Management of Opioid-Induced Pruritus

Introduction to Treatment

The National Comprehensive Cancer Network recommends the first-line treatment for opioid-induced pruritus includes antihistamines such as diphenhydramine (25-50 mg IV or PO every 6 hours) or promethazine (12.5-25 mg PO every 6 hours) 1, 2, 3
Assess for other causes of pruritus (other medications, underlying conditions) before attributing symptoms solely to opioids 1, 3

Begin with antihistamines: diphenhydramine 25-50 mg IV or PO every 6 hours (sedating) 1, 4
Begin with antihistamines: promethazine 12.5-25 mg PO every 6 hours (sedating) 1, 4
Cetirizine (non-sedating option) may also be beneficial 5
Consider opioid rotation (changing to a different opioid) if symptomatic management has failed 1, 4
Consider adding small doses of mixed agonist-antagonist: nalbuphine 0.5-1 mg IV every 6 hours as needed 1, 5
Consider continuous infusion of naloxone: start at 0.25 mcg/kg/h and titrate up as needed 1
Naltrexone is effective for treating opioid-induced pruritus when cessation of opioid therapy is impossible (first-choice recommendation in this situation) 6
Methylnaltrexone may be an alternative 6

Opioid-induced pruritus occurs in 10-50% of patients receiving opioids 5, 4
Pruritus is more likely to occur early in the course of opioid treatment 4
When using naloxone or other opioid antagonists, careful dose titration is essential to avoid reversing analgesic effects 5, 4
Sedating antihistamines may compound opioid-induced sedation, so monitor patients closely 5
If multiple treatments fail, consider neuraxial analgesics or neuroablative techniques to potentially reduce the opioid dose 1