Danazol in refractory pruritus of myeloproliferative disorders

Danazol therapy combined with intermittent application of chemotherapy induces lasting remission in myeloproliferative disorder (MPD): an alternative for the elderly with advanced MPD

There is no good alternative therapy available for elderly patients with advanced myeloproliferative disorders (MPD) who failed on conventional therapies and are not candidates for bone marrow transplant. We report here an effective therapy that induced exceptionally long-lasting remissions and improved quality of life. Eighteen elderly patients (mean age: 70·6 years) (16 myelofibrosis and 2 thrombocythemia) who had failed on conventional therapies were treated. Danazol was administered daily at 200-800 mg throughout the study. Chemotherapy was applied intermittently as needed to reduce spleen size and blood counts. Busulfan (2-4 mg/day) was used most often and 6-mercaptopurine (6-MP) (50-100 mg/day) and/or cytarabine (100-200 mg/m(2)) if the white blood cell (WBC) count rose rapidly. When MPD stabilized, chemotherapy was discontinued and dosage of danazol was reduced. Therapy was well tolerated. Overall, 61% of patients responded with unexpectedly long-lasting remissions and improved quality of life. Three (17%) had excellent (E) response, defined by normalization of blood counts and non-palpable spleen, while eight (44%) had good (G) response, defined by rise of Hct by ≥7% and ≥50% reduction of spleen. Mean duration of remission was 45 months (10-78 months) in E responders and 11 months in G responders (2-22 months). This regimen offers a safe and effective alternative for advanced MPD in the elderly.

Treatment of pruritus associated with systemic disorders in the elderly: a review of the role of new therapies

Generalised pruritus is common in the elderly. Idiopathic 'senile pruritus' is a diagnosis of exclusion, and an underlying systemic disorder should be sought. Thyroid disease, haematological malignancy, iron deficiency, cholestasis or renal impairment may be responsible for pruritus. Rarely pruritus may occur after cerebral infarction or as a paraneoplastic phenomenon. The mechanisms of pruritus are poorly understood. In systemic disorders, correction of the underlying disorder alleviates itch. However, when this cannot be achieved, a symptomatic approach is required. Response to treatment varies enormously and an empirical approach is often required. Topical applications are available to soothe the skin and bandaging techniques may improve their efficacy. A number of more targeted treatments are available for renal and cholestatic pruritus. Novel therapies such as thalidomide, opioid antagonists, ondansetron and phototherapy with ultraviolet (UV)-B radiation are now being used. Treatment of pruritus needs to be individualised, and the elderly present a particular challenge. Adequate delivery of simple emollients may be impossible because of physical impairment The elderly are more vulnerable to the adverse effects of treatments, comorbidities may alter the pharmacokinetics of drug metabolism and polypharmacy increases the likelihood of adverse drug interactions. Cognitive impairment can lead to poor compliance with treatment. The patient's general health, the severity of symptoms and the adverse effects of treatment all need to be considered. Most treatments are of benefit only to some patients; others derive only marginal improvement. Many of the newer treatments are unlicensed for pruritus and should preferably be administered under specialist supervision. We review the literature concerning the treatment of itch associated with systemic diseases, with particular emphasis on issues relevant to the elderly. Pruritus is a difficult symptom to treat. However, it is hoped that research into the mechanisms underlying the pruritus of systemic disease will allow a better understanding so that we should be able to look forward to more specific and effective therapies in the future.