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

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.

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.[2345] 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.[678] 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

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

Table 1

Patient personal and medication profile

Table 2

Lab values before starting Pregabalin

Discussion

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.[910]

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

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Conflicts of interest

There are no conflicts of interest.