Introduction: It is difficult to manage that pruritus complicated with jaundice, for invalidity of almost all antihistamines. Recently, effects of paroxetine for pruritus are reported, but the report to invalid cases of paroxetine is rare. We report a case treated effectively with mirtazapine for pruritus of the paroxetine invalid. Case report: A 56-years old woman was diagnosed cancer of head of pancreas and peritoneal dissemination.After stenting by a plastic stent for obstructive jaundice in previous hospital, she came to our hospital. But, her total bilirubin (T-bil) were very high (9.9 mg/dl), and she was suffering from systemic pruritus. The NRS (numerical rating scale) score for pruritus was 9-10. Though she was prescribed an antihistamine in previous hospital, it was invalid. We had changed it to paroxetine, but pruritus were protraction two weeks later. After changing it to mirtazapine, the pruritus became NRS 1 on the next day, and recurrence was not seen subsequently. Conclusion: For pruritus of the paroxetine invalid, mirtazapine is important as one of the choices.

The guide to proper use of methadone in Japan describes the SAG method (a method of stopping all leading opioids and starting methadone). Based on strict evaluation, our palliative care department introduces methadone by adding to the preceding opioid, and then tapering or discontinuation the preceding opioid. This time, we considered the clinical significance of 28 patients who received this method. In 20 of 28 cases (71.4%), methadone reached the maximum dose, and methadone titration could be safely performed without exacerbation of pain or serious adverse events. However, in order for this method to be performed safely, it is necessary to pay attention to the pharmacological properties of methadone, which has a long half-life, and to make a detailed evaluation and drug adjustment of the analgesic effect and adverse events after the introduction of methadone.