A 78-year-old male diagnosed in January 2012 with SS stage III-B/IV-A1 (T4N0M0) with extensive skin involvement, whose personal history was a 20-cigarette smoker, benign atrial fibrillation, type diabetes mellitus.
The patient was diagnosed with flat liquen in 2010 by the Department of Pathology, presenting pruritus controlled with corticosteroids and antihistamines, PUVAtherapy and acitretin.
When diagnosed with SS, oral chlorambucil therapy is prescribed.
After 10 months, in November 2012, loss of response was observed starting second-line treatment with bexarotene along with gabapentin 300 mg daily in order to improve pruritus control.
Cutaneous progression after 2 months of treatment, as well as insomnia and depression, associated with uncontrollable pruritus, led to the initiation of a third-line treatment with doxorubicin-vincing medication (PCP regimen).
Unfortunately, after two cycles of treatment, the patient continued without response or improvement of pruritus.
The following available option, extracorporeal photopheresis, was rejected by the reference center, and in view of this situation, it was decided to administer aprepitant as anti-pruritus therapy, an off-label use.
The literature was reviewed from the Department of Hygiene and next to the Hematology Service, and the doses used in the different series of published cases were compared starting with a dose of 80 mg daily for 48 days.
Since this was an indication outside the technical file, the patient was asked to sign an informed consent.
Each pack of Emend® (aprepitant) includes a dose of 125 mg and two of 80 mg. Given that in this case the dose to be used was 80 mg, it was decided to prepare a suspension of aprepitant.
Aprepitant4 capsules (125 mg +80 mg +80 mg) were extracted and oral prescriptions were administered in 7 mL of the vehicle Ora-Plus® and another 7 mL of Ora-S syringes were administered.
The suspension was stable for 90 days and kept in a refrigerator.
The patient was provided with both oral and written information on the days of taking the treatment, the need to store in a refrigerator and the most common side effects.
Fifteen days after starting treatment with aprepitant, the patient reported significant improvement in pruritus.
So far, pruritus had been subjectively assessed at all times.
The patient was evaluated with a visual analog scale (VAS) for pruritus (0 = no pruritus and 10 = worst imaginable pruritus), with a VAS of 5.
Given the effectiveness of the treatment and the absence of adverse effects, it was decided to follow the 80 mg regimen every 48 hours.
After one week, the patient was admitted for vesicular lesions and pain in the right hemithorax.
During admission, good control of pruritus was maintained.
Gabapentin was also discontinued due to tremors associated with the treatment and a fourth line treatment was given for CTCL (pegylated liposomal doxorubicin).
When the patient was discharged, the aprepitant syringes were not taken by mistake, with approximately 1 week without treatment and upon return to consultation, she reported worsening of itching, and therefore restarted treatment with aprepitant.
After 3 cycles of chemotherapy, doxorubicin was discontinued due to progression to the skin.
The last option was weekly gemcitabine, which had to be withdrawn due to poor tolerance.
Finally, with a VAS of 9, it was decided to discontinue all chemotherapy and maintain the best supportive therapy, continuing treatment with aprepitant until the end of the disease.
