Antihistamines versus aspirin for itching in late pregnancy (Review)

Young GL, Jewell D

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2007, Issue 4 http://www.thecochranelibrary.com

Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

TABLE OF CONTENTS ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . . SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . . METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparison 01. Antihistamines versus aspirin for itching in late pregnancy . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 01.01. Comparison 01 Antihistamines versus aspirin for itching in late pregnancy, Outcome 01 Failure to obtain relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 6 6

Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Antihistamines versus aspirin for itching in late pregnancy (Review)

Young GL, Jewell D

This record should be cited as: Young GL, Jewell D. Antihistamines versus aspirin for itching in late pregnancy. Cochrane Database of Systematic Reviews 1997, Issue 1. Art. No.: CD000027. DOI: 10.1002/14651858.CD000027. This version rst published online: 20 January 1997 in Issue 1, 1997. Date of most recent substantive amendment: 01 October 1996

ABSTRACT Background While not common, itching in pregnancy (not due to liver disease) can be distressing. Objectives The objective of this review was to assess the effects of treatment for itching in late pregnancy. Search strategy We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2007). Selection criteria Randomised trials of treatments for itching in women in late pregnancy with normal liver function. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Main results One study of 38 women was included. This was a small crossover trial, using alternate allocation. The trial compared a histamine, chlorpheniramine, with aspirin. Aspirin was more effective than chlorpheniramine in relieving itching (odds ratio 2.39, 95% condence interval 1.25 to 4.57). However, chlorpheniramine was more effective than aspirin when a rash was present. Authors conclusions Aspirin appears to be more effective than chlorpheniramine for relief of itching in pregnancy when no rash is present. If there is a rash, chlorpheniramine may be more effective.

PLAIN LANGUAGE SUMMARY Antihistamines or aspirin for itching in late pregnancy A few women get itching towards the end of pregnancy, and it can be so distressing that they sometimes ask for induction of labour. Antihistamines and aspirin are two possible drugs that might be used to alleviate the itching. The review of trials found one study involving 38 women, assessing separately women who had a rash with their itching and those who had no rash. The trial was of poor methodologically but it did identify dramatic improvements for the women, but did not assess any outcomes on the baby. The review found that when there was a rash present with the itching, 93% of women got relief with antistamines compared with 13% getting relief with aspirin. When there was no rash present, 95% of women got relief with aspirin compared with none getting any relief with antihistamines. These results suggest that antihistamines are effective when there is a rash and aspirin is effective when there is no rash. However, these ndings need conrmation in a well designed randomised trial and safety for the baby needs to be assessed.
Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd 1

BACKGROUND Itching in pregnancy may be due to serious liver disease. This possibility should be excluded by liver function tests. Itching is not common in pregnancy but, when present, can be distressing enough even to merit induction of labour.

can be found in the Search strategies for identication of studies section within the editorial information about the Cochrane Pregnancy and Childbirth Group. Trials identied through the searching activities described above are given a code (or codes) depending on the topic. The codes are linked to review topics. The Trials Search Co-ordinator searches the register for each review using these codes rather than keywords. We did not apply any language restrictions.

OBJECTIVES To compare antihistamines (chlorpheniramine) with aspirin for the treatment of itching in late pregnancy.

METHODS OF THE REVIEW CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW Types of studies Any randomized controlled trials of treatments for itching in pregnancy. Types of participants Pregnant women in the last trimester. Types of intervention Chlorpheniramine 4 mg three times daily for 4 days versus aspirin 600 mg four times daily. Types of outcome measures Marked relief of itching. (Slight relief was considered as no relief.) The only trial included in this review was a small crossover trial. The method of randomization is not described but a letter to the author discovered that alternate allocation was used. It is not clear whether either the participants or assessors were blinded. DESCRIPTION OF STUDIES For details of the included study (Read 1977), see table of Characteristics of included studies. Trials under consideration were evaluated for methodological quality and appropriateness for inclusion, without consideration of their results. Included trial data were processed as described in Mulrow 1997.

METHODOLOGICAL QUALITY

SEARCH METHODS FOR IDENTIFICATION OF STUDIES See: methods used in reviews. We searched the Cochrane Pregnancy and Childbirth Groups Trials Register by contacting the Trials Search Co-ordinator (January 2007). The Cochrane Pregnancy and Childbirth Groups Trials Register is maintained by the Trials Search Co-ordinator and contains trials identied from: (1) quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); (2) monthly searches of MEDLINE; (3) handsearches of 30 journals and the proceedings of major conferences; (4) weekly current awareness search of a further 37 journals. Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service

RESULTS One study of 38 women was included (Read 1977). Overall, women were slightly more likely to obtain relief with aspirin rather than antihistamine. However, marked differences were discovered between women with a rash and those with no visible skin changes. Of 15 women with a rash, 14 obtained marked or total relief with chlorpheniramine whereas only two obtained such relief with aspirin. Conversely, with no rash none obtained relief with chlorpheniramine whereas 20 out of 21 did when they took aspirin.

DISCUSSION See Implications.

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Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

AUTHORS CONCLUSIONS Implications for practice Itching in late pregnancy where a rash is present may be eased by an antihistamine. Where there is no rash aspirin may be helpful. Aspirin causes inhibition of platelet aggregation and this might theoretically have implications for the woman and for her baby at birth though it is likely not to be of practical importance. Implications for research This interesting study should be repeated as a randomized placebo controlled trial. The basis for the different responses to treatment depending on the presence of a rash merits investigation. The authors suggest that aspirin may relieve itch through its antiprostaglandin action against prostaglandin E1.

POTENTIAL CONFLICT OF INTEREST None known.

ACKNOWLEDGEMENTS None.

SOURCES OF SUPPORT External sources of support [Information not provided] Internal sources of support No sources of support supplied

REFERENCES

Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

References to studies included in this review

Read 1977 {published data only} Read MD. A new hypothesis of itching in pregnancy. Practitioner 1977;218:845847.

Additional references
Mulrow 1997 Mulrow CD, Oxman AD editors. Cochrane Collaboration Handbook [updated September 1997]. The Cochrane Library [database on disk and CDROM]. The Cochrane Collaboration 1997, issue 4.

References to other published versions of this review

Young 1995 Young GL. Antihistamines vs aspirin for itching in late pregnancy. [revised 30 April 1993]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue2, Oxford: Update Software, 1995.

TABLES

Characteristics of included studies

Study Methods Participants Interventions Outcomes Notes Allocation concealment Read 1977 Alternate allocation to treatment with aspirin or antihistamine (chlorpheniramine) for 4 days. Women were reviewed and then crossed over to the other treatment. 36 women between 33 and 38 weeks gestation and with normal liver function tests attending a Manchester Hospital. Chlorpheniramine 4mg three times daily or asprin 600mg four times daily for 4 days then cross over. Relief of itching. A Adequate ANALYSES

Comparison 01. Antihistamines versus aspirin for itching in late pregnancy

Outcome title 01 Failure to obtain relief No. of studies 2 No. of participants 72 Statistical method Peto Odds Ratio 95% CI Effect size 2.38 [0.96, 5.93]

INDEX TERMS Medical Subject Headings (MeSH) Antipruritics [ therapeutic use]; Aspirin [ therapeutic use]; Chlorpheniramine [ therapeutic use]; Histamine H1 Antagonists [ therapeutic use]; Pregnancy Complications [ drug therapy]; Pregnancy Trimester, Third; Pruritus [ drug therapy] MeSH check words Female; Humans; Pregnancy
Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd 4

COVER SHEET Title Authors Contribution of author(s) Issue protocol rst published Review rst published Date of most recent amendment Date of most recent SUBSTANTIVE amendment Whats New Date new studies sought but none found Date new studies found but not yet included/excluded Date new studies found and included/excluded Date authors conclusions section amended Contact address Antihistamines versus aspirin for itching in late pregnancy Young GL, Jewell D Information not supplied by author 1997/1 1997/1 17 January 2007 01 October 1996

1 January 2007: search updated. No new trial reports identied. 01 January 2007

Information not supplied by author

Information not supplied by author

Information not supplied by author

Dr Gavin Young Temple Sowerby Medical Practice Linden Park Temple Sowerby Penrith Cumbria CA10 1RW UK E-mail: gavinlyoung@btinternet.com Tel: +44 176 8361232 Fax: +44 176 8361980 10.1002/14651858.CD000027 CD000027 Cochrane Pregnancy and Childbirth Group HM-PREG
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DOI Cochrane Library number Editorial group Editorial group code

Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Analysis 01.01.
Review:

GRAPHS AND OTHER TABLES Comparison 01 Antihistamines versus aspirin for itching in late pregnancy, Outcome 01 Failure to obtain relief

Antihistamines versus aspirin for itching in late pregnancy

Comparison: 01 Antihistamines versus aspirin for itching in late pregnancy Outcome: 01 Failure to obtain relief Study Treatment n/N 01 Failure to obtain relief when rash present Read 1977 Subtotal (95% CI) 1/15 15 13/15 15 41.9 41.9 0.04 [ 0.01, 0.18 ] 0.04 [ 0.01, 0.18 ] Control n/N Peto Odds Ratio 95% CI Weight (%) Peto Odds Ratio 95% CI

Total events: 1 (Treatment), 13 (Control) Test for heterogeneity: not applicable Test for overall effect z=4.32 p=0.00002

02 Failure to obtain relief when no rash present Read 1977 Subtotal (95% CI) 21/21 21 1/21 21 58.1 58.1 41.57 [ 12.56, 137.53 ] 41.57 [ 12.56, 137.53 ]

Total events: 21 (Treatment), 1 (Control) Test for heterogeneity: not applicable Test for overall effect z=6.11 Total (95% CI) p<0.00001 36 36 100.0 2.38 [ 0.96, 5.93 ]

Total events: 22 (Treatment), 14 (Control) Test for heterogeneity chi-square=52.45 df=1 p=<0.0001 I =98.1% Test for overall effect z=1.86 p=0.06

0.1 0.2

0.5

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Antihistamines versus aspirin for itching in late pregnancy (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd