M, Moulton M, Baumrucker SJ. Is There a Role for 5-HT 3 Receptor Antagonists in the Treatment of Opioid-Induced Pruritus? Am J Hosp Palliat Care 2017; 35:740-744. [PMID: 29020799 DOI: 10.1177/1049909117736062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pruritus is an unpleasant irritation symptom that can be related to various systemic and dermatological conditions. Although underreported, pruritus is a common adverse event noted after use of opioid pain medications. This article reviews the current understanding of the mechanism of opioid-induced pruritus (OIP) and various pharmacological therapies. 5-Hydroxytryptamine 3 (5-HT3) receptor antagonists are potentially effective for treating OIP and may be a valuable treatment option if further controlled studies are encouraging.
Collapse
Affiliation(s)
- Saima Rashid
- 1 Department of Pulmonary and Critical Care, Mercy Health, Cincinnati, OH, USA
| | | | - Mudher Al-Shathir
- 3 Department of Pulmonary and Critical Care, Mercy Health, Cincinnati, OH
| | - Marie Moulton
- 1 Department of Pulmonary and Critical Care, Mercy Health, Cincinnati, OH, USA
| | - Steven J Baumrucker
- 4 Hospice and Palliative Medicine, Wellmont Health System, Kingsport, TN, USA
| |
Collapse
|
26
|
Ojha T, Pathak V, Shi Y, Hennink WE, Moonen CTW, Storm G, Kiessling F, Lammers T. Pharmacological and physical vessel modulation strategies to improve EPR-mediated drug targeting to tumors. Adv Drug Deliv Rev 2017; 119:44-60. [PMID: 28697952 PMCID: PMC5919100 DOI: 10.1016/j.addr.2017.07.007] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/22/2017] [Accepted: 07/06/2017] [Indexed: 02/08/2023]
Abstract
The performance of nanomedicine formulations depends on the Enhanced Permeability and Retention (EPR) effect. Prototypic nanomedicine-based drug delivery systems, such as liposomes, polymers and micelles, aim to exploit the EPR effect to accumulate at pathological sites, to thereby improve the balance between drug efficacy and toxicity. Thus far, however, tumor-targeted nanomedicines have not yet managed to achieve convincing therapeutic results, at least not in large cohorts of patients. This is likely mostly due to high inter- and intra-patient heterogeneity in EPR. Besides developing (imaging) biomarkers to monitor and predict EPR, another strategy to address this heterogeneity is the establishment of vessel modulation strategies to homogenize and improve EPR. Over the years, several pharmacological and physical co-treatments have been evaluated to improve EPR-mediated tumor targeting. These include pharmacological strategies, such as vessel permeabilization, normalization, disruption and promotion, as well as physical EPR enhancement via hyperthermia, radiotherapy, sonoporation and phototherapy. In the present manuscript, we summarize exemplary studies showing that pharmacological and physical vessel modulation strategies can be used to improve tumor-targeted drug delivery, and we discuss how these advanced combination regimens can be optimally employed to enhance the (pre-) clinical performance of tumor-targeted nanomedicines.
Collapse
Affiliation(s)
- Tarun Ojha
- Department of Nanomedicines and Theranostics, Institute for Experimental Molecular Imaging (ExMI), RWTH Aachen University Clinic, 52074 Aachen, Germany; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG, Utrecht, The Netherlands
| | - Vertika Pathak
- Department of Nanomedicines and Theranostics, Institute for Experimental Molecular Imaging (ExMI), RWTH Aachen University Clinic, 52074 Aachen, Germany
| | - Yang Shi
- Department of Nanomedicines and Theranostics, Institute for Experimental Molecular Imaging (ExMI), RWTH Aachen University Clinic, 52074 Aachen, Germany
| | - Wim E Hennink
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG, Utrecht, The Netherlands
| | - Chrit T W Moonen
- Imaging division, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Gert Storm
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG, Utrecht, The Netherlands; Department of Targeted Therapeutics, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, 7500 AE Enschede, The Netherlands
| | - Fabian Kiessling
- Department of Nanomedicines and Theranostics, Institute for Experimental Molecular Imaging (ExMI), RWTH Aachen University Clinic, 52074 Aachen, Germany.
| | - Twan Lammers
- Department of Nanomedicines and Theranostics, Institute for Experimental Molecular Imaging (ExMI), RWTH Aachen University Clinic, 52074 Aachen, Germany; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG, Utrecht, The Netherlands; Department of Targeted Therapeutics, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, 7500 AE Enschede, The Netherlands.
| |
Collapse
|
27
|
Hierarchical Specification of Pruriceptors by Runt-Domain Transcription Factor Runx1. J Neurosci 2017; 37:5549-5561. [PMID: 28476948 DOI: 10.1523/jneurosci.0094-17.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/11/2017] [Accepted: 04/26/2017] [Indexed: 02/04/2023] Open
Abstract
The somatic sensory neurons in dorsal root ganglia (DRG) detect and transmit a diverse array of sensory modalities, such as pain, itch, cold, warm, touch, and others. Recent genetic and single-cell RNA sequencing studies have revealed a group of DRG neurons that could be particularly relevant for acute and chronic itch information transmission. They express the natriuretic peptide type B (NPPB), as well as a cohort of receptors and neuropeptides that have been implicated in chronic itch manifestation, including the interleukin-31 receptor A (IL-31ra) and its coreceptor oncostatin M receptor (Osmr), the cysteinyl leukotriene receptor 2 (Cysltr2), somatostatin, and neurotensin. However, how these neurons are generated during development remains unclear. Here we report that Runx1 is required to establish all these molecular features of NPPB+ neurons. We further show that while early embryonic Runx1 activity is required for the formation of NPPB+ cells, at later stages Runx1 switches to a genetic repressor and thus its downregulation becomes a prerequisite for the proper development of these pruriceptors. This mode by Runx1 is analogous to that in controlling another group of pruriceptors that specifically express the chloroquine receptor MrgprA3. Finally, behavioral studies using both sexes of mice revealed marked deficits in processing acute and chronic itch in Runx1 conditional knock-out mice, possibly attributable to impaired development of various pruriceptors.SIGNIFICANCE STATEMENT Our studies reveal a generalized control mode by Runx1 for pruriceptor development and consolidate a hierarchical control mechanism for the formation of sensory neurons transmitting distinct modalities. Among dorsal root ganglion neurons that initially express the neurotrophin receptor TrkA, Runx1 is necessary for the proper development of those neurons that innervate tissues derived from the ectoderm such as skin epidermis and hair follicles. These Runx1-dependent cutaneous sensory neurons are then divided into two groups based on persistent or transient Runx1 expression. The Runx1-persistent group is involved in transmitting mechanical and thermal information, whereas the Runx1-transient group transmits pruriceptive information. Such hierarchical control mechanisms may provide a developmental solution for the formation of sensory circuits that transmit distinct modalities.
Collapse
|
28
|
Abstract
There are several practice gaps in the evaluation and management of itch. These gaps include a dearth of objective measures of itch, infrequent use of validated patient-reported outcomes for itch, non-evidence-based treatment, and lack of consensus about the ideal workup for generalized itch. The present article reviews these gaps and presents potential solutions.
Collapse
Affiliation(s)
- Jonathan I Silverberg
- Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1600, Chicago, IL 60611, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1600, Chicago, IL 60611, USA; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1600, Chicago, IL 60611, USA; Northwestern Medicine Multidisciplinary Eczema Center, 676 North St. Clair Street, Suite 1600, Chicago, IL 60611, USA.
| |
Collapse
|
29
|
Siemens W, Xander C, Meerpohl JJ, Buroh S, Antes G, Schwarzer G, Becker G. Pharmacological interventions for pruritus in adult palliative care patients. Cochrane Database Syst Rev 2016; 11:CD008320. [PMID: 27849111 PMCID: PMC6734122 DOI: 10.1002/14651858.cd008320.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the original Cochrane review published in 2013 (Issue 6). Pruritus occurs in patients with disparate underlying diseases and is caused by different pathologic mechanisms. In palliative care patients, pruritus is not the most prevalent but is one of the most puzzling symptoms. It can cause considerable discomfort and affects patients' quality of life. OBJECTIVES To assess the effects of different pharmacological treatments for preventing or treating pruritus in adult palliative care patients. SEARCH METHODS For this update, we searched CENTRAL (the Cochrane Library), and MEDLINE (OVID) up to 9 June 2016 and Embase (OVID) up to 7 June 2016. In addition, we searched trial registries and checked the reference lists of all relevant studies, key textbooks, reviews and websites, and we contacted investigators and specialists in pruritus and palliative care regarding unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) assessing the effects of different pharmacological treatments, compared with a placebo, no treatment, or an alternative treatment, for preventing or treating pruritus in palliative care patients. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the identified titles and abstracts, performed data extraction and assessed the risk of bias and methodological quality. We summarised the results descriptively and quantitatively (meta-analyses) according to the different pharmacological interventions and the diseases associated with pruritus. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 10 'Summary of findings' tables. MAIN RESULTS In total, we included 50 studies and 1916 participants in the review. We added 10 studies with 627 participants for this update. Altogether, we included 39 different treatments for pruritus in four different patient groups.The overall risk of bias profile was heterogeneous and ranged from high to low risk. However, 48 studies (96%) had a high risk of bias due to low sample size (i.e. fewer than 50 participants per treatment arm). Using GRADE criteria, we downgraded our judgement on the quality of evidence to moderate in seven and to low in three comparisons for our primary outcome (pruritus), mainly due to imprecision and risk of bias.In palliative care participants with pruritus of different nature, the treatment with the drug paroxetine, a selective serotonin reuptake inhibitor, reduced pruritus by 0.78 points (numerical analogue scale from 0 to 10; 95% confidence interval (CI) -1.19 to -0.37; one RCT, N = 48, quality of evidence: moderate) compared to placebo.For participants suffering from uraemic pruritus (UP), gabapentin was more effective than placebo (visual analogue scale (VAS): 0 to 10), mean difference (MD) -5.91, 95% CI -6.87 to -4.96; two RCTs, N = 118, quality of evidence: moderate). The κ-opioid receptor agonist nalfurafine showed amelioration of UP (VAS 0 to 10, MD -0.95, 95% CI -1.32 to -0.58; three RCTs, N = 422, quality of evidence: moderate) and only few adverse events. Moreover, cromolyn sodium relieved UP participants from pruritus by 2.94 points on the VAS (0 to 10) (95% CI -4.04 to -1.83; two RCTs, N = 100, quality of evidence: moderate) compared to placebo.In participants with cholestatic pruritus (CP), data favoured rifampin (VAS: 0 to 100, MD -24.64, 95% CI -31.08 to -18.21; two RCTs, N = 42, quality of evidence: low) and flumecinol (RR > 1 favours treatment group; RR 1.89, 95% CI 1.05 to 3.39; two RCTs, N = 69, quality of evidence: low) and showed a low incidence of adverse events in comparison with placebo. The opioid antagonist naltrexone reduced pruritus for participants with CP (VAS: 0 to 10, MD -2.26, 95% CI -3.19 to -1.33; two RCTs, N = 52, quality of evidence: moderate) compared to placebo. However, effects in participants with UP were inconclusive (percentage difference -12.30%, 95% CI -25.82% to 1.22%, one RCT, N = 32). Furthermore, large doses of opioid antagonists (e.g. naltrexone) could be inappropriate in palliative care patients because of the risk of reducing analgesia.For participants with HIV-associated pruritus, it is uncertain whether drug treatment with hydroxyzine hydrochloride, pentoxifylline, triamcinolone or indomethacin reduces pruritus because the evidence was of very low quality (e.g. small sample size, lack of blinding). AUTHORS' CONCLUSIONS Different interventions tended to be effective for CP and UP. However, therapies for patients with malignancies are still lacking. Due to the small sample sizes in most meta-analyses and the heterogeneous methodological quality of the included trials, the results should be interpreted cautiously in terms of generalisability.
Collapse
Affiliation(s)
- Waldemar Siemens
- Faculty of Medicine, University of Freiburg, GermanyClinic for Palliative Care, Medical Center ‐ University of FreiburgRobert‐Koch‐Straße 3FreiburgGermany
| | - Carola Xander
- Faculty of Medicine, University of Freiburg, GermanyClinic for Palliative Care, Medical Center ‐ University of FreiburgRobert‐Koch‐Straße 3FreiburgGermany
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
| | - Sabine Buroh
- University Medical CenterLibrary of the Center of SurgeryHugstetterstrasse 55FreiburgBaden‐WürttembergGermany79115
| | - Gerd Antes
- Medical Center ‐ University of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
| | - Guido Schwarzer
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Gerhild Becker
- Faculty of Medicine, University of Freiburg, GermanyClinic for Palliative Care, Medical Center ‐ University of FreiburgRobert‐Koch‐Straße 3FreiburgGermany
| | | |
Collapse
|
30
|
Makarem J, Mireskandari SM, Jafarzadeh A, Rahbar Nikoukar L, Aghaii S. Intravenous Midazolam as More Effective Than Propofol for Preventing Pruritus After Intrathecal Sufentanil in Surgical Patients: A Randomized Blinded Trial. Anesth Pain Med 2016; 7:e37535. [PMID: 29181332 PMCID: PMC5696882 DOI: 10.5812/aapm.37535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/26/2016] [Accepted: 08/17/2016] [Indexed: 11/16/2022] Open
Abstract
Background Pruritus is a troublesome side effect of intrathecal opioids. Midazolam can reinforce GABA-mediated inhibition of the medullary dorsal horn neurons, and thus theoretically has potential to suppress opioid-induced pruritus. Objectives This prospective double-blinded randomized trial aimed at comparing the effects of propofol, midazolam, and a combination of the two on the prevention of pruritus induced by intrathecal sufentanil. Methods Eighty-four patients undergoing spinal anesthesia with 3 mL hyperbaric bupivacaine 0.5% and 5 μg sufentanil (1 mL) were randomly allocated to one of the three study groups: Group 1, who were administered 20 mg intravenous (IV) propofol bolus, then 50 μg/kg/min IV infusion; Group 2, who were administered 0.03 mg/kg IV midazolam bolus, then 0.02 mg/kg/h IV infusion; and Group 3, who were administered 10 mg IV propofol and 0.015 mg/kg IV midazolam bolus, then 25 μg/kg/min propofol and 0.01 mg/kg/h midazolam IV infusion. The incidence rates and severity of pruritus were assessed intraoperatively and postoperatively for 24 hours. Results The Ramsay Sedation Score was highest for the propofol group throughout the duration of the anesthetic process. Overall, 17 patients in the propofol group (60.7%), eight patients in the midazolam group (28.6%), and nine patients in the propofol-midazolam group (32.1%) developed pruritus (P = 0.027). Intraoperative pruritus was observed in seven patients in the propofol group (25%), two patients in the midazolam group (7.1%), and five patients in the midazolam-propofol group (17.9%) (P = 0.196). Postoperative pruritus developed in 12 patients in the propofol group (42.9%), six patients in the midazolam group (21.4%), and four patients in the midazolam-propofol group (14.3%) (P = 0.041). There was no significant difference between the groups with respect to the severity of pruritus (P > 0.05). Conclusions This study showed that in comparison with propofol, the administration of 0.03 mg/kg IV midazolam bolus followed by 0.02 mg/kg/h could be more effective in the prevention of intrathecal sufentanil-induced pruritus without increasing sedation and other side effects.
Collapse
Affiliation(s)
- Jalil Makarem
- Department of Anesthesiology & Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Mireskandari
- Department of Anesthesiology & Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Seyed Mohammad Mireskandari, Department of Anesthesiology & Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, PO Box 1419733141, Tehran, Iran. Tel: +98-2161190, Fax: +98-2161192329, E-mail:
| | - Afshin Jafarzadeh
- Department of Anesthesiology & Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Laya Rahbar Nikoukar
- Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Aghaii
- Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
31
|
Hu J, Zhang C, Yan J, Wang R, Wang Y, Xu M. Sufentanil and Bupivacaine Combination versus Bupivacaine Alone for Spinal Anesthesia during Cesarean Delivery: A Meta-Analysis of Randomized Trials. PLoS One 2016; 11:e0152605. [PMID: 27032092 PMCID: PMC4816294 DOI: 10.1371/journal.pone.0152605] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/16/2016] [Indexed: 12/29/2022] Open
Abstract
Objective The addition of lipophilic opioids to local anesthetics for spinal anesthesia has become a widely used strategy for cesarean anesthesia. A meta-analysis to quantify the benefits and risks of combining sufentanil with bupivacaine for patients undergoing cesarean delivery was conducted. Methods A comprehensive literature search without language or date limitation was performed to identify clinical trials that compared the addition of sufentanil to bupivacaine with bupivacaine alone for spinal anesthesia in healthy parturients choosing cesarean delivery. The Q and I2 tests were used to assess heterogeneity of the data. Data from each trial were combined using relative ratios (RRs) for dichotomous data or weighted mean differences (WMDs) for continuous data and corresponding 95% confidence intervals (95% CIs) for each trial. Sensitivity analysis was conducted by removing one study a time to assess the quality and consistency of the results. Begg’s funnel plots and Egger’s linear regression test were used to detect any publication bias. Results This study included 9 trials containing 578 patients in the final meta-analysis. Sufentanil addition provided a better analgesia quality with less breakthrough pain during surgery than bupivacaine alone (RR = 0.10, 95% CI 0.06 to 0.18, P < 0.001). Sensory block onset time was shorter and first analgesic request time was longer in sufentanil added group compared with the bupivacaine-alone group (WMD = −1.0 min, 95% CI −1.5 to −0.58, P < 0.001 and WMD = 133 min, 95% CI 75 to 213, P < 192, respectively). There was no significant difference in the risk of hypotension and vomiting between these two groups. But pruritus was more frequentely reported in the group with sufentanil added (RR = 7.63, 95% CI 3.85 to 15.12, P < 0.001). Conclusion Bupivacaine and sufentanil combination is superior to that of bupivacaine alone for spinal anesthesia for cesarean delivery in analgesia quality. Women receiving the combined two drugs had less breakthrough pain, shorter sensory block onset time, and longer first analgesic request time. However, the addition of sufentanil to bupivacaine increased the incidence of pruritus.
Collapse
Affiliation(s)
- Jiajia Hu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jianqin Yan
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- * E-mail:
| | - Ruike Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Ying Wang
- Department of Anesthesiology, Fujian Provincial Cancer Hospital, Teaching hospital of Fujian Medical University, Fuzhou, China
| | - Mu Xu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
32
|
Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, Lumbiganon P. Pharmacological interventions for generalised itching (not caused by systemic disease or skin lesions) in pregnancy. Cochrane Database Syst Rev 2016; 2:CD011351. [PMID: 26891962 PMCID: PMC8665832 DOI: 10.1002/14651858.cd011351.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Generalised itching is one of the most common dermatological symptoms in pregnant women. Having itchy skin during pregnancy may be very frustrating and can lead to poor sleep, exhaustion and impaired quality of life. There is a need for a systematic review to evaluate the effectiveness and safety of pharmacological interventions for treating itching in pregnancy. OBJECTIVES To assess the effectiveness and safety of pharmacological interventions for treating generalised itching (not caused by systemic diseases or skin lesions) in pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2016) and the reference list of the one identified study. SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating interventions for itching in pregnancy.Quasi-RCTs, cluster-RCTs, RCTs using a cross-over design, and studies reported in abstract form (without full text) were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the one trial report that was identified from the search strategy and this was subsequently excluded. MAIN RESULTS There are no included studies as we did not identify any relevant trials. AUTHORS' CONCLUSIONS Generalised itching (not caused by systemic disease or skin lesions) is quite a common symptom in pregnancy. However, there is no evidence from randomised controlled trials to guide practice in terms of the effectiveness and safety of pharmacological interventions for treating this condition.Well-designed randomised controlled trials are needed in order to evaluate the effectiveness of topical and systemic pharmacological interventions as well as any adverse effects of the interventions. Such studies should consider important outcomes such as relief of itching, women's satisfaction, sleep disturbance, and adverse effects.
Collapse
Affiliation(s)
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Biostatistics and Demography, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Ussanee S Sangkomkamhang
- Khon Kaen HospitalDepartment of Obstetrics and GynaecologySrichan RoadMaungKhon KaenThailand40000
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | | |
Collapse
|
33
|
Side Effects and Efficacy of Neuraxial Opioids in Pregnant Patients at Delivery: A Comprehensive Review. Drug Saf 2016; 39:381-99. [DOI: 10.1007/s40264-015-0386-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
34
|
Siemens W, Xander C, Meerpohl JJ, Antes G, Becker G. Drug treatments for pruritus in adult palliative care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:863-70. [PMID: 25585583 DOI: 10.3238/arztebl.2014.0863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/16/2014] [Accepted: 09/16/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pruritus is a rare but troublesome symptom in palliative-care patients with a variety of underlying diseases. The pharmacotherapy of pruritus is often off-label, and an evidence-based evaluation is needed. METHODS A Cochrane Review published in 2013 was updated with a systematic literature search up to January 2014. Randomized and controlled trials (RCTs) with adult palliative-care patients were included. RESULTS In the 43 RCTs that were analyzed, three of which were more recent than the Cochrane Review, 8 clinically relevant active substances were investigated in a total of 19 RCTs. Effective drugs for pruritus in palliative-care patients included paroxetine for pruritus of diverse origins (1 RCT; strong effect) and indomethacin for HIV-induced prutitus (1 RCT; median effect = moderate reduction). Effective drugs for pruritus in uremia were gabapentin (2 RCTs; strong effect), nalfurafin (3 RCTs; moderate effect), naltrexone (3 RCTs; heterogeneous effects, ranging from weak to strong), and cromoglicic acid (2 RCTs; moderate to strong effect). Effective drugs for cholestatic pruritus were rifampicin (3 RCTs; moderate effect), flumecinol (2 RCTs; weak to moderate effect), and naltrexone (2 RCTs; moderate to strong effect). Undesired effects were most common with naltrexone (dizziness: 0% -50% , nausea: 0% -50% ) and nalfurafin (nasopharyngitis: 8% -12% , insomnia: 7% -15%). CONCLUSION In view of the diverse etiologies of pruritus in palliative-care patients, careful consideration should be given to the choice of drug used to treat it. The substances listed here have moderate to strong antipruritic effects and merit further study in RCTs of high methodological quality.
Collapse
Affiliation(s)
- Waldemar Siemens
- Department of Palliative Care, Freiburg University Medical Center, Freiburg, Freiburg University Medical Center, German Cochrane Center, Freiburg, These two authors have contributed equally to the manuscript and share first authorship
| | | | | | | | | |
Collapse
|
35
|
Abstract
INTRODUCTION Pruritus without visible dermatoses may be the first manifestation of hematological malignancies such as Hodgkin disease, chronic lymphocytic leukemia and mycosis fungoides (MF) and may precede the definitive diagnosis by weeks to years. CASE REPORT We present a case of 'invisible' MF associated with chronic generalized pruritus in an elderly patient. CONCLUSION Our case highlights the importance of performing skin biopsies in patients with chronic unexplained pruritus, especially in the absence of cutaneous lesions. This can prompt the clinician to consider possible underlying malignancy, such as 'invisible' MF.
Collapse
|
36
|
Abstract
Given its profound analgesic nature, neuraxial opioids are frequently used for pain management. Unfortunately, the high incident rate of itch/pruritus after spinal administration of opioid analgesics reported in postoperative and obstetric patients greatly diminishes patient satisfaction and thus the value of the analgesics. Many endeavors to solve the mystery behind neuraxial opioid-induced itch had not been successful, as the pharmacological antagonism other than the blockade of mu opioid receptors remains elusive. Nevertheless, as the characteristics of all opioid receptor subtypes have become more understood, more studies have shed light on the potential effective treatments. This review discusses the mechanisms underlying neuraxial opioid-induced itch and compares pharmacological evidence in nonhuman primates with clinical findings across diverse drugs. Both nonhuman primate and human studies corroborate that mixed mu/kappa opioid partial agonists seem to be the most effective drugs in ameliorating neuraxial opioid-induced itch while retaining neuraxial opioid-induced analgesia.
Collapse
|
37
|
Pruritus in Systemic Diseases: A Review of Etiological Factors and New Treatment Modalities. ScientificWorldJournal 2015; 2015:803752. [PMID: 26240837 PMCID: PMC4512616 DOI: 10.1155/2015/803752] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/11/2015] [Accepted: 06/16/2015] [Indexed: 02/07/2023] Open
Abstract
Pruritus is the most frequently described symptom in dermatology and can significantly impair the patient's quality of life. In 10–50% of adults with persistent pruritus, it can be an important dermatologic clue for the presence of a significant underlying systemic disease such as renal insufficiency, cholestasis, hematologic disorder, or malignancy (Etter and Myers, 2002; Zirwas and Seraly, 2001). This review describes the presence of pruritus in different systemic diseases. It is quite important to discover the cause of pruritus for providing relief for the patients experiencing substantial morbidity caused by this condition.
Collapse
|
38
|
Atkar R, Sterling JC. Testicular cancer as an underlying cause of intractable chronic pruritus. Clin Exp Dermatol 2015; 40:694-5. [DOI: 10.1111/ced.12577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2014] [Indexed: 11/30/2022]
Affiliation(s)
- R. Atkar
- Department of Dermatology; Box 46; Addenbrookes Hospital; Cambridge CB2 0QQ UK
| | - J. C. Sterling
- Department of Dermatology; Box 46; Addenbrookes Hospital; Cambridge CB2 0QQ UK
| |
Collapse
|
39
|
[Two cases of severe pruritus revealing Hodgkin's disease in children]. Ann Dermatol Venereol 2014; 141:765-8. [PMID: 25433928 DOI: 10.1016/j.annder.2014.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/15/2014] [Accepted: 09/01/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pruritus in children is a frequent reason for consultation, most often related to a common dermatosis. Where dermatological investigation fails to reveal a dermatological cause, a general cause may be suspected. We report three cases of pruritus revealing Hodgkin's lymphoma in children. PATIENTS AND METHODS Case 1: a 14-year-old girl presented pruritus with diffuse scratching lesions present for 6 months, associated with right cervical lymph nodes occurring after the onset of pruritus. Tomodensitometry revealed involvement of the supra- and sub-diaphragmatic lymph nodes as well as pulmonary involvement. Lymph node biopsy confirmed nodular sclerosing Hodgkin's lymphoma. Case 2: a 14-year-old boy was hospitalized for suspected psychogenic pruritus. He presented intense itching, predominantly in the lower extremities and at night, occurring over the previous 6 months as well as night sweats. Examination showed that the patient had lost 5kg in 1 month and had a low-grade fever of 38°C; he presented linear striated scratching lesions on both legs. Cervical and inguinal lymphadenopathy was seen. The chest scan also revealed supra-diaphragmatic adenomegalies. The biopsy confirmed Hodgkin's lymphoma. DISCUSSION Systemic causes of pruritus in children are poorly described in the literature. In these two cases, pruritus allowed a diagnosis of Hodgkin's lymphoma to be made, emphasizing the important role of dermatologists in the early diagnosis of haematological malignancy.
Collapse
|
40
|
Abstract
Pruritus is a troublesome side-effect of neuraxial (epidural and intrathecal) opioids. Sometimes it may be more unpleasant than pain itself. The prevention and treatment still remains a challenge. A variety of medications with different mechanisms of action have been used for the prevention and treatment of opioid-induced pruritus, with mixed results. The aim of this article is to review the current body of literature and summarize the current understanding of the mechanisms and the pharmacological therapies available to manage opioid-induced pruritus. The literature source of this review was obtained via PubMed, Medline and Cochrane Database of Systematic Reviews until 2012. The search results were limited to the randomized controlled trials, systemic reviews and non-systemic reviews.
Collapse
Affiliation(s)
- Kamal Kumar
- Department of Anesthesia, Schulich School of Medicine, London Health Sciences, Victoria Hospital, London, Ontario, Canada
| | | |
Collapse
|
41
|
Abe K, Kobayashi K, Yoshino S, Taguchi K, Nojima H. Withdrawal of repeated morphine enhances histamine-induced scratching responses in mice. Drug Chem Toxicol 2014; 38:167-73. [DOI: 10.3109/01480545.2014.922095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
42
|
Concurrent presentation of hodgkin lymphoma and multiple myeloma. Case Rep Hematol 2013; 2013:398769. [PMID: 24027647 PMCID: PMC3762140 DOI: 10.1155/2013/398769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/22/2013] [Indexed: 11/26/2022] Open
Abstract
The simultaneous presentation of the Hodgkin lymphoma and multiple myeloma in the absence of prior chemotherapy or radiation is very rare. Here, we discuss a 72-year-old patient who initially presented with generalized pruritis. Workup led to a diagnosis of multiple myeloma which progressed and required treatment. As part of his pretreatment workup, an MRI was performed to evaluate skeletal lesions. This revealed diffuse and bulky adenopathy which was confirmed by PET. A biopsy of an axillary node was consistent with the nodular sclerosing type Hodgkin lymphoma. He was treated with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy × 6 resulting in complete resolution of his adenopathy and pruritis as well as improvement in his myeloma.
Collapse
|
43
|
Milette K, Hudson M, Korner A, Baron M, Thombs BD. Sleep disturbances in systemic sclerosis: evidence for the role of gastrointestinal symptoms, pain and pruritus. Rheumatology (Oxford) 2013; 52:1715-20. [DOI: 10.1093/rheumatology/ket223] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
|
44
|
Xander C, Meerpohl JJ, Galandi D, Buroh S, Schwarzer G, Antes G, Becker G. Pharmacological interventions for pruritus in adult palliative care patients. Cochrane Database Syst Rev 2013:CD008320. [PMID: 23749733 DOI: 10.1002/14651858.cd008320.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pruritus is not the most prevalent but one of the most puzzling symptoms in palliative care patients. It can cause considerable discomfort and has a major impact on patients' quality of life. In the field of palliative care, pruritus is a symptom occurring in patients with disparate underlying diseases and based on different pathologic mechanisms but ending in the same phenomenon. The pathogenesis of pruritus is complex and not fully elucidated. Thus, it is still very difficult to treat pruritus effectively. Evidence-based treatment approaches are needed. OBJECTIVES The objective was to evaluate the efficacy of different pharmacological treatments for preventing or treating pruritus in adult palliative care patients. SEARCH METHODS A systematic literature search up to January 2012 was performed and it was updated in August 2012. The following databases were searched: The Cochrane Library (CENTRAL, DARE, CDSR) (2012, issue 8 of 12); MEDLINE (1950 to August 2012); EMBASE (1980 to August 2012) and three other databases. In addition, we searched trials registries and checked the reference lists of all relevant studies, key textbooks, reviews, and websites, and contacted investigators and specialists in pruritus and palliative care regarding unpublished data. SELECTION CRITERIA We included randomised controlled trials assessing the effects of different pharmacological treatments on preventing or treating pruritus in palliative care patients. DATA COLLECTION AND ANALYSIS Two review authors independently assessed identified titles and abstracts. Three independent review authors performed assessment of all potentially relevant studies, data extraction, assessment of risk of bias and methodological quality. Results were summarised descriptively according to the different pharmacological interventions and the type of underlying pruritus. Where possible, results were presented in meta-analyses. MAIN RESULTS In total, 38 reports comprising 40 studies and 1286 participants were included in the review. Altogether, 30 different treatments for pruritus in four different patient groups were included.The findings of this review indicated that the treatment of pruritus for palliative care patients is challenging and requires an individualistic approach. Results showed that effective therapeutic choices have to be guided by the pathophysiology of the pruritus. Various forms of pruritus occur, especially in the field of palliative care, and sometimes the origin of the pruritus is difficult to determine. Therefore, identifying the underlying cause of pruritus is of prime importance in order to develop tailored treatment plans, even if in palliative care the treatment is focused towards the symptom and not necessarily the underlying disease.Results show that in palliative care patients with pruritus of different natures, treatment with the drug paroxetine, a selective serotonin reuptake inhibitor, may be beneficial. For patients suffering from pruritus associated with HIV infection, indomethacin was described as the most effective drug, although the evidence was weak. For patients suffering from chronic kidney disease-associated pruritus, gabapentin may be an option. An alternative treatment for this patient group seems to be the κ-opioid receptor agonist nalfurafine, which has shown significant amelioration of pruritus and acceptable adverse effects. As they have exhibited a low incidence of adverse effects, rifampicin and flumecinol may be recommended for patients with cholestatic pruritus. The opioid antagonist naltrexone has been shown to offer a therapeutic alternative for patients suffering from uraemic or cholestatic pruritus. However, these drugs are often inappropriate in the palliative population because of the risk of reducing analgesia when giving high doses of naltrexone. AUTHORS' CONCLUSIONS The findings of this review indicate that the number of systemic and topical drugs used for the different subforms of pruritus is increasing. Different interventions have been shown to be effective in the treatment of pruritus of different origins. Nevertheless, an optimal therapy for pruritus is constrained due to the limited understanding of crucial itch mediators and receptors in the various subforms of itch. Ideal antipruritic therapies are still lacking, especially for palliative care patients.This systematic review also indicates that there is insufficient evidence to give any concrete recommendations regarding treatment of pruritus in palliative care patients. Due to the very small sample sizes and poor methodological quality of the majority of studies that were included, the results of this review need to be interpreted with caution. Furthermore, the generalizability is questionable. Additional studies, and particularly carefully designed treatment trials, are needed to provide valid evidence for adequate treatment of pruritus in palliative care patients.
Collapse
Affiliation(s)
- Carola Xander
- German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg,Germany.
| | | | | | | | | | | | | |
Collapse
|
45
|
Han L, Ma C, Liu Q, Weng HJ, Cui Y, Tang Z, Kim Y, Nie H, Qu L, Patel KN, Li Z, McNeil B, He S, Guan Y, Xiao B, LaMotte R, Dong X. A subpopulation of nociceptors specifically linked to itch. Nat Neurosci 2013; 16:174-82. [PMID: 23263443 PMCID: PMC3557753 DOI: 10.1038/nn.3289] [Citation(s) in RCA: 404] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 11/26/2012] [Indexed: 02/06/2023]
Abstract
Itch-specific neurons have been sought for decades. The existence of such neurons has been doubted recently as a result of the observation that itch-mediating neurons also respond to painful stimuli. We genetically labeled and manipulated MrgprA3(+) neurons in the dorsal root ganglion (DRG) and found that they exclusively innervated the epidermis of the skin and responded to multiple pruritogens. Ablation of MrgprA3(+) neurons led to substantial reductions in scratching evoked by multiple pruritogens and occurring spontaneously under chronic itch conditions, whereas pain sensitivity remained intact. Notably, mice in which TRPV1 was exclusively expressed in MrgprA3(+) neurons exhibited itch, but not pain, behavior in response to capsaicin. Although MrgprA3(+) neurons were sensitive to noxious heat, activation of TRPV1 in these neurons by noxious heat did not alter pain behavior. These data suggest that MrgprA3 defines a specific subpopulation of DRG neurons mediating itch. Our study opens new avenues for studying itch and developing anti-pruritic therapies.
Collapse
Affiliation(s)
- Liang Han
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
| | - Chao Ma
- Department of Anatomy, Histology and Embryology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China, 100005
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520
| | - Qin Liu
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Hao-Jui Weng
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Yiyuan Cui
- The State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Zongxiang Tang
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Yushin Kim
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
| | - Hong Nie
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520
| | - Lintao Qu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520
| | - Kush N Patel
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Zhe Li
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
| | - Benjamin McNeil
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
| | - Shaoqiu He
- Department of Anesthesiology & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, 21205
| | - Yun Guan
- Department of Anesthesiology & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, 21205
| | - Bo Xiao
- The State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Robert LaMotte
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520
| | - Xinzhong Dong
- The Solomon H. Snyder Department of Neuroscience, Center for Sensory Biology
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| |
Collapse
|
46
|
Cunha PR, Delfini Filho O. Pruritus: still a challenge. An Bras Dermatol 2013; 87:735-41. [PMID: 23044567 DOI: 10.1590/s0365-05962012000500011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 01/26/2012] [Indexed: 11/22/2022] Open
Abstract
Pruritus is a symptom that may be associated with a wide array of diseases - skin diseases, systemic diseases or even those without a defined cause. According to its severity and evolution, it may compromise the patients' quality of life in a significant way. New therapeutic approaches, in which histamine release is not the main event, are being described for pruritus control. Therefore, taking into account the origin of the mediators of pruritus, we conducted a review of the available resources emphasizing that, although very important, anti-histamines are not the answer for every kind of pruritus.
Collapse
|
47
|
Wang T, Liu Y, Yin J, Lian S, Li M, Zheng Z, Zeng F, Zhang S. A multicenter, double-blind, randomized, noninferiority comparison of 14 days' treatment with oral olopatadine 10 mg or cetirizine 10 mg in Chinese adults with cutaneous pruritus. Pharmacology 2013; 91:117-22. [PMID: 23327861 DOI: 10.1159/000345447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 10/24/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess whether olopatadine hydrochloride (OH) was noninferior to cetirizine in the treatment of cutaneous pruritus (CP). PATIENTS AND METHODS Patients with CP presenting at seven centers in China were randomly allocated to double-blind treatment with 5 mg of OH orally twice a day or cetirizine 10 mg orally once a day for 2 weeks. Patients were followed up on days 7 and 14. Noninferiority was predefined as a 20% maximum difference in the reduction of symptom score reducing indices (SSRI). Both intention-to-treat (ITT) and per-protocol populations were analyzed. RESULTS 174 patients (86 receiving OH and 88 cetirizine) were included in the ITT population. In the ITT population, the mean reduction in SSRI was 0.640 ± 0.274 in the OH group and 0.603 ± 0.289 in the cetirizine group. The one-sided 97.5% CI (-0.047) met the criteria for noninferiority. Noninferiority was also demonstrated for SSRI in the per-protocol population, with reductions of 0.640 ± 0.271 with OH and 0.596 ± 0.287 with cetirizine (97.5% CI -0.043).The total effectiveness rate (TER) was similar in the OH (90.0%) and cetirizine (80.0%) groups. The corresponding one-sided 97.5% CI (-1.0%) also demonstrated noninferiority. The incidence of adverse events was 47.1% in the OH group and 41.4% in the cetirizine group (p = 0.453). CONCLUSION The efficacy of OH was noninferior to that of cetirizine in controlling itching indicating that it can be considered as a clinically relevant alternative therapy to cetirizine for the management of CP in adult Chinese patients.
Collapse
Affiliation(s)
- Tao Wang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, PR China
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Wiechert AC, Garrett LA, Lin G, Goodman A. Management of a skin metastasis in a patient with advanced ovarian cancer. GYNECOLOGIC ONCOLOGY CASE REPORTS 2012; 2:124-6. [PMID: 24371642 DOI: 10.1016/j.gynor.2012.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 07/24/2012] [Indexed: 11/24/2022]
Abstract
► Skin metastasis of ovarian cancer is rare, often nodular in appearance, and conveys a poor prognosis. ► This patient developed an unusual maculo-papular rash which was biopsy-proven to be metastatic endometrioid adenocarcinoma. ► Pruritic symptoms from skin metastases should be palliated; SSRIs, local radiation, and topical creams all may play a role.
Collapse
Affiliation(s)
- Andrew C Wiechert
- Brigham & Women's Hospital, Department of Obstetrics, Gynecology and Reproductive Biology, 75 Francis Street, ASB1-3-078, Boston, MA 02115, USA ; Massachusetts General Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 55 Fruit Street, Boston, MA 02114, USA
| | - Leslie A Garrett
- Massachusetts General Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 55 Fruit Street, Boston, MA 02114, USA
| | - George Lin
- Brigham & Women's Hospital, Department of Pathology, 75 Francis Street, Boston, MA 02115, USA
| | - Annekathryn Goodman
- Massachusetts General Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 55 Fruit Street, Boston, MA 02114, USA
| |
Collapse
|
49
|
Haest C, Casaer MP, Daems A, De Vos B, Vermeersch E, Morren MA, Van Steenbergen W, Ceuppens JL, Moons P. Measurement of itching: Validation of the Leuven Itch Scale. Burns 2011; 37:939-50. [DOI: 10.1016/j.burns.2011.04.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 04/13/2011] [Accepted: 04/15/2011] [Indexed: 11/24/2022]
|
50
|
Nakao K, Ando A, Hirakata M, Ando N, Takeshita K, Miyamoto Y, Mochizuki H. [Pharmacological and clinical profiles of nalfurafine hydrochloride (Remitch) capsules 2.5 microg) , a new therapeutic agent for the treatment of uremic pruritus in hemodialysis patients]. Nihon Yakurigaku Zasshi 2010; 135:205-214. [PMID: 20467170 DOI: 10.1254/fpj.135.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|