Using Transdermal Buprenorphine to Treat Chronic Pruritus in a Young Adult with Lymphoma and Anxiety

Outcomes 1. By understanding the opioidergic etiology of pruritus and the theoretical rationale for treating pruritus with buprenorphine, learners will self-report the ability to propose future studies to investigate this potential therapeutic option for refractory pruiritus. 2. Using a case-based approach to explore the psychosocial impact of chronic pruritus, learners will self-report the ability to apply a psychosocial lens to the treatment of this symptom, and to advocate for urgent and effective treatment options in their clinical practice. Key Message Pruritus is a bothersome symptom that can worsen anxiety, stress, and overall quality of life for patients with serious illness. Improved treatment algorithms and new therapeutics are needed. We present a case of treating lymphoma-associated pruritus with transdermal buprenorphine. Introduction Pruritus is a symptom that is incompletely understood, difficult to treat, and bothersome to patients (4). Pruritus may occur in patients with cancer (via immunologic or paraneoplastic mechanisms), uremia, cholestasis, and those receiving opioid medications. Multiple mechanisms have been implicated, including histaminergic, immunologic, and neuropathic. Chronic pruritus worsens quality of life and is associated with anxiety, stress, and other psychological symptoms (3). Anxiety has also been demonstrated to worsen pruritus, leading to an "itch-anxiety cycle." Activation of the mu-opioid receptor worsens pruritus, whereas activation of the kappa-opioid receptor suppresses itch (1,5). Based on this mechanism, transdermal buprenorphine, a partial mu agonist, has been trialed in patients with cholestatic pruritus, which is mediated by endogenous opioids (2). Case: A 22-year-old woman with refractory primary mediastinal large B-cell lymphoma with CNS involvement, anxiety, depression, and healthcare-associated PTSD was admitted to the neuro ICU with increased intracranial pressure from her CNS disease. She had profound altered mental status, with delirium worsened by her chronic severe pruritus. The pruritus was attributed to her lymphoma, and she previously tried many medications without effect. She had trialed transdermal buprenorphine for pain, and found her pruritus had improved. During this hospitalization, the palliative care team trialed multiple medications to treat pruritus without effect. Transdermal buprenorphine was trialed, and symptoms improved. Her altered mental status and anxiety also improved. Conclusion There is tremendous need for more effective treatment for pruritus in patients with serious illness. We will outline the mechanisms of pruritus and identify evidence-based treatments. We will focus on the potential role of transdermal buprenorphine in treatment of opioidergic pruritus, and propose studies to further investigate its potential. Chronic pruritus contributes to anxiety, stress, and other psychosocial symptoms for patients receiving palliative care. Treating the pruritus effectively is a key step in supporting quality of life. Keywords Managing Suffering and Distress / Emergencies / Refractory Symptom Management