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Medications for the Prevention of Pruritus in Women Post Cesarean Delivery with Intrathecal Morphine: A Systematic Review and Meta-analysis
Abstract Number: T-15
Abstract Type: Meta Analysis/Review of the Literature
Intrathecal morphine provides excellent analgesia after cesarean delivery (CD), but can be associated with troublesome pruritus in 60-100% of patients.(1) It is often difficult to treat and is refractory to conventional antipruritic treatment. A variety of medications have been used for pruritus prophylaxis with varying success. We performed this meta-analysis to evaluate the efficacy of medications in preventing this pruritus.
This review complies with the PRISMA guidelines. A literature search of multiple electronic databases was conducted. We included randomized controlled trials (RCTs) that compared drugs used for prophylaxis of pruritus with a control group in women undergoing CD under spinal anesthesia with intrathecal morphine. Quality of the studies was assessed using modified oxford scoring system. Dichotomous data were extracted and summarized using relative risks (RR) with 95% confidence intervals (CIs). Statistical analysis was conducted using Cochrane Review Manager 5.3.
Nineteen RCTs with 2435 patients (prophylaxis vs. control: 1219 vs. 1216) were included. 474 patients received serotonin antagonists(ondansetron, granisetron, tropisetron); 222 received dopamine antagonists (alizapride, droperidol); 179 received opioid agonist-antagonists (nalbuphine, butorphanol); 145 received opioid antagonists (naltrexone, nalmefene, naloxone); 80 received histamine antagonists (diphenhydramine, promethazine); 89 received propofol and 30 received celecoxib. The incidence of pruritus was not reduced with serotonin antagonist prophylaxis compared with control group (RR:0.91; 95%CI:0.82-1.0; p=0.06) (Figure 1). However, their use significantly reduced the severity and need for treatment of pruritus. There was a significant reduction in the incidence (RR:0.91; 95%CI:0.84-0.97; p=0.008) and severity of pruritus (RR:0.39; 95%CI:0.17-0.91; p=0.03) with dopamine antagonist prophylaxis. Nalbuphine decreased the incidence (RR:0.85; 95% CI:0.75-0.95; p=0.006), severity and need for treatment of pruritus [27.77% vs. 75.55%; RR (95% CI) = 0.37 (0.26 –0.52); P=0.00001](Figure 1). There was no difference in the incidence, severity and need for treatment of pruritus with opioid and histamine antagonists, propofol and celecoxib.
This is a comprehensive analysis of medications used in pruritus prophylaxis after CD. Serotonin antagonists reduced the severity and need for treatment, while dopamine antagonists and nalbuphine significantly reduced the overall incidence of intrathecal morphine-induced pruritus in women post CD.
1. J Clin Anesth 2003;15:234–9.