Pharmacological interventions for pruritus in adult palliative care patients
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 s...
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| Veröffentlicht in: | Cochrane database of systematic reviews 2016-11, Vol.2016 (11), p.CD008320-CD008320 |
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| creator | Siemens, Waldemar Xander, Carola Meerpohl, Joerg J Buroh, Sabine Antes, Gerd Schwarzer, Guido Becker, Gerhild Siemens, Waldemar |
| description | 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reviews and websites, and we contacted investigators and specialists in pruritus and palliative care regarding unpublished data.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 s, 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, |
| doi_str_mv | 10.1002/14651858.CD008320.pub3 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6734122</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1841129488</sourcerecordid><originalsourceid>FETCH-LOGICAL-c4733-68a60a190d014a136b58180b743de998f564dd3d74e35a3feadc5b7ff24845223</originalsourceid><addsrcrecordid>eNqFUU1PwyAYJkbj5vQvLD162YRCW3ox0fmZLNGDnsk7SjcMLRXamf17mfvI9OKJlzxf8D4IDQkeE4zjK8LShPCEjyd3GHMa43HTzegR6q-B0Ro5Pph76Mz7D4xpmsfZKerFGWc5IaSPpq8LcBVIa-xcSzCRrlvllqputa19VFoXNa5zuu18gCIoOtNGDRijodVLFUlwKtxbHRT-HJ2UYLy62J4D9P5w_zZ5Gk1fHp8nN9ORZBmlo5RDioHkuMCEAaHpLOGE41nGaKHynJdJyoqCFhlTNAFaKihkMsvKMmacJXFMB-h64xv-XKlChmwHRjROV-BWwoIWv5FaL8TcLkWaUUZ-DC63Bs5-dsq3otJeKmOgVrbzgnBGSJwzzgM13VCls947Ve5jCBbrKsSuCrGrYh1Og3B4-Mi9bLf7QLjdEL60USshrVy4kP-P75-UbyLEmyw</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1841129488</pqid></control><display><type>article</type><title>Pharmacological interventions for pruritus in adult palliative care patients</title><source>MEDLINE</source><source>Cochrane Library</source><source>EZB-FREE-00999 freely available EZB journals</source><source>Alma/SFX Local Collection</source><creator>Siemens, Waldemar ; Xander, Carola ; Meerpohl, Joerg J ; Buroh, Sabine ; Antes, Gerd ; Schwarzer, Guido ; Becker, Gerhild ; Siemens, Waldemar</creator><creatorcontrib>Siemens, Waldemar ; Xander, Carola ; Meerpohl, Joerg J ; Buroh, Sabine ; Antes, Gerd ; Schwarzer, Guido ; Becker, Gerhild ; Siemens, Waldemar</creatorcontrib><description>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 s, 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.</description><identifier>ISSN: 1465-1858</identifier><identifier>EISSN: 1465-1858</identifier><identifier>EISSN: 1469-493X</identifier><identifier>DOI: 10.1002/14651858.CD008320.pub3</identifier><identifier>PMID: 27849111</identifier><language>eng</language><publisher>Chichester, UK: John Wiley & Sons, Ltd</publisher><subject>2019 4. Palliative, supportive, frailty ; Adult ; Anesthetics ; Anesthetics - therapeutic use ; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use ; Anti‐Inflammatory Agents, Non‐Steroidal ; Cancer ; Cholestasis ; Cholestasis - complications ; HIV Infections ; HIV Infections - complications ; Humans ; Medicine General & Introductory Medical Sciences ; Palliative and supportive care ; Palliative Care ; Pruritus ; Pruritus - drug therapy ; Pruritus - etiology ; Pruritus - prevention & control ; Receptors, Opioid, kappa ; Receptors, Opioid, kappa - agonists ; Renal Insufficiency, Chronic ; Renal Insufficiency, Chronic - complications ; Selective Serotonin Reuptake Inhibitors - therapeutic use ; Serotonin Uptake Inhibitors ; Supportive ; Symptomatic relief</subject><ispartof>Cochrane database of systematic reviews, 2016-11, Vol.2016 (11), p.CD008320-CD008320</ispartof><rights>Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4733-68a60a190d014a136b58180b743de998f564dd3d74e35a3feadc5b7ff24845223</citedby><cites>FETCH-LOGICAL-c4733-68a60a190d014a136b58180b743de998f564dd3d74e35a3feadc5b7ff24845223</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,780,784,885,27923,27924</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/27849111$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Siemens, Waldemar</creatorcontrib><creatorcontrib>Xander, Carola</creatorcontrib><creatorcontrib>Meerpohl, Joerg J</creatorcontrib><creatorcontrib>Buroh, Sabine</creatorcontrib><creatorcontrib>Antes, Gerd</creatorcontrib><creatorcontrib>Schwarzer, Guido</creatorcontrib><creatorcontrib>Becker, Gerhild</creatorcontrib><creatorcontrib>Siemens, Waldemar</creatorcontrib><title>Pharmacological interventions for pruritus in adult palliative care patients</title><title>Cochrane database of systematic reviews</title><addtitle>Cochrane Database Syst Rev</addtitle><description>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 s, 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.</description><subject>2019 4. Palliative, supportive, frailty</subject><subject>Adult</subject><subject>Anesthetics</subject><subject>Anesthetics - therapeutic use</subject><subject>Anti-Inflammatory Agents, Non-Steroidal - therapeutic use</subject><subject>Anti‐Inflammatory Agents, Non‐Steroidal</subject><subject>Cancer</subject><subject>Cholestasis</subject><subject>Cholestasis - complications</subject><subject>HIV Infections</subject><subject>HIV Infections - complications</subject><subject>Humans</subject><subject>Medicine General & Introductory Medical Sciences</subject><subject>Palliative and supportive care</subject><subject>Palliative Care</subject><subject>Pruritus</subject><subject>Pruritus - drug therapy</subject><subject>Pruritus - etiology</subject><subject>Pruritus - prevention & control</subject><subject>Receptors, Opioid, kappa</subject><subject>Receptors, Opioid, kappa - agonists</subject><subject>Renal Insufficiency, Chronic</subject><subject>Renal Insufficiency, Chronic - complications</subject><subject>Selective Serotonin Reuptake Inhibitors - therapeutic use</subject><subject>Serotonin Uptake Inhibitors</subject><subject>Supportive</subject><subject>Symptomatic relief</subject><issn>1465-1858</issn><issn>1465-1858</issn><issn>1469-493X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2016</creationdate><recordtype>article</recordtype><sourceid>RWY</sourceid><sourceid>EIF</sourceid><recordid>eNqFUU1PwyAYJkbj5vQvLD162YRCW3ox0fmZLNGDnsk7SjcMLRXamf17mfvI9OKJlzxf8D4IDQkeE4zjK8LShPCEjyd3GHMa43HTzegR6q-B0Ro5Pph76Mz7D4xpmsfZKerFGWc5IaSPpq8LcBVIa-xcSzCRrlvllqputa19VFoXNa5zuu18gCIoOtNGDRijodVLFUlwKtxbHRT-HJ2UYLy62J4D9P5w_zZ5Gk1fHp8nN9ORZBmlo5RDioHkuMCEAaHpLOGE41nGaKHynJdJyoqCFhlTNAFaKihkMsvKMmacJXFMB-h64xv-XKlChmwHRjROV-BWwoIWv5FaL8TcLkWaUUZ-DC63Bs5-dsq3otJeKmOgVrbzgnBGSJwzzgM13VCls947Ve5jCBbrKsSuCrGrYh1Og3B4-Mi9bLf7QLjdEL60USshrVy4kP-P75-UbyLEmyw</recordid><startdate>20161116</startdate><enddate>20161116</enddate><creator>Siemens, Waldemar</creator><creator>Xander, Carola</creator><creator>Meerpohl, Joerg J</creator><creator>Buroh, Sabine</creator><creator>Antes, Gerd</creator><creator>Schwarzer, Guido</creator><creator>Becker, Gerhild</creator><creator>Siemens, Waldemar</creator><general>John Wiley & Sons, Ltd</general><scope>7PX</scope><scope>RWY</scope><scope>ZYTZH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20161116</creationdate><title>Pharmacological interventions for pruritus in adult palliative care patients</title><author>Siemens, Waldemar ; Xander, Carola ; Meerpohl, Joerg J ; Buroh, Sabine ; Antes, Gerd ; Schwarzer, Guido ; Becker, Gerhild ; Siemens, Waldemar</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4733-68a60a190d014a136b58180b743de998f564dd3d74e35a3feadc5b7ff24845223</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2016</creationdate><topic>2019 4. Palliative, supportive, frailty</topic><topic>Adult</topic><topic>Anesthetics</topic><topic>Anesthetics - therapeutic use</topic><topic>Anti-Inflammatory Agents, Non-Steroidal - therapeutic use</topic><topic>Anti‐Inflammatory Agents, Non‐Steroidal</topic><topic>Cancer</topic><topic>Cholestasis</topic><topic>Cholestasis - complications</topic><topic>HIV Infections</topic><topic>HIV Infections - complications</topic><topic>Humans</topic><topic>Medicine General & Introductory Medical Sciences</topic><topic>Palliative and supportive care</topic><topic>Palliative Care</topic><topic>Pruritus</topic><topic>Pruritus - drug therapy</topic><topic>Pruritus - etiology</topic><topic>Pruritus - prevention & control</topic><topic>Receptors, Opioid, kappa</topic><topic>Receptors, Opioid, kappa - agonists</topic><topic>Renal Insufficiency, Chronic</topic><topic>Renal Insufficiency, Chronic - complications</topic><topic>Selective Serotonin Reuptake Inhibitors - therapeutic use</topic><topic>Serotonin Uptake Inhibitors</topic><topic>Supportive</topic><topic>Symptomatic relief</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Siemens, Waldemar</creatorcontrib><creatorcontrib>Xander, Carola</creatorcontrib><creatorcontrib>Meerpohl, Joerg J</creatorcontrib><creatorcontrib>Buroh, Sabine</creatorcontrib><creatorcontrib>Antes, Gerd</creatorcontrib><creatorcontrib>Schwarzer, Guido</creatorcontrib><creatorcontrib>Becker, Gerhild</creatorcontrib><creatorcontrib>Siemens, Waldemar</creatorcontrib><collection>Wiley-Blackwell Cochrane Library</collection><collection>Cochrane Library</collection><collection>Cochrane Library (Open Aceess)</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Cochrane database of systematic reviews</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Siemens, Waldemar</au><au>Xander, Carola</au><au>Meerpohl, Joerg J</au><au>Buroh, Sabine</au><au>Antes, Gerd</au><au>Schwarzer, Guido</au><au>Becker, Gerhild</au><au>Siemens, Waldemar</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Pharmacological interventions for pruritus in adult palliative care patients</atitle><jtitle>Cochrane database of systematic reviews</jtitle><addtitle>Cochrane Database Syst Rev</addtitle><date>2016-11-16</date><risdate>2016</risdate><volume>2016</volume><issue>11</issue><spage>CD008320</spage><epage>CD008320</epage><pages>CD008320-CD008320</pages><issn>1465-1858</issn><eissn>1465-1858</eissn><eissn>1469-493X</eissn><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 s, 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.</abstract><cop>Chichester, UK</cop><pub>John Wiley & Sons, Ltd</pub><pmid>27849111</pmid><doi>10.1002/14651858.CD008320.pub3</doi><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1465-1858 |
| ispartof | Cochrane database of systematic reviews, 2016-11, Vol.2016 (11), p.CD008320-CD008320 |
| issn | 1465-1858 1465-1858 1469-493X |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6734122 |
| source | MEDLINE; Cochrane Library; EZB-FREE-00999 freely available EZB journals; Alma/SFX Local Collection |
| subjects | 2019 4. Palliative, supportive, frailty Adult Anesthetics Anesthetics - therapeutic use Anti-Inflammatory Agents, Non-Steroidal - therapeutic use Anti‐Inflammatory Agents, Non‐Steroidal Cancer Cholestasis Cholestasis - complications HIV Infections HIV Infections - complications Humans Medicine General & Introductory Medical Sciences Palliative and supportive care Palliative Care Pruritus Pruritus - drug therapy Pruritus - etiology Pruritus - prevention & control Receptors, Opioid, kappa Receptors, Opioid, kappa - agonists Renal Insufficiency, Chronic Renal Insufficiency, Chronic - complications Selective Serotonin Reuptake Inhibitors - therapeutic use Serotonin Uptake Inhibitors Supportive Symptomatic relief |
| title | Pharmacological interventions for pruritus in adult palliative care patients |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-12T15%3A25%3A41IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Pharmacological%20interventions%20for%20pruritus%20in%20adult%20palliative%20care%20patients&rft.jtitle=Cochrane%20database%20of%20systematic%20reviews&rft.au=Siemens,%20Waldemar&rft.date=2016-11-16&rft.volume=2016&rft.issue=11&rft.spage=CD008320&rft.epage=CD008320&rft.pages=CD008320-CD008320&rft.issn=1465-1858&rft.eissn=1465-1858&rft_id=info:doi/10.1002/14651858.CD008320.pub3&rft_dat=%3Cproquest_pubme%3E1841129488%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1841129488&rft_id=info:pmid/27849111&rfr_iscdi=true |