Opioid-Induced Pruritus Management

Introduction to Opioid-Induced Pruritus

Pruritus is more likely to occur early in the course of opioid treatment, which fits the patient's presentation, according to the National Comprehensive Cancer Network 1, 2
Opioid-induced pruritus affects 2-10% of patients receiving oral opioids and is mediated through opioid receptor mechanisms and histamine release, as reported by the British Journal of Dermatology 3, 2

The American Society of Anesthesiologists recommends antihistamines, such as diphenhydramine 25-50 mg IV/PO every 6 hours or promethazine 12.5-25 mg PO every 6 hours, as first-line therapy with high-level evidence 1, 2
If antihistamines fail, consider nalbuphine 2.5-5 mg IV, which is superior to antihistamines for opioid-induced pruritus, according to Praxis Medical Insights 2
Alternatively, ondansetron may be tried, though evidence is mixed and it should not be relied upon as first-line, as noted by the Journal of the National Comprehensive Cancer Network and Praxis Medical Insights 1, 4

If pruritus persists beyond one week, reassess for other causes of pruritus and consider opioid rotation to a different opioid that may not cause cross-reactivity, as recommended by the Journal of the National Comprehensive Cancer Network and Praxis Medical Insights 1, 4, 5
Low-dose naloxone continuous infusion starting at 0.25 mcg/kg/h, titrated carefully to avoid reversing analgesia, may also be considered, according to Praxis Medical Insights 2, 4

Do not discontinue buprenorphine based solely on isolated pruritus without trying symptomatic management first, as advised by the Journal of the National Comprehensive Cancer Network and Praxis Medical Insights 1, 2
Be aware that sedating antihistamines will compound buprenorphine's CNS depressant effects and require close monitoring, as noted by Praxis Medical Insights 5