Pruritus: Having the Itch to Scratch

TEACHING CASE 2

Please read and answer the following pre-test questions. Next, read the case and answer the extended response questions. You may use any resources (text books, articles, EPERC Fast Facts, etc.) to find the answers. Please document the sources at the end of this document.

Pre-test Questions

Question 1: A 75 y.o. female with end-stage liver disease is experiencing mild pruritus. What is the initial recommended treatment?

A. Diphenhydramine

B. Hydroxyzine

C. Emollients

D. Naloxone

Question 2: A 69 y.o. male with ESRD is admitted to hospice 5 days ago. He develops severe pruritus despite topical emollients. Which of the following is NOT expected to alleviate his pruritus?

A. Butorphanol

B. Ketamine

C. Gabapentin

D. Capsaicin

Question 3: A 37 y.o. male with cholangiocarcinoma is admitted to your hospice. He is icteric and complaining of intense itching. Which of the following medications will be most helpful in alleviating his pruritus?

A. Diphenhydramine

B. Hydrocortisone cream

C. Naltrexone

D. Mirtazapine

Learning Objectives:

1) Understand the underlying pathophysiologic mechanism of pruritus in diseases commonly seen by palliative medicine practitioners

2) Describe non-pharmacologic and pharmacologic treatments for pruritis

Case Presentation: A 72 year old female with a biliary stricture from a non-operable pancreatic mass presents with persistent pruritus despite recent biliary stenting. The itching has been “relentless”, leading her to scratch to the point of bleeding on her legs. On examination she has stable vital signs with mild scleral icterus. Weight is 62 kg. Her heart, lungs, and abdominal exam are pertinent for mild right upper quadrant pain on deep palpation. Integumentary exam reveals hyperpigmentation, thickened skin and excoriations predominantly on her legs and arms. She has tried topical and oral Benadryl without relief. Labs are notable for total bilirubin of 5.0 and mildly elevated transaminases.

Extended Answer Questions:

1) Name 4 disorders or diseases in which practitioners are most likely to encounter pruritus in the palliative care setting:

2) Describe the 4 main categories of pruritus seen in the palliative care population, including their pathophysiologic mechanism of action:

3) Why is this patient not responding to topical or oral antihistamines?

4) Describe 3 non-pharmacologic treatments for disorders of pruritus in palliative care

5) Describe 4 pharmacologic treatments used for pruritus in palliative care patients. Include the mechanism of action, starting dose, and common side effects.

NAME / MECH OF ACTION / STARTING DOSE / SIDE EFFECTS

6) You tell this patient to discontinue the antihistamine. What would be your next steps in her care plan?

7) Please list the resources you used to answer the above questions.