Neuraxial opioid-induced pruritus: An update

Kamal Kumar, Sudha Indu Singh, Kamal Kumar, Sudha Indu Singh

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.

Keywords: Complications; epidural; itching; neuraxial opioids; post-operative; pruritus; spinal.

Conflict of interest statement

Conflict of Interest: None declared.

References

    1. Ballantyne JC, Loach AB, Carr DB. Itching after epidural and spinal opiates. Pain. 1988;33:149–60.
    1. Szarvas S, Harmon D, Murphy D. Neuraxial opioid-induced pruritus: A review. J Clin Anesth. 2003;15:234–9.
    1. Kam PC, Tan KH. Pruritus: Itching for a cause and relief? Anaesthesia. 1996;51:1133–8.
    1. Charuluxananan S, Somboonviboon W, Kyokong O, Nimcharoendee K. Ondansetron for treatment of intrathecal morphine-induced pruritus after cesarean delivery. Reg Anesth Pain Med. 2000;25:535–9.
    1. Warwick JP, Kearns CF, Scott WE. The effect of subhypnotic doses of propofol on the incidence of pruritus after intrathecal morphine for caesarean section. Anaesthesia. 1997;52:270–5.
    1. Charuluxananan S, Kyokong O, Somboonviboon W, Narasethakamol A, Promlok P. Nalbuphine versus ondansetron for prevention of intrathecal morphine-induced pruritus after cesarean delivery. Anesth Analg. 2003;96:1789–93.
    1. Bonnet MP, Marret E, Josserand J, Mercier FJ. Effect of prophylactic 5-HT3 receptor antagonists on pruritus induced by neuraxial opioids: A quantitative systematic review. Br J Anaesth. 2008;101:311–9.
    1. Yeh HM, Chen LK, Lin CJ, Chan WH, Chen YP, Lin CS, et al. Prophylactic intravenous ondansetron reduces the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. Anesth Analg. 2000;91:172–5.
    1. Shah MK, Sia AT, Chong JL. The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour. Anaesthesia. 2000;55:1008–13.
    1. Colbert S, O’Hanlon DM, Galvin S, Chambers F, Moriarty DC. The effect of rectal diclofenac on pruritus in patients receiving intrathecal morphine. Anaesthesia. 1999;54:948–52.
    1. Törn K, Tuominen M, Tarkkila P, Lindgren L. Effects of sub-hypnotic doses of propofol on the side effects of intrathecal morphine. Br J Anaesth. 1994;73:411–2.
    1. Dimitriou V, Voyagis GS. Opioid-induced pruritus: Repeated vs single dose ondansetron administration in preventing pruritus after intrathecal morphine. Br J Anaesth. 1999;83:822–3.
    1. Krajnik M, Zylicz Z. Understanding pruritus in systemic disease. J Pain Symptom Manage. 2001;21:151–68.
    1. LaBella FS, Kim RS, Templeton J. Opiate receptor binding activity of 17-alpha estrogenic steroids. Life Sci. 1978;23:1797–804.
    1. Reich A, Szepietowski JC. Opioid-induced pruritus: An update. Clin Exp Dermatol. 2010;35:2–6.
    1. Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth. 1995;42:891–903.
    1. Chauvin M, Samii K, Schermann JM, Sandouk P, Bourdon R, Viars P. Plasma pharmacokinetics of morphine after i.m., extradural and intrathecal administration. Br J Anaesth. 1982;54:843–7.
    1. Gourlay GK, Murphy TM, Plummer JL, Kowalski SR, Cherry DA, Cousins MJ. Pharmacokinetics of fentanyl in lumbar and cervical CSF following lumbar epidural and intravenous administration. Pain. 1989;38:253–9.
    1. Vercauteren MP, Vandeput DM, Meert TF, Adriaensen HA. Patient-controlled epidural analgesia with sufentanil following caesarean section: The effect of adrenaline and clonidine admixture. Anaesthesia. 1994;49:767–71.
    1. Kyriakides K, Hussain SK, Hobbs GJ. Management of opioid-induced pruritus: A role for 5-HT3 antagonists? Br J Anaesth. 1999;82:439–41.
    1. Nordberg G, Hedner T, Mellstrand T, Dahlström B. Pharmacokinetic aspects of intrathecal morphine analgesia. Anesthesiology. 1984;60:448–54.
    1. Koenigstein H. Experimental study of itch stimuli in animals. Arch Derm Syphilol. 1948;57:828–49.
    1. Hawkey CJ. COX-2 inhibitors. Lancet. 1999;353:307–14.
    1. Gulhas N, Erdil FA, Sagir O, Gedik E, Togal T, Begec Z, et al. Lornoxicam and ondansetron for the prevention of intrathecal fentanyl-induced pruritus. J Anesth. 2007;21:159–63.
    1. Ganesh A, Maxwell LG. Pathophysiology and management of opioid-induced pruritus. Drugs. 2007;67:2323–33.
    1. Schmelz M. Opioid-induced pruritus. Mechanisms and treatment regimens. Anaesthesist. 2009;58:61–5.
    1. Andrew D, Craig AD. Spinothalamic lamina I neurons selectively sensitive to histamine: A central neural pathway for itch. Nat Neurosci. 2001;4:72–7.
    1. Stanfa LC, Singh L, Williams RG, Dickenson AH. Gabapentin, ineffective in normal rats, markedly reduces C-fibre evoked responses after inflammation. Neuroreport. 1997;8:587–90.
    1. Fan P. Nonopioid mechanism of morphine modulation of the activation of 5-hydroxytryptamine type 3 receptors. Mol Pharmacol. 1995;47:491–5.
    1. Tzeng JI, Chu KS, Ho ST, Cheng KI, Liu KS, Wang JJ. Prophylactic iv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control. Can J Anaesth. 2003;50:1023–6.
    1. Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology. 1984;61:276–310.
    1. Pernia A, Calderón E, Calderón Pla E, Torres LM. Ondansetron in the treatment of the pruritus associated with the spinal infusion of opiates. Rev Esp Anestesiol Reanim. 2000;47:425–6.
    1. Pirat A, Tuncay SF, Torgay A, Candan S, Arslan G. Ondansetron, orally disintegrating tablets versus intravenous injection for prevention of intrathecal morphine-induced nausea, vomiting, and pruritus in young males. Anesth Analg. 2005;101:1330–6.
    1. Ko MC, Song MS, Edwards T, Lee H, Naughton NN. The role of central mu opioid receptors in opioid-induced itch in primates. J Pharmacol Exp Ther. 2004;310:169–76.
    1. Miller JL, Hagemann TM. Use of pure opioid antagonists for management of opioid-induced pruritus. Am J Health Syst Pharm. 2011;68:1419–25.
    1. Kjellberg F, Tramèr MR. Pharmacological control of opioid-induced pruritus: A quantitative systematic review of randomized trials. Eur J Anaesthesiol. 2001;18:346–57.
    1. Ko MC, Lee H, Song MS, Sobczyk-Kojiro K, Mosberg HI, Kishioka S, et al. Activation of kappa-opioid receptors inhibits pruritus evoked by subcutaneous or intrathecal administration of morphine in monkeys. J Pharmacol Exp Ther. 2003;305:173–9.
    1. Lee H, Naughton NN, Woods JH, Ko MC. Effects of butorphanol on morphine-induced itch and analgesia in primates. Anesthesiology. 2007;107:478–85.
    1. Togashi Y, Umeuchi H, Okano K, Ando N, Yoshizawa Y, Honda T, et al. Antipruritic activity of the kappa-opioid receptor agonist, TRK-820. Eur J Pharmacol. 2002;435:259–64.
    1. Lawhorn CD, McNitt JD, Fibuch EE, Joyce JT, Leadley RJ., Jr Epidural morphine with butorphanol for postoperative analgesia after cesarean delivery. Anesth Analg. 1991;72:53–7.
    1. Charuluxananan S, Kyokong O, Somboonviboon W, Lertmaharit S, Ngamprasertwong P, Nimcharoendee K. Nalbuphine versus propofol for treatment of intrathecal morphine-induced pruritus after cesarean delivery. Anesth Analg. 2001;93:162–5.
    1. Tamdee D, Charuluxananan S, Punjasawadwong Y, Tawichasri C, Patumanond J, Sriprajittichai P. A randomized controlled trial of pentazocine versus ondansetron for the treatment of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. Anesth Analg. 2009;109:1606–11.
    1. Waxler B, Dadabhoy ZP, Stojiljkovic L, Rabito SF. Primer of postoperative pruritus for anesthesiologists. Anesthesiology. 2005;103:168–78.
    1. Nakatsuka N, Minogue SC, Lim J, Montgomery CJ, Court CA, Malherbe S, et al. Intravenous nalbuphine 50 microg x kg (-1) is ineffective for opioid-induced pruritus in pediatrics. Can J Anaesth. 2006;53:1103–10.
    1. Colbert S, O’Hanlon DM, Chambers F, Moriarty DC. The effect of intravenous tenoxicam on pruritus in patients receiving epidural fentanyl. Anaesthesia. 1999;54:76–80.
    1. Lee LH, Irwin MG, Lim J, Wong CK. The effect of celecoxib on intrathecal morphine-induced pruritus in patients undergoing Caesarean section. Anaesthesia. 2004;59:876–80.
    1. Samimi S, Davari Tanha F, Malekian M. A blinded study using celecoxib for prevention of morphine induced pruritus in patients undergoing cesarean section. J Fam Reprod Health. 2011;2:35–9.
    1. Saiah M, Borgeat A, Wilder-Smith OH, Rifat K, Suter PM. Epidural-morphine-induced pruritus: Propofol versus naloxone. Anesth Analg. 1994;78:1110–3.
    1. Kostopanagiotou G, Pandazi A, Matiatou S, Kontogiannopoulou S, Matsota P, Niokou D, et al. The impact of intraoperative propofol administration in the prevention of postoperative pruritus induced by epidural morphine. Eur J Anaesthesiol. 2006;23:418–21.
    1. Horta ML, Morejon LC, da Cruz AW, Dos Santos GR, Welling LC, Terhorst L, et al. Study of the prophylactic effect of droperidol, alizapride, propofol and promethazine on spinal morphine-induced pruritus. Br J Anaesth. 2006;96:796–800.
    1. Schreiber S, Bleich A, Pick CG. Venlafaxine and mirtazapine: Different mechanisms of antidepressant action, common opioid-mediated antinociceptive effects: A possible opioid involvement in severe depression? J Mol Neurosci. 2002;18:143–9.
    1. Schreiber S, Rigai T, Katz Y, Pick CG. The antinociceptive effect of mirtazapine in mice is mediated through serotonergic, noradrenergic and opioid mechanisms. Brain Res Bull. 2002;58:601–5.
    1. Davis MP, Frandsen JL, Walsh D, Andresen S, Taylor S. Mirtazapine for pruritus. J Pain Symptom Manage. 2003;25:288–91.
    1. Sheen MJ, Ho ST, Lee CH, Tsung YC, Chang FL, Huang ST. Prophylactic mirtazapine reduces intrathecal morphine-induced pruritus. Br J Anaesth. 2008;101:711–5.
    1. Timmer CJ, Sitsen JM, Delbressine LP. Clinical pharmacokinetics of mirtazapine. Clin Pharmacokinet. 2000;38:461–74.
    1. Horta ML, Vianna PT. Effect of intravenous alizapride on spinal morphine-induced pruritus. Br J Anaesth. 2003;91:287–9.
    1. Winhoven SM, Coulson IH, Bottomley WW. Brachioradial pruritus: Response to treatment with gabapentin. Br J Dermatol. 2004;150:786–7.
    1. Manenti L, Vaglio A, Costantino E, Danisi D, Oliva B, Pini S, et al. Gabapentin in the treatment of uremic itch: An index case and a pilot evaluation. J Nephrol. 2005;18:86–91.
    1. Manenti L, Vaglio A. Gabapentin for uraemic pruritus. Nephrol Dial Transplant. 2005;20:1278–9.
    1. Gunal AI, Ozalp G, Yoldas TK, Gunal SY, Kirciman E, Celiker H. Gabapentin therapy for pruritus in haemodialysis patients: A randomized, placebo-controlled, double-blind trial. Nephrol Dial Transplant. 2004;19:3137–9.
    1. Yesudian PD, Wilson NJ. Efficacy of gabapentin in the management of pruritus of unknown origin. Arch Dermatol. 2005;141:1507–9.
    1. Sheen MJ, Ho ST, Lee CH, Tsung YC, Chang FL. Preoperative gabapentin prevents intrathecal morphine-induced pruritus after orthopedic surgery. Anesth Analg. 2008;106:1868–72.
    1. Summey BT, Jr, Yosipovitch G. Pharmacologic advances in the systemic treatment of itch. Dermatol Ther. 2005;18:328–32.
    1. Iannetti GD, Zambreanu L, Wise RG, Buchanan TJ, Huggins JP, Smart TS, et al. Pharmacological modulation of pain-related brain activity during normal and central sensitization states in humans. Proc Natl Acad Sci U S A. 2005;102:18195–200.
    1. Suzuki R, Rahman W, Rygh LJ, Webber M, Hunt SP, Dickenson AH. Spinal-supraspinal serotonergic circuits regulating neuropathic pain and its treatment with gabapentin. Pain. 2005;117:292–303.
    1. Chiravanich W, Oofuvong M, Kovitwanawong N. Single dose of gabapentin for prophylaxis intrathecal morphine-induced pruritus in orthopedic surgery: A randomized controlled trial. J Med Assoc Thai. 2012;95:186–90.

Source: PubMed

3
Abonnere