Pharmacotherapeutics of aprepitant and pregabalin in neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T-cell lymphoma
Palliative care nurse specialists are required to have a high level of knowledge and expertise in the management of complex symptoms. As a result of patient complexity, clinicians are often faced with advising on multiple drug regimes. This often requires clinical nurse specialists to have knowledge of pharmacotherapeutics to ensure safe and rational prescribing. In the form of a case study, the author has critically discussed the use of aprepitant and pregabalin in the management of neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T cell lymphoma. These drugs are not routinely prescribed together and therefore the author has explored potential pharmacokinetic interactions.
The case presented a 49-year-old lady with an advanced metastatic cutaneous T-cell lymphoma with failed remission despite extensive oncological treatment. She was referrd to the to hospital specialist palliative care team for treatment of refractory pruritus and neuropathic pain.
Aprepitant is considered an effective anti-pruritic agent that is normally well tolerated; however, careful consideration must be taken because of extensive drug interactions. Caution is also required in patients with hepatic impairment. Pregabalin is often used in specialist palliative care for the management of neuropathic pain because of its efficacy and ease of titration. Caution must be taken in prescribing in patients with renal impairment. As pregabalin is not bound to plasma proteins nor metabolised by the liver, the risk of pharmacokinetic interaction with aprepitant is minimal. As both drugs cross the blood brain-barrier, clinicians must monitor for adverse central nervous system activity. This case study highlights the importance of pharmacotherapeutics in ensuring safe and rational prescribing, with the need to continue to integrate this knowledge into future practice as nurse prescribers.
The author is employed as a clinical nurse specialist in a hospital specialist palliative care team. Palliative care is an ‘approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness’ (World Health Organization, 2002). It is the role of the specialist palliative care team to provide expert advice on the management of complex symptoms while providing holistic and supportive care to patients and their families (Association of Palliative Medicine, 2012). This requires a unique approach to clinical assessment, as nurses must not only manage physical symptoms but also provide psychosocial, spiritual, emotional and practical support.
Because of an ageing population, people are living longer with multiple comorbidities (OECD and European Union, 2013) and this often presents challenges for specialist palliative care because of the increasing patient complexities. Clinical nurse specialists are required to have a high level of knowledge and skill when providing advice on complex symptom management (van de Steen et al, 2014). This also includes knowledge of pharmacotherapeutics to ensure safe and rational prescribing of medications (Maxwell et al, 2017). Pharmacotherapeutics describes the clinical indication for giving a drug and the effect it has on the body.
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