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Year : 2016  |  Volume : 8  |  Issue : 1  |  Page : 74-76  

Effectiveness of posthemodialysis administration of pregabalin (75 mg) in treatment resistance uremia pruritus


1 Department of Pharmacy Practice, School of Pharmacy, Monash University, Selangor, Malaysia
2 Ajaber Kidney Centre, Eastern Province Alahsa, Saudi Arabia
3 Department of Pharmaceutical Practice, College of Pharmacy, Princess Noura University, Riyadh, Saudi Arabia

Date of Submission06-Jul-2015
Date of Decision18-Aug-2015
Date of Acceptance25-Aug-2015
Date of Web Publication13-Jan-2016

Correspondence Address:
Tahir Mehmood Khan
Department of Pharmacy Practice, School of Pharmacy, Monash University, Selangor
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.171736

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   Abstract 


Uremic pruritus (UP) is one of the complications faced by majority of the patients with end stage renal disease (ESRD). Due to complex pathophysiology of UP, most of the anti-inflammatory and tropical lubricants often not provide a long lasting control over pruritus. Recently the uses of certain anti-epileptics are found to demonstrate promising relief to UP. To test the effect of 75 mg pregabalin in patients with treatment resistance pruritus. Data was prospectively collected from a patient with ESRD and suffering from treatment resistance pruritus. Intensity of pruritus was recorded using 5D-itching scale (5D-IS) and visual analogue scale (VAS). Pre and post assessment was done for this patient, on initial assess the parathyroid hormone level of the patient was 70.5 pg/ml with a serum phosphate level of 2.61 mmol/L. Upon initial assess the VAS score was 8 and 5D-IS score was twenty. After the duration of four weeks of pregabalin 75 mg post hemodialysis, 5D-IS score reduced to 8 and VAS score move down to 3. Pregabalin 75 mg post hemodialysis was found to reduce the intensity of UP. Pregabalin 75 mg post hemodialysis can be another option to treat UP.

Keywords: Pregabalin, renal failure, uremic pruritus


How to cite this article:
Khan TM, Aziz A, Suleiman AK. Effectiveness of posthemodialysis administration of pregabalin (75 mg) in treatment resistance uremia pruritus. J Pharm Bioall Sci 2016;8:74-6

How to cite this URL:
Khan TM, Aziz A, Suleiman AK. Effectiveness of posthemodialysis administration of pregabalin (75 mg) in treatment resistance uremia pruritus. J Pharm Bioall Sci [serial online] 2016 [cited 2019 Jul 22];8:74-6. Available from: http://www.jpbsonline.org/text.asp?2016/8/1/74/171736



Uremic pruritus (UP) is one of the most common complications faced by end-stage renal disease patients (ESRD). For ESRD patients, UP may act a main barrier to the routine life activities of the patient and affect the quality of life of the patient.[1] Overall, almost every ESRD patients have experience of mild to severe itching.[2] Along with the biochemical changes (i.e., elevated urea nitrogen level, imbalance/high calcium and phosphorus level, high parathyroid hormone level, anemia, and high uric acid level.[2],[3],[4],[5] Other known hypothesis explaining UP pathophysiology are inflammatory, opioid, and neuropathic nature of UP. Till to date, the use of psychotropic medicines to treat UP are found effective and well studies. Earlier studies have shown that Gabapentin was found to be showing promising role in the treatment of UP.[6],[7],[8] In addition, the use of other compound from the Gabapentin family, that is, pregabalin was studied among UP patients and was also found effective.[9] The current case study is an investigation the use of pregabalin at a different dose and frequency for the management of treatment-resistant UP among 59-year-old male patients.


   Case Report Top


AB is the 59-year-old man known the case of end-stage renal disease was recently identified having persistent pruritus. The initial assessment was using 5D-itching scale (5D-IS) and a Visual Analogue Scale (VAS) from 1 to 10 to express the severity of pruritus. Upon assessment score on 5D-IS was 26 and score for VAS was 8 [Figure 1]. The patient was on hemodialysis from last seven year. Previous he was treated using two anti-inflammatory agents, that is, loratadine (10 mg) and chlorphenamine maleate (4 mg) along with the Vaseline lotion [Table 1]. The patient was stressed due to frequent itching on chest, abdomen, and back. Overall, the skin of patient look hydrated and there was no pigmentation, open wound, or bruises. However, white scratch marks were there due to wooden itch scratcher and nails. In addition, he was hypertensive and was on amlodipine. Lab results have shown a low level of albumin, red blood cells, and serum calcium. While, phosphorus, blood urea nitrogen, serum uric acid, and creatinine were elevated [Table 2]. Keeping in view the neuropathic nature of pruritus, pregabalin 75 mg posthemodialysis was recommended after performing a careful assessment for the patients. The main issue covered during the assessment was the contraindication and warnings as mentioned by the manufacturer in the monograph. On assessment, it was confirmed that patient have no current or past history of angioedema, heart failure, and arterio-ventricular block. Furthermore, patient platelets count was normal, he was not overweighed, have no blurred vision, arthralgia, and current not on any Angiotensin Converting Enzymes Inhibitors (ACEIs). Postassessment after 4 weeks of administering pregabalin has shown marked improvement in the both VAS and 5D-IS score.
Figure 1: Pre and Post assessment using 5D-IS and VAS

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Table 1: Patient personal and medication profile

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Table 2: Lab values before starting Pregabalin

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   Discussion Top


From decades, pruritus remained as a known and well-studied complication among the patients with the end-stage renal disease. Till to date, UP is associated with a variety of etiological factors. However, almost all of them hypothesized, but none was seen to effectively prove the association at a cellular level. In general two of these hypothesis were well addressed; one is the inflammatory nature of the disease and the second one is the neuropathic reasoning for UP. Keeping in view the neuropathic nature of the disease, pregabalin was used in the current case. Use of pregabalin has demonstrated a very effective response and had reduced the 5D-IS and VAS from 20 and 8 to 8 and 3. This significant decline in itching proves a potential role of pregabalin among the patient with treatment resistance pruritus. Thus, supporting the findings of other studies recommending the use of pregabalin in treatment resistance pruritus.[9],[10]

Findings of this study confirms the neuropathic nature of disease, thus in a situation when phosphate and parathyroid hormone level correction, use of lubricants/emollients, and anti-inflammatory agents fail to provide control over the UP, use of pregabalin will be fruitful not only to provide control over the UP episodes, but will also help to improve the quality of life of the patients. However, it is not yet clear, how pregabalin reduces UP. Either it acts through reducing the calcium influx at the nerve endings or it reduces the level of glutamate, noradrenaline, and substance P.[11] Future research addressing this issue may provide a better understanding toward the pathophysiology of UP, and justify the use of pregabalin as a first line therapy for pruritus among UP patients. One more issue that is highlight by this study is the posthemodialysis use of pregabalin 75 mg instead of a daily dose of 25 mg. Tough no pharmacokinetic monitoring was done to estimate the serum levels, however, using 75 mg posthemodialysis as a single dose may be more suitable than the 25 mg daily. At the moment, the current study limit sufficient data to support the use of 75 mg posthemodialysis over 25 mg daily dose, however, methodologically strong studies can be conducted to make a comparison of the effectiveness of two strengths.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Narita I, Alchi B, Omori K, Sato F, Ajiro J, Saga D, et al. Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients. Kidney Int 2006;69:1626-32.  Back to cited text no. 1
    
2.
Balaskas EV, Chu M, Uldall RP, Gupta A, Oreopoulos DG. Pruritus in continuous ambulatory peritoneal dialysis and hemodialysis patients. Perit Dial Int 1993;13 Suppl 2:S527-32.  Back to cited text no. 2
    
3.
Carmichael AJ, McHugh MM, Martin AM, Farrow M. Serological markers of renal itch in patients receiving long term haemodialysis. Br Med J (Clin Res Ed) 1988;296:1575.  Back to cited text no. 3
    
4.
Johansson O, Hilliges M, Ståhle-Bäckdahl M. Intraepidermal neuron-specific enolase (NSE)-immunoreactive nerve fibres: Evidence for sprouting in uremic patients on maintenance hemodialysis. Neurosci Lett 1989;99:281-6.  Back to cited text no. 4
    
5.
Massry SG, Popovtzer MM, Coburn JW, Makoff DL, Maxwell MH, Kleeman CR. Intractable pruritus as a manifestation of secondary hyperparathyroidism in uremia. Disappearance of itching after subtotal parathyroidectomy. N Engl J Med 1968;279:697-700.  Back to cited text no. 5
[PUBMED]    
6.
Tassone DM, Boyce E, Guyer J, Nuzum D. Pregabalin: A novel gamma-aminobutyric acid analogue in the treatment of neuropathic pain, partial-onset seizures, and anxiety disorders. Clin Ther 2007;29:26-48.  Back to cited text no. 6
    
7.
Taylor CP, Angelotti T, Fauman E. Pharmacology and mechanism of action of pregabalin: The calcium channel alpha2-delta (alpha2-delta) subunit as a target for antiepileptic drug discovery. Epilepsy Res 2007;73:137-50.  Back to cited text no. 7
    
8.
Zareba G. New treatment options in the management of fibromyalgia: Role of pregabalin. Neuropsychiatr Dis Treat 2008;4:1193-201.  Back to cited text no. 8
    
9.
Aperis G, Paliouras C, Zervos A, Arvanitis A, Alivanis P. The use of pregabalin in the treatment of uraemic pruritus in haemodialysis patients. J Ren Care 2010;36:180-5.  Back to cited text no. 9
    
10.
Shavit L, Grenader T, Lifschitz M, Slotki I. Use of pregabalin in the management of chronic uremic pruritus. J Pain Symptom Manage 2013;45:776-81.  Back to cited text no. 10
    
11.
Fehrenbacher JC, Taylor CP, Vasko MR. Pregabalin and gabapentin reduce the release of substance P and CGRP from rat spinal tissues only after inflammation or activation of protein kinase C. Pain 2003;105:133-41.  Back to cited text no. 11
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]


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