Pharmacological control of opioid-induced pruritus: a quantitative systematic review of randomized trials

Abstract

Background and objective Numerous drugs have been used to prevent or to treat opioid-induced pruritus in the surgical setting. Their relative efficacy is not well understood. Methods The methods employed involved the systematic search (MEDLINE, EMBASE, Cochrane library, bibliographies, without language restriction, up to June 2000) for full reports of randomized comparisons of any intervention which is thought to be anti-pruritic (active) compared with placebo or no treatment (control) in surgical (including labour) patients receiving opioids. The number of patients who had no pruritus were analysed using relative risk and number-neededto-treat with 95% confidence interval. Results Twenty-two trials (1477 patients) were analysed. Two trials (66 patients), both with low-dose propofol, were on treatment of established pruritus; propofol had no anti-pruritic effect compared with Intralipid. In prophylaxis trials, the average incidence of pruritus with control was 59% (range, 10% to 100%). Most mu-receptor antagonists were efficacious: intravenous naloxone 0.25-2.4 mg kg À1 h À1 , relative risk 2.31 (95% confidence interval, 1.5 to 3.54), numberneeded-to-treat to prevent pruritus compared with control 3.5; oral naltrexone 9 mg, relative risk 2.80 (1.35-5.80), number-needed-to-treat 1.7; naltrexone 6 mg was less effective and 3 mg did not work; different intravenous and epidural nalbuphine regimens, relative risk 1.71 (1.12-2.62), number-needed-to-treat 4.2. Intravenous nalmefene 0.5 or 1 mg was not antipruritic. Intravenous (but not epidural) droperidol 2.5 mg was efficacious, relative risk, 1.71 (1.28-2.29), number-needed-to-treat 4.9. There was a lack of evidence for any anti-pruritic efficacy with prophylactic propofol, epidural or intrathecal epinephrine, epidural clonidine, epidural prednisone, intravenous ondansetron, or intramuscular hydroxyzine. Conclusion Naloxone, naltrexone, nalbuphine and droperidol are efficacious in the prevention of opioidinduced pruritus; minimal effective doses remain unknown. There is a lack of valid data on the efficacy of interventions for the treatment of established pruritus.

Association of lipophilic opioids and hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. Randomized controlled study

“…Thus, newborn infants showed no signs of fetal distress. Our results were similar to those described in the literature, proving that the drug combination is safe in the doses used 7,9,19,21,28 .…”

“…Although the occurrence of nausea and vomiting during cesarean section is considered relevant, and frequently related to uterine exteriorization and peritoneal exposure, it has been currently described that opioids given intrathecally may confer protection against such adverse effects 9 . In a systematic review, Dahl et al 28 reported that the incidence of nausea and vomiting did not increase with the use of fentanyl and sufentanil, in agreement with findings by other authors 1,26 . Those authors described that antiemetic agents were required only in groups where the local anesthetic was used alone.…”

A low-dose remifentanil infusion is well tolerated for sedation in mechanically ventilated, critically-ill patients

“…27 In our study, three patients complained of itching; in one case it caused enough discomfort to require interruption of the infusion. The association with midazolam could decrease the incidence of itching during remifentanil sedation; 28 in other cases droperidol could be useful.…”

“…The association with midazolam could decrease the incidence of itching during remifentanil sedation; 28 in other cases droperidol could be useful. 27 Remifentanil's prompt elimination can stop itching in patients who do not respond to pharmacological therapy.…”

Butorphanol prevents morphine-induced pruritus without increasing pain and other side effects: a systematic review of randomized controlled trials

“…There were two earlier systematic reviews 34,35 on the pharmacological intervention of opioid-induced pruritus, but both did not focus on butorphanol and studies of pediatric patients were excluded. In our systematic review, four trials in children were available, and the combined data from three trials reporting the occurrence of pruritus showed that butorphanol could significantly reduce morphine-induced pruritus.…”