Support Care Cancer (2004) 12:208–209 DOI 10.1007/s00520-003-0581-2

Giampiero Porzio Federica Aielli Filomena Narducci Katia Cannita Domenico Piccolo Paolo Marchetti

Received: 21 August 2003 Accepted: 3 December 2003 Published online: 21 January 2004
Springer-Verlag 2004 G. Porzio · F. Aielli · F. Narducci Supportive Care and Rehabilitation Unit, Medical Oncology Department, University of L’Aquila, L’Aquila, Italy K. Cannita · P. Marchetti Medical Oncology Department, University of L’Aquila, L’Aquila, Italy

SHORT COMMUNICATION

Pruritus in a patient with advanced cancer successfully treated with continuous infusion of granisetron

Abstract We present a case of a patient with advanced cancer affected by severe pruritus not related with cholestasis and/or opioid treatment successfully treated with subcutaneous continuous infusion of granisetron (3 mg/24 h diluted in normal saline via a disposable elastomeric infusion device). Confirmatory studies with a control group are warranted to confirm these preliminary results.

Keywords Pruritus · Granisetron

D. Piccolo Dermatological Oncology Unit, University of L’Aquila, L’Aquila, Italy G. Porzio ()) Dipartimento di Medicina Sperimentale, Universit degli Studi, 67100 L’Aquila, Italy e-mail: [email protected] Tel.: +39-86-2368522 Fax: +39-86-2368264

Introduction Pruritus is a distressing symptom in patients with advanced cancer. It may be related to cancer or cholestasis or caused by treatment with opioids. Pathogenesis is not fully explained; increasing attention is dedicated to the role of histamine, serotonin (5 HT3), and opioid receptors [5]. 5 HT3 antagonists seem to be effective in the treatment of opioid-induced and cholestatic pruritus, while conflicting results concerning uremic pruritus are available [4, 6, 1]. We present a case of a patient with advanced cancer affected by severe pruritus not related with cholestasis and/or opioid treatment successfully

treated with subcutaneous continuous infusion of granisetron.

Case report A 69-year-old woman was admitted to the Supportive Care and Rehabilitation Unit at the Medical Oncology Department of the University of L’Aquila for ascites and severe pruritus. She was previously treated with surgery and salvage chemotherapy for an intestinal leiomyosarcoma. From 3 months before admission, she was treated only with palliative care considering the progression of disease. At admission, a careful evaluation of symptoms was performed. Edmonton Symptoms Assessment System (ESAS) documented severe asthenia (ESAS 10), anxiety (ESAS 8), poor

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quality of life (ESAS 8), and mild/moderate anorexia (ESAS 6). Pruritus was scored 10 by the patient using a visual analogue scale (VAS). Moreover, the patient reported sleep deprivation from 2 weeks. Pruritus was previously treated by the family physician with topical corticosteroid and capsaicin without results. Skin was dry, without rush, and with evidence of scratching lesions localized to the thorax, abdomen, and arms. Laboratory findings and ultrasonography did not document cholestasis and/or iron deficiency. The patient was not being treated with opioids. A single dose of 3 mg intravenous granisetron was administered with prompt reduction of pruritus (VAS 4 after 2 h). On the basis of this result, a continuous subcutaneous infusion of granisetron (3 mg/24 h diluted in normal saline) was started via a disposable elastomeric infusion device. During the following three days, VAS was registered twice a day and the scores were always 4; we observed restoration of sleep and improvement of anxiety (ESAS 3) and quality of life (ESAS 5). No systemic side effects related to granisetron were evidenced. The site of injection was covered with a transparent medication and monitored twice a day by a registered nurse; no skin reactions were observed, and the patient did not complain of pain and/or burning. On the fourth day of treatment, the dose of granisetron was titrated to 2 mg/24 h. Pruritus recurred within 24 h (VAS 8). The initial dose was readministered with good symptom control (VAS 3). The patient was discharged home with a disposable elastomeric infusion device and monitored by the family physician. She died at home after 14 days without recurrence of pruritus.

Discussion Pruritus is a symptom difficult to treat in patients with advanced neoplasm. It is commonly associated with colestasis, iron deficiency, and/or opioid treatment. Cancer per se can cause pruritus with an unknown mechanism

probably related to some mediators such as serotonin. 5 HT3 antagonists have been employed with interesting results in treatment of cholestatic and uremic and opioidinduced pruritus. To our knowledge, no data are available on the treatment of cancer-related pruritus with 5 HT3 antagonists, as well as no reports are available on subcutaneous continuous infusion of granisetron. Granisetron is stable in a disposable elastomeric infusion device, and it is compatible with other drugs commonly employed in palliative care (haloperidol, lorazepam, metoclopramide, morphine) [2, 8]. Moreover, based on our experience, subcutaneous administration is feasible and easy to use at home, even for several days. These characteristics make granisetron attractive for the treatment of patients with advanced cancer affected by pruritus. We observed a dose-response effect confirming some previously published reports on the treatment of cholestasis and opioid-related pruritus with 5 HT3 antagonists [7, 3]. To date, the high cost of the drug limits the use of 5 HT3 in the treatment of cancer-related pruritus, but we believe that the resolution of symptom and the improvement of quality of life balance the expenses. In conclusion, subcutaneous continuous infusion of granisetron seems to be effective in the treatment of pruritus in patients with advanced cancer. Further controlled studies are mandatory to evaluate the role of the 5 HT3 antagonists in the treatment of cancer-induced pruritus.

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