Managing cholestatic pruritus in palliative care

Posted on November 3, 2014 by pallcare

Dr Claire Magee, Consultant in Palliative Medicine, Coventry Community Specialist Palliative Care Team, Coventry, UK, explains the background to her longer article published in the November/December issue of the European Journal of Palliative Care.

Dr Claire Magee

Pruritus or itch may not be the commonest symptom seen in palliative care patients, but when present it can cause considerable discomfort and severely impact on quality of life. In my work as a palliative medicine clinician the handful of patients I have cared for with severe pruritus remain in my memory. The symptom is distressing and can lead to sleep deprivation, social embarrassment and significant psychological problems. In addition, the scratching can lead to reduced skin integrity and subsequent infections. There are notable similarities between pruritus and pain; perception and tolerance varies greatly with both the patient’s physical and emotional state contributing.

In palliative care there are numerous reasons why patients may experience pruritus, one of which is cholestasis (a reduction in bile flow). Others include uraemia, opioids, haematological disorders, solid tumours and skin conditions. Identifying the underlying cause is key to forming a treatment plan, but in reality pruritus is often multifactorial.

 The pathophysiology is complex and poorly understood so together these issues make management a real challenge.

When faced with symptoms such as pain, breathlessness or nausea, most professionals working with palliative patients will be familiar and comfortable with the potential treatment options. However, when managing a patient with pruritus confidence can be low with limited exposure and a lack of consensus on treatment strategies contributing to this. I can recall a patient with cholestatic pruritus where numerous drugs were tried one after another in a desperate attempt to manage his symptoms. 

 As part of an MSc in Palliative Care I chose to conduct a systematic review on the management of cholestatic pruritus with the aim to create a guideline for use in palliative care, based on the available research evidence.

It is notable that most of the literature refers to studies in chronic liver disease so the degree to which this can be reliably extrapolated to palliative care is uncertain. I discuss how non-drug measures and topical drug treatments should always be considered. 

Dry skin is often an exacerbating factor so simple measures such as topical emollients can bring significant relief alongside topical drugs such as menthol lotion. Where there is obstruction of the common bile duct, stenting may be a suitable palliative procedure preventing the need for drug treatment and the subsequent risk of side effects. 

Several targeted drug treatments should be considered. In the paper I discuss the role of naltrexone, rifampicin, cholestyramine, ondansetron, sertraline, paroxetine and mirtazapine with a proposed treatment flow chart. An individualised approach to management will always be needed, but by highlighting key considerations and potential drug options the paper aims to support decision-making.

Read a copy of the full article in the November/December 2014 issue of European Journal of Palliative

 
This post relates to a longer article, ‘Managing cholestatic pruritus in palliative care’, by Claire Magee, published in the November/December 2014 issue of the European Journal of Palliative Care (vol. 21.6).  If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive, when it goes online later this week. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online. (Another good reason for joining the EAPC!)