Itching - Liver disease or allergy?

[Jay-Jay, RN]

My husband has Ca. of the bladder. One of the most common sites for mets is the liver, and he already has mets to the pelvis and lymph nodes. I have noticed a trace of jaundice in his complexion and eyes recently, but the latest tests show the bilirubin is normal. His ALT is elevated, however. At the same time I noticed the jaundice, he began having really bad problems with itching. No rash is evident, he just itches EVERYWHERE. He is also hiccuping a lot, which might indicate spread to the diaphragm/liver area.

We have had to start to used Tylenol #3 fairly frequently to control the pain in the last week, whereas before it was just a tablet or two at bedtime, or for breakthrough when he'd had to do a lot of walking during the day. While in hospital in March, he had codeine listed as an allergy, but I never found out why. He now thinks he made a mistake in reporting to the nurses that he was allergic to it, but I'm starting to wonder. At what point does liver dysfunction produce itching? Would an elevated ALT level cause itching? What else might be causing this? He's on Dilantin 300 mg daily, and his other meds are just regular BP meds, plus Ranitidine for acid reflux/hiatus hernia.

[Audreyfay]

From my experience, liver disease can cause itching. However, if he had some possible problems with the codeine before, why not ask for a different pain medication? Especially if he is needing more than before. There are so many pain meds out there, why not try a different one, in case it is the codeine?

My heart goes out to you and your husband Jane. I will include you in my prayers. Take care, Audrey

[Jay-Jay, RN]

Thank you, Audrey. Y'know, I have special qualifications in palliative care. I just never thought I'd be using them so close to home....

Maybe that's why God put us together!

[NRSKarenRN, BSN, RN]

side effects

the major hazards of codeine, as of other narcotic analgesics, are respiratory depression and, to a lesser degree, circulatory depression. respiratory arrest, shock, and cardiac arrest have occurred.

the most frequently observed adverse reactions include lightheadedness, dizziness, sedation, nausea, vomiting, and sweating. these effects seem to be more prominent in ambulatory patients and in those who are not suffering severe pain. in such individuals, lower doses are advisable. some adverse reactions may be alleviated in the ambulatory patient if he lies down.

other adverse reactions include the following:

central nervous system -- euphoria, dysphoria, weakness, headache, insomnia, agitation, disorientation, and visual disturbances.

genitourinary-- urinary retention or hesitancy, anti- diuretic effect, and reduced libido and/or potency.

allergic-- pruritus, urticaria, other skin rashes, edema, and, rarely, hemorrhagic urticaria.

gastrointestinal -- dr. mouth, anorexia, constipation, and biliary tract spasm.

cardiovascular-flushing of the face, bradycardia, palpitation, faintness, and syncope.

http://www.rxlist.com/cgi/generic3/codeine_ad.htm

tylenol with codiene

what side effects may occur?

side effects cannot be anticipated. if any develop or change in intensity, inform your doctor as soon as possible. only your doctor can determine if it is safe for you to continue taking tylenol with codeine.

• more common side effects may include:
  dizziness, light-headedness, nausea, sedation, shortness of breath, vomiting
  

• less common side effects may include:
  abdominal pain, allergic reactions, constipation, depressed feeling, exaggerated feeling of well-being, itchy skin http://www.healthsquare.com/newrx/tyl1466.htm
  

clue phone : need another pain med !!!!

[NRSKarenRN, BSN, RN]

Medline + Drug information:

http://www.nlm.nih.gov/medlineplus/druginfo/drug_Aa.html

[NRSKarenRN, BSN, RN]

Urticaria, pruritus

In some patients, opioids produce urticaria or pruritus. These effects are the result of mast cell destabilization by the opioid and subsequent histamine release. Usually the rash and pruritus can be managed by routine administration of long-acting, nonsedating antihistamines while opioid dosing continues (eg, fexofenadine, 60 mg po bid; diphenhydramine, loratadine, or doxepin, 10–30 mg po q hs).

Pg 23

http://www.ama-assn.org/ethic/epec/download/module_4.pdf

Great articile about Cancer Pain management too.

Atarax = Hydroxyzine Hydrochloride (US) was tolerated well and greatly reduced itching with clients with liver disease and CHEEP too. Drowsiness wears off after few days.

[NRSKarenRN, BSN, RN]

opiate-related therapies and management of pain (conference coverage)

mar 2004 - this 3-part review presents the most recent advances in 3 broad categories of pain management: opiate-related management, nonopioid pharmacologic approaches to pain medicine, and nonpharmacologic pain treatments, including clinical approaches, pathophysiology, and products in development within each of these categories.

http://www.medscape.com/viewarticle/472405?src=search

medscape requires free registration.

-----------------

opioid analgesics comparison

from rxfiles

----------------

vicoprofen might be helpful as combines synthetic codiene with ibuprofen--often helpful with bone pain. however that + coumadin would be a concern for bleeding.