Effectiveness of a treatment algorithm for hemodialysis-associated pruritus in terms of changes in medications

Background Hemodialysis-associated pruritus (HAP) is a serious complication that occurs in 60–80% of hemodialysis patients, which not only decreases quality of life but also worsens prognosis. We have developed a treatment algorithm to take a comprehensive cause-specific approach to HAP and used it at our facility since June 2009. In this treatment algorithm, moisturizers and topical steroids are used depending on skin condition and severity of pruritus; administration of nalfurafine hydrochloride is considered in treatment-resistant cases. If pruritus improves, we attempt to taper topical steroids by switching to lower potency or by dose reduction or discontinuation. Here, we examined the effectiveness of the treatment algorithm over 9 years in terms of changes in medications. Methods Subjects were hemodialysis patients who received treatment for HAP at our facility: 89 in May 2009 before introduction of the algorithm, and 131 in April 2013, 164 in October 2014, 190 in October 2015, 181 in October 2016, 215 in October 2017, and 224 patients in October 2018 after its introduction. A questionnaire survey was conducted on the presence of pruritus, severity (using a visual analogue scale [VAS] and Shiratori severity scores), frequency, and insomnia due to pruritus. Changes in medications were investigated using medical records and compared. Results The proportion of patients with pruritus decreased significantly from 96.6% in 2009 to 66.8% in 2018 ( p < 0.001). Median VAS score significantly decreased from 53.0 mm in 2009 to 24.5 mm in 2018 ( p < 0.001), and the proportion of patients with insomnia due to pruritus also significantly decreased from 25.8% in 2009 to 2.2% in 2018 ( p < 0.001). The proportion of patients who used moisturizers significantly increased from 34.8 to 89.7% ( p < 0.001). The proportion of patients receiving topical steroids decreased from 47.2 to 35.7%, but the difference was not significant ( p = 0.085). Conclusions The treatment algorithm was shown to be useful for improving HAP, but future challenges were identified, including promoting use of lower potency topical steroids or discontinuation. Further prospective studies are required to confirm the role of each treatment intervention in a comprehensive cause-specific approach to HAP.