DOCSLIB.ORG

A Case Report of Pruritus from an Antipruritic

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
A Case Report of Pruritus from an Antipruritic tiisli;iliisi<iii .liiunnil <>/ iir (1997) 58, I9G-198 CASE REPORT Naltrexone: A case report of pruritus from an antipruritic John R Sullivan and Alan Watson Department of Dermatology, Royal Newcastle Hospital, Newcastle, New South Wales, Australia CASE REPORT SUMMARY A 52-year-old woman with stage lib myeosis fungoides devel- Intense, generalized pruritus associated with mycosis oping on a background of follicular mucinosis complained of fiingoides was relieved using subcutaneous naloxone a progressively worsening itcb over the past 11 years. The itch but intensified wben changed to the new oral opioid involved her entire body from scalp to toe, including botb infil- antagonist, naltrexone. Recballcnge again led to trated plaques and normal-appearing skin. She was often cov- worsening in pruritus. This unexpected adverse effect ered with excoriations with frequent secondary infection. Tbe is surprising as naltrexone and naloxone are currently itch persisted throughout the day and was exacerbated by heat thought to work via similar opioid receptor binding. and stress. At night she woke frequently due to the itch and The worsening of tbe itch may bave been due to adap- was distressed by her bloodstained fingernails and sheets. tation in opioid receptor expression induced by pro- Medical examination including neurological and gastro- longed naloxone therapy, possibly highlighting intestinal systems, but excluding her skin, was unremarkable. differential opioid receptor affinity between naltrexone Normal investigations included: renal function, bilirubin, liver and naloxone, or may have represented an idiosyn- transaminases, bile salts, full blood count (except for lym- cratic adverse reaction. Naltrexone and naloxone have pbopenia 0.7 x lOVLj, thyroid function tests, vitamin D, been reported to reduce pruritus due to cholestasis, parathyroid hormone, calcium, magnesium, phosphate, blood uraemia, morphine epidurals, and possibly atopic der- sugar level, iron studies, urinalysis, and thoracic and matitis and urticaria. Naltrexone has the convenience abdominal computed tomography scans. Serology for HIV was of oral administration and a longer half-life. The role negaUve. Abnormal results included: elevated lactate dehydro- of the opioid system and naltrexone in pruritus is genase and 7-glutamyltranspeptidase to 1.5 times the normal reviewed. limit, which was atti'ibuted by the hepatologist to a fatty hver largely due to steroid therapy. Repeated fungal scrapings were Key words: adverse reaction, cutaneous T-cell negative. lymphoma, mycosis fungoides, naloxone. Her itch did improve to a limited extent with systemic, intra- lesional and topical eorticosteroids in combination with emollients, wet dressings and oatmeal baths. However, she INTRODUCTION suffered from mild hypertension and osteoporosis with several rib and vertebral fractures partially attributable to ber long- Unrelieved itch is a very distressing symptom and can lead to term corticosteroid therapy. Trials of several steroid-spa ring depression and even suicide or euthanasia. We report on a agents, including azathioprine, methotrexate and dapsone, patient with stage lib mycosis fungoides with intractable itch failed due to adverse drug reactions. She bad essentially no that had not been controlled with conventional therapies. Tlius improvement in symptoms with antiihistamines, altbough she a trial ofthe opioid antagonists was undertaken. NalLrexone (ound doxepin beneficial because of its sedative and calming is a pure opioid antagonist with the convenience of an oral effects. Other therapies included PLfVA phototherapy. Her itch formulation and longer half-life tban naloxone.' NalLrexone improved in two localized areas that had received spot elec- has been reported to reduce pruritus due to cholestasis,^ tron beam therapy for tumours and these areas remained free uraemia,^ morphine epidurals,* and possibly atopic dermati- of excoriations for more than 6 months. tis and urticaria.'''^ Because of the intractable itch, subcutaneous naloxone injections (0.2 mg doses) were administered at night and repeated at 3-4 hourly intervals as required. Tliis reduced the Correspondence: Dr John R Sullivan, The Skin and Cancer itch such that she was able to sleep undisturbed (for up to 4 h Foundation, 171 Bourke Si, Uarlinghiirst, (NSW 2010, Australia. at a time) for tbe first time in several years; she no longer John R Sulli\an, MB, BS(llons). Alan Watson, FACD, scratched until her sheets were stained witli blood. There were Submitted Ifi February 1997: fiicppled 2 April 1997. no other changes in her therapy or condition. After 6 weeks Pruritus and nallrexorie 197 of naloxone therapy oral nalLrexone was given. Within 30 min renal failure there may be an elevation in p-endorpbin. Thus of tiiking 50 mji of naltrexone she suffered intense generalized naltrexone (50 mg daily) has been trialled in a small, 7-day itch with subsequent uncontrollable scratching until she bled randomized, double-blind, placebo-controlled eross-over trial and she was unable tu sleep. She also described coldness in with significant symptomatic relief from pruritus.' A reduc- her arms and legs, minor paraesthesia in her fingers and toes, tion in circulating histamine, possibly due to reduced hista- and a discomfort affecting her neek. This took over a day to mine release from basophils, was also demonstrated.^ settle and recurred with subsequent self-initiated rechallenge Opioid peptides may also have a peripheral role, p-endorphin with the same dose I week later. Naloxone was recommenced and a met-enkephalin analogue eause marked enhancement but after several months of therapy she described a decline in of histamine-indueed pruritus,'' and opioids cause cutaneous its beneficial effect, which improved with an increased dose blood vessel dilatation. Met-enkephalin-like immunoreactivity (0.4 mg) and more intermittent use. has also been identified in cutaneous Merkel cells in rats.'* Opioids are also direct mast cell degranulators."' Naltrexone is chemically related to naloxone and is thought DISCUSSION to be a pure opioid competitive antagonist, with a balf-life of 3.9 h. Naltrexone is metabolized by the liver to produce simi- Pruritus arises as a consequence of afferent nerve impulses larly active metabolites. The major metabolite is 6-|3-naltrexol, transmitted via peripheral unmyelinated C fibres. These fibres which has a half-life of 12.9 h. Its pharmacological effects last are related to but distinct from those that mediate pain.'' This 24-72 h and it is largely excreted by the kidney.-"-^' Naltrexone distinction is supported by morphine's reduction in pain per- has been used to block physical dependence to heroin, mor- ception but worsening or causation of itch.^ These C fihres phine and alcohol on a trial basis in Australia and has also synapse with secondary neurones in the dorsal horn of the been used as therapy for self-injurious behaviour.""'^^ A spinal cord that send axons via the lateral spinothalamic theoretical benefit of a reduction in self-injurious behaviour, tract to the eontralateral thalanius. Tertiary neurones then possibly via dissociation of autononiic ner\ous system func- relay this information to the cortex, leading to the perception tioning,'^ is reduced scratching, leading to less skin damage, of itch.^ lichenification and subsequent perpetuation of itch. Itch is a common side effect of opioids. The literature The most common side effect of naltrexone is the opioid contains numerous reports demonstrating the reduction in witlidrawal reaction. This is minimized by performing the pruritus of different aetiologies by the opioid antagonist naloxone challenge test as outlined in the product information' naloxone.^"'"*"'^ Naltrexone has been used successfully in or the gradual introduction of naltrexone with slowly in- patients with itch due to chronic renal failure^ and epidural creasing doses, which may be important in Ihe case of morphine.* Reports in psoriasis" and urticaria and atopic der- cholestasis for the reasons described earlier. Some authors matitis,^-^ including placebo controlled trials, have achieved have thus used a small initial dose of 2 mg, which was in- variable results. There is increasing evidence for increased creased over 2-4 weeks to 50 mg to minimize opioid with- opioid activity in patients with pruritus of cholestasis.^'"''" drawal reactions." Others have started with 50 mg of Naltrexone has been used in these patients with success in naltrexone daily.'" We trialled a 50 mg daily dose because the several small trials.'"" patient had been receiving regular subcutaneous 0.2 mg Endogenous opioids have been implicated in the patho- naloxone injections for 6 weeks prior to naltrexone therapy genesis and modification of pruritus perception. Naturally being initiated. Tolerance to the antipruritic effect of naltrex- oecurring endogenous opioid peptides include the enkephalins. one has occurred with prolonged therapy, possibly due to the endorphins and the dynorphins. These interact with sev- adaptation of central opioid receptor expression.'" As the ben- eral elosely related receptors. Opioid antagonists eompetitively efieial effect was re-established following a break from ther- bind to three specific classes of opioid receptors in the CNS (i.e. apy, Carson et al. subsequently suggested 'drug holidays' of 2 p., 8 and K); there are also probably several subclasses of these days each week.'^ receptors.'' Naloxone and naltrexone bind to all these receptor Most side effects
Load more

Recommended publications
  • 288 Part 348—External Analgesic Drug Products
    Pt. 348 21 CFR Ch. I (4–1–11 Edition) should be used and any or all of the ad- Subpart C—Labeling ditional indications for sunscreen drug 348.50 Labeling of external analgesic drug products may be used. products. (c) Warnings. The labeling of the AUTHORITY: 21 U.S.C. 321, 351, 352, 353, 355, product states, under the heading 360, 371. ‘‘Warnings,’’ the warning(s) for each in- gredient in the combination, as estab- SOURCE: 57 FR 27656, June 19, 1992, unless otherwise noted. lished in the warnings section of the applicable OTC drug monographs un- less otherwise stated in this paragraph Subpart A—General Provisions (c). § 348.1 Scope. (1) For combinations containing a skin (a) An over-the-counter external an- protectant and a sunscreen identified in algesic drug product in a form suitable §§ 347.20(d) and 352.20(b). The warnings for topical administration is generally for sunscreen drug products in recognized as safe and effective and is § 352.60(c) of this chapter are used. not misbranded if it meets each condi- (2) [Reserved] tion in this part and each general con- (d) Directions. The labeling of the dition established in § 330.1 of this product states, under the heading ‘‘Di- chapter. rections,’’ directions that conform to (b) References in this part to regu- the directions established for each in- latory sections of the Code of Federal gredient in the directions sections of Regulations are to chapter I of title 21 the applicable OTC drug monographs, unless otherwise noted. unless otherwise stated in this para- § 348.3 Definitions.
    [Show full text]
  • Deadly Pediatric Poisons: Nine Common Agents That Kill at Low Doses Joshua B
    Emerg Med Clin N Am 22 (2004) 1019–1050 Deadly pediatric poisons: nine common agents that kill at low doses Joshua B. Michael, MD, Matthew D. Sztajnkrycer, MD, PhD* Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Children are exposed more frequently to potentially toxic substances than any other age group [1]. According to data compiled by the American Association of Poison Control Centers (AAPCC), more than 1.3 million exposures involving children age 12 and younger were reported to poison control centers in 2001 [2]. Of these, more than 1 million (79%) involved children 3 years old or younger. The peak incidence for pediatric poisonings occurs in toddlers age 1 to 3 years, as does the peak incidence for hospitalization [3]. Most exposures in this age group are unintentional and reflect acquisition of developmental milestones and subsequent behaviors while exploring the environment. Children may be attracted to potentially toxic substances based on color or appearance of the agent or the container, mistakenly identifying it as a candy or beverage. Younger children are more willing to taste dangerous substances than older children and perform hand-mouth behaviors nearly 10 times an hour [4,5]. Physical environmental change plays a significant role in the epidemiology of accidental ingestion [6]. In approximately half of all accidental poisonings, the product either was in use at the time of ingestion or had been moved recently from its usual storage site. Ingestion characteristics differ significantly in toddler exposures com- pared with adolescent or adult exposures [7]. Most exposures are nontoxic because the intent is exploration rather than self-harm.
    [Show full text]
  • Pathophysiology and Treatment of Pruritus in Elderly
    International Journal of Molecular Sciences Review Pathophysiology and Treatment of Pruritus in Elderly Bo Young Chung † , Ji Young Um †, Jin Cheol Kim , Seok Young Kang , Chun Wook Park and Hye One Kim * Department of Dermatology, Kangnam Sacred Heart Hospital, Hallym University, Seoul KS013, Korea; [email protected] (B.Y.C.); [email protected] (J.Y.U.); [email protected] (J.C.K.); [email protected] (S.Y.K.); [email protected] (C.W.P.) * Correspondence: [email protected] † These authors contributed equally to this work. Abstract: Pruritus is a relatively common symptom that anyone can experience at any point in their life and is more common in the elderly. Pruritus in elderly can be defined as chronic pruritus in a person over 65 years old. The pathophysiology of pruritus in elderly is still unclear, and the quality of life is reduced. Generally, itch can be clinically classified into six types: Itch caused by systemic diseases, itch caused by skin diseases, neuropathic pruritus, psychogenic pruritus, pruritus with multiple factors, and from unknown causes. Senile pruritus can be defined as a chronic pruritus of unknown origin in elderly people. Various neuronal mediators, signaling mechanisms at neuronal terminals, central and peripheral neurotransmission pathways, and neuronal sensitizations are included in the processes causing itch. A variety of therapies are used and several novel drugs are being developed to relieve itch, including systemic and topical treatments. Keywords: elderly; ion channel; itch; neurotransmission pathophysiology of itch; pruritogen; senile pruritus; treatment of itch 1. Introduction Citation: Chung, B.Y.; Um, J.Y.; Kim, Pruritus is a relatively common symptom that anyone can experience at any point in J.C.; Kang, S.Y.; Park, C.W.; Kim, H.O.
    [Show full text]
  • Matrine Inhibits Itching by Lowering the Activity of Calcium Channel
    www.nature.com/scientificreports OPEN Matrine inhibits itching by lowering the activity of calcium channel Xiao Geng1, Hao Shi1, Fan Ye1, Han Du2, Linnan Qian1, Leying Gu1, Guanyi Wu1, Chan Zhu1, Yan Yang1, Changming Wang1, Yuan Zhou1, Guang Yu 1, Qin Liu3, Xinzhong Dong 4,5, 1 1 Received: 12 January 2018 Lei Yu & Zongxiang Tang Accepted: 22 June 2018 Sophorae Flavescentis Radix (SFR) is a medicinal herb with many functions that are involved in anti- Published: xx xx xxxx infammation, antinociception, and anticancer. SFR is also used to treat a variety of itching diseases. Matrine (MT) is one of the main constituents in SFR and also has the efect of relieving itching, but the antipruritic mechanism is still unclear. Here, we investigated the efect of MT on anti-pruritus. In acute and chronic itch models, MT signifcantly inhibited the scratching behavior not only in acute itching induced by histamine (His), chloroquine (CQ) and compound 48/80 with a dose-depended manner, but also in the chronic pruritus models of atopic dermatitis (AD) and acetone-ether-water (AEW) in mice. Furthermore, MT could be detected in the blood after intraperitoneal injection (i.p.) and subcutaneous injection (s.c.). Finally, electrophysiological and calcium imaging results showed that MT inhibited the excitatory synaptic transmission from dorsal root ganglion (DRG) to the dorsal horn of the spinal cord by suppressing the presynaptic N-type calcium channel. Taken together, we believe that MT is a novel drug candidate in treating pruritus diseases, especially for histamine-independent and chronic pruritus, which might be attributed to inhibition of the presynaptic N-type calcium channel.
    [Show full text]
  • Betamethasone (As Dipropionate)
    Decentralised Procedure Public Assessment Report Calcipotriol/Betamethason Orifarm 50 Mikrogramm/g + 0.5 mg/g Gel Calcipotriol (as monohydrate) / Betamethasone (as dipropionate) DE/H/6738/001/DC Applicant: Helm AG Nordkanalstrasse 28 20097 Hamburg Date: 2nd August 2021 This module reflects the scientific discussion for the approval of the above-mentioned product<s>. The procedure was finalised on 19th April 2021. TABLE OF CONTENTS I. INTRODUCTION ......................................................................................................................... 4 II. EXECUTIVE SUMMARY ....................................................................................................... 4 II.1 Problem statement ..................................................................................................................... 4 II.2 About the product ..................................................................................................................... 4 II.3 General comments on the submitted dossier .......................................................................... 4 II.4 General comments on compliance with GMP, GLP .............................................................. 4 III. SCIENTIFIC OVERVIEW AND DISCUSSION ................................................................... 5 III.1 Quality aspects ........................................................................................................................... 5 III.2 Non-clinical aspects ..................................................................................................................
    [Show full text]
  • An Evidence-Based Review of the Efficacy of Antihistamines in Relieving Pruritus in Atopic Dermatitis
    EVIDENCE-BASED DERMATOLOGY: ORIGINAL CONTRIBUTION An Evidence-Based Review of the Efficacy of Antihistamines in Relieving Pruritus in Atopic Dermatitis Peter A. Klein, MD, MPA; Richard A. F. Clark, MD Objective: To critically review the body of clinical tri- use of antihistamines in relieving pruritus. One grade B als that refute or support the efficacy of antihistamines trial supported the efficacy of antihistamines in reliev- in relieving pruritus in patients with atopic dermatitis. ing pruritus. All remaining trials (grade C) lacked pla- cebo controls or randomization, or contained fewer than Design: Review of MEDLINE from 1966 through March 20 patients in each treatment group. 1999, the Cochrane Database of Systematic Reviews, and Best Evidence to identify therapeutic trials of antihista- Conclusions: Although antihistamines are often used mines in patients with atopic dermatitis. in the treatment of atopic dermatitis, little objective evi- dence exists to demonstrate relief of pruritus. The ma- Main Outcome Measures: All randomized con- jority of trials are flawed in terms of the sample size or trolled trials or clinical trials of antihistamines used in study design. Based on the literature alone, the efficacy the treatment of atopic dermatitis. We found 16 studies of antihistamines remains to be adequately investi- throughout the literature. gated. Anecdotally, sedating antihistamines have some- times been useful by virtue of their soporific effect and Results: Large, randomized, double-blind, placebo- bedtime use may be warranted. There is no evidence to controlled clinical trials with definitive conclusions (grade support the effectiveness of expensive nonsedating agents. A trials) have not been performed. Two grade B trials (small, rigorous, randomized trials with uncertain re- sults due to moderate to high a or b error) refuted the Arch Dermatol.
    [Show full text]
  • Mining the Essential Oils of the Anthemideae
    African Journal of Biotechnology Vol. 3 (12), pp. 706-720, December 2004 Available online at http://www.academicjournals.org/AJB ISSN 1684–5315 © 2004 Academic Journals Review Mining the essential oils of the Anthemideae Jaime A. Teixeira da Silva Faculty of Agriculture, Kagawa University, Miki-cho, Ikenobe, 2393, Kagawa-ken, 761-0795, Japan. E-mail: [email protected]; Telfax: +81 (0)87 898 8909. Accepted 21 November, 2004 Numerous members of the Anthemideae are important cut-flower and ornamental crops, as well as medicinal and aromatic plants, many of which produce essential oils used in folk and modern medicine, the cosmetic and pharmaceutical industries. These oils and compounds contained within them are used in the pharmaceutical, flavour and fragrance industries. Moreover, as people search for alternative and herbal forms of medicine and relaxation (such as aromatherapy), and provided that there are no suitable synthetic substitutes for many of the compounds or difficulty in profiling and mimicking complex compound mixtures in the volatile oils, the original plant extracts will continue to be used long into the future. This review highlights the importance of secondary metabolites and essential oils from principal members of this tribe, their global social, medicinal and economic relevance and potential. Key words: Apoptosis, artemisinin, chamomile, essential oil, feverfew, pyrethrin, tansy. THE ANTHEMIDAE Chrysanthemum (Compositae or Asteraceae family, Mottenohoka) containing antioxidant properties and are a subfamily Asteroideae, order Asterales, subclass popular food in Yamagata, Japan. Asteridae, tribe Anthemideae), sometimes collectively termed the Achillea-complex or the Chrysanthemum- complex (tribes Astereae-Anthemideae) consists of 12 subtribes, 108 genera and at least another 1741 species SECONDARY METABOLITES AND ESSENTIAL OILS (Khallouki et al., 2000).
    [Show full text]
  • Salvinorin a Analogues PR37 and PR38 Attenuate Compound 48
    British Journal of DOI:10.1111/bph.13212 www.brjpharmacol.org BJP Pharmacology RESEARCH PAPER Correspondence Jakub Fichna, Department of Biochemistry, Faculty of Medicine, Medical University of Salvinorin A analogues Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland. E-mail: jakub.fi[email protected] PR-37 and PR-38 attenuate ---------------------------------------------------------------- Received 18 January 2015 compound 48/80-induced Revised 26 May 2015 Accepted itch responses in mice 1 June 2015 M Salaga1, P R Polepally2, M Zielinska1, M Marynowski1, A Fabisiak1, N Murawska1, K Sobczak1, M Sacharczuk3,JCDoRego4, B L Roth5, J K Zjawiony2 and J Fichna1 1Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland, 2Department of BioMolecular Sciences, Division of Pharmacognosy and Research Institute of Pharmaceutical Sciences, School of Pharmacy, University of Mississippi, University, MS, USA, 3Department of Molecular Cytogenetic, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Jastrzebiec, Poland, 4Platform of Behavioural Analysis (SCAC), Institute for Research and Innovation in Biomedicine (IRIB), Faculty of Medicine & Pharmacy, University of Rouen, Rouen Cedex, France, and 5Department of Pharmacology, Division of Chemical Biology and Medicinal Chemistry, Medical School, NIMH Psychoactive Drug Screening Program, University of North Carolina, Chapel Hill, NC, USA BACKGROUND AND PURPOSE The opioid system plays a crucial role in several physiological processes in the CNS and in the periphery. It has also been shown that selective opioid receptor agonists exert potent inhibitory action on pruritus and pain. In this study we examined whether two analogues of Salvinorin A, PR-37 and PR-38, exhibit antipruritic properties in mice. EXPERIMENTAL APPROACH To examine the antiscratch effect of PR-37 and PR-38 we used a mouse model of compound 48/80-induced pruritus.
    [Show full text]
  • Role of Nitric Oxide in the Antipruritic Effect of WIN 55212-2, A
    Basic and Clinical July, August 2020, Volume 11, Number 4 Research Paper: Role of Nitric Oxide in the Antipruritic Effect of WIN 55,212-2, a Cannabinoid Agonist Oyku Zeynep Gercek1 , Busra Oflaz1 , Neslihan Oguz1 , Koray Demirci1 , Ozgur Gunduz1 , Ahmet Ulugol1* 1. Department of Medical Pharmacology, Faculty of Medicine, Trakya University, Turkey. Use your device to scan and read the article online Citation: Zeynep Gercek, O., Oflaz, B., Oguz, N., Demirci, K., Gunduz, O., & Ulugol, A. (2020). Role of Nitric Oxide in the Antipruritic Effect of WIN 55,212-2, a Cannabinoid Agonist. Basic and Clinical Neuroscience, 11(4), 473-480. http://dx.doi. org/10.32598/bcn.9.10.465 : http://dx.doi.org/10.32598/bcn.9.10.465 A B S T R A C T Introduction: For centuries, cannabinoids are known to be effective in pain relief. Itch is an unpleasant sensation that provokes a desire to scratch. Since itch and pain are two sensations Article info: sharing a lot in common, we aimed to investigate whether the cannabinoid agonist WIN Received: 30 Mar 2018 55,212-2 reduces serotonin-induced scratching behavior and also observe whether modulation First Revision:25 Apr 2018 of Nitric Oxide (NO) production mediates the antipruritic effect of WIN 55,212-2. Accepted: 29 Apr 2019 Methods: Scratching behavior is induced by intradermal injection of serotonin (50 µg/50 Available Online: 01 Jul 2020 µL/mouse) to BALB/c mice. The cannabinoid agonist WIN 55,212-2 (1, 3, 10 mg/kg, IP) was given 30 min before serotonin injection. To observe the effect of NO modulation on the antipruritic effect of cannabinoids, the endothelial nitric oxide synthase (NOS) inhibitor L-NAME (3 mg/kg, IP), the neuronal NOS inhibitor 7-nitroindazole (3 mg/kg, IP), and the NO precursor L-arginine (100 mg/kg, IP) were administered together with WIN 55,212-2.
    [Show full text]
  • Standard Treatment Guidelines and Essential Drugs List
    STANDARD TREATMENT GUIDELINES AND ESSENTIAL DRUGS LIST FOR THE MINISTRY OF HEALTH, TONGA- 2007. Standard Treatment Guidelines Tonga 2007 Standard Treatment Guidelines and Essential Drugs List: Ministry of Health. First Edition, 2007 Copyright © 2007, Ministry of Health, Tonga All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, scanned or transmitted in any form without the permission of the copyright owner. Ministry of Health PO Box 59 Nuku’alofa Tonga Phone: 676 23200 Fax: 676 24291 E-mail address: [email protected] Editors: Siale ‘Akau’ola & Siutaka Siua Cover design by: Owen Towle Formatted by: T. Nauna Paongo Printed by: Taulua Press STG 2 Ministry of Health Standard Treatment Guidelines Tonga 2007 TABLE OF CONTENTS 1. FOREWORD: 13 2. ABBREVIATIONS AND ACRONYMS: 14 3. ACKNOWLEDGEMENTS: 17 4. INTRODUCTION: 19 5. ACCIDENT AND EMERGENCY (A&E): 21 5.1. General Approach to A&E 21 5.2. Cardiac Arrest 26 5.3. Other Life Threatening Emergencies 30 5.4. Infectious Diseases 52 5.5. Severe Hypertension 58 5.6. Abdominal Pain 59 5.7. Surgical Problems 60 5.8. Red Eye 66 5.9. Dog Bite 67 6. CARDIOVASCULAR CONDITIONS. 68 6.1. Heart Failure 68 6.2. Myocardial Infarction 72 6.3. Cardiogenic Shock 77 6.4. Acute Coronary Syndrome (ACS) 79 6.5. Cardiac Arrythmias 80 6.6. Cardiac Arrest 87 6.7. Hypertension 89 6.8. Aortic Dissection 93 6.9. Bacterial Endocarditis 96 6.10. Infective Endocarditis Prophylaxis 97 7. CENTRAL NERVOUS SYSTEM (CNS) CONDITIONS 104 7.1 Headache 104 STG 3 Ministry of Health Standard Treatment Guidelines Tonga 2007 7.2 Seizures 107 7.3 Meningitis 108 7.4 Stroke 108 7.5 Involuntary Movement Disorders 110 7.6 Epilepsy 111 8 COMMON EAR, NOSE AND THROAT PROBLEMS.
    [Show full text]
  • Drug-Induced Pruritus: a Review
    Acta Derm Venereol 2009; 89: 236–244 REVIEW ARTICLE Drug-induced Pruritus: A Review Adam REICH1, Sonja STÄNDER2 and Jacek C. SZepietowsKI1,3 1Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 2Clinical Neurodermatology, Department of Dermatology, University Hospital of Münster, Germany, and 3Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland Pruritus is an unpleasant sensation that leads to scrat- polate to drugs that are prescribed mainly in outpatient ching. In addition to several diseases, the administration clinics, as only inpatients were analysed. In another of drugs may induce pruritus. It is estimated that pru- study on skin reactions due to antibacterial agents used ritus accounts for approximately 5% of all skin adverse in 13,679 patients treated by general practitioners, reactions after drug intake. However, to date there has cutaneous adverse effects were reported in 135 (1%) been no systematic review of the natural course and pos- subjects, and general pruritus accounted for 13.3% of sible underlying mechanisms of drug-induced pruritus. these reactions (4). In a recent analysis of 200 patients For example, no clear distinction has been made between with drug reactions, 12.5% showed pruritus without acute or chronic (lasting more than 6 weeks) forms of skin lesions (5). However, only a few drugs have been pruritus. This review presents a systematic categoriza- analysed more carefully in relation to pruritus, mainly tion of the different forms of drug-induced pruritus, with antimalarials, opioids, and hydroxyethyl starch (see special emphasis on a therapeutic approach to this side- below). Furthermore, analysing the available data on effect.
    [Show full text]
  • Chronic Pruritus – Pathogenesis, Clinical Aspects and Treatment
    DOI: 10.1111/j.1468-3083.2010.03850.x JEADV INVITED ARTICLE Chronic pruritus – pathogenesis, clinical aspects and treatment M Metz,†* S Sta¨ nder‡ †Allergie-Centrum-Charite´ , Department of Dermatology, Venerology and Allergology, Charite´ – Universita¨ tsmedizin Berlin, Berlin, Germany and ‡Competence Center for Pruritus, Department of Dermatology, University Hospital of Mu¨ nster, Mu¨ nster, Germany *Correspondence: M Metz. E-mail: [email protected] Abstract Chronic pruritus is a major symptom in numerous dermatological and systemic diseases. Similar to chronic pain, chronic pruritus can have a dramatic impact on the quality of life and can worsen the general condition of the patient considerably. The pathogenesis of itch is diverse and involves a complex network of cutaneous and neuronal cells. In recent years, more and more itch-specific mediators and receptors, such as interleukin-31, gastrin-releasing peptide receptor or histamine H4 receptor have been identified and the concept of itch-specific neurons has been further characterized. Understanding of the basic principles is important for development of target-specific treatment of patients with chronic pruritus. In this review, we summarize the current knowledge about the pathophysiological principles of itch and provide an overview about current and future treatment options. Received: 26 May 2010; Accepted: 16 August 2010 Keywords atopic dermatitis, itch, mast cell, pruritus, urticaria Key points d Chronic pruritus is a common problem affecting a large proportion of the population. d The pathophysiological mechanisms underlying chronic pruritus are still insufficiently understood. d In the skin, diverse and complex interactions of keratinocytes, mast cells and sensory nerves largely determine the occurrence and the control of pruritus.
    [Show full text]