From the Guidelines
Rifampicin should be considered as the first-line treatment for itching in liver cirrhosis patients, as it has been shown to be effective in reducing pruritus with a relatively good safety profile, as evidenced by the 2018 British Association of Dermatologists' guidelines 1. The treatment of itching in liver cirrhosis patients involves a step-wise approach, with multiple pharmacological and non-pharmacological options available.
- First-line treatment: Rifampicin, starting at a dose of 150 mg twice daily, with a maximum dose of 600 mg daily, as recommended by the British Association of Dermatologists' guidelines 1.
- Second-line treatment: Cholestyramine, at a dose of 4 g/day to a maximum of 16 g/day, as suggested by the British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines 1.
- Third-line treatment: Sertraline, at a dose of 75-100 mg daily, as recommended by the British Association of Dermatologists' guidelines 1.
- Non-pharmacological measures: Keeping skin moisturized with fragrance-free lotions, avoiding hot showers, wearing loose cotton clothing, and maintaining cool ambient temperatures. It is essential to note that liver transplantation may be considered in extreme cases of uncontrolled pruritus, as recommended by the AASLD practice guidelines 1. However, this option should only be considered after all other available treatments have been exhausted, due to the potential risks and complications associated with liver transplantation. The choice of treatment should be individualized based on the patient's specific condition, severity of symptoms, and medical history, and should be made in consultation with a healthcare provider. Regular monitoring of liver function and adjustment of treatment as needed is crucial to ensure the best possible outcomes for patients with liver cirrhosis and itching.
From the Research
Treatment Options for Itching in Liver Cirrhosis Patients
- Cholestyramine: a bile acid sequestrant that can help eliminate pruritogens 2, 3
- Rifampicin: an inducer of hepatic metabolism that can ameliorate pruritus and lower serum concentrations of alkaline phosphatase and bile acids 4, 2, 5
- Naltrexone: a µ-opioid antagonist that can influence the perception of itch by the central nervous system 2, 3
- Sertraline: an SSRI that can also influence the perception of itch by the central nervous system 2
- Bezafibrate: a promising future anti-pruritic treatment option 2
- Ileal bile acid transporter inhibitors: a promising future anti-pruritic treatment option 2
Pathogenesis of Pruritus in Liver Disease
- Bile salts: a possible contributor to cholestatic pruritus 3, 6
- Histamine: a possible contributor to cholestatic pruritus 3, 6
- Progesterone metabolites: a possible contributor to cholestatic pruritus 3, 6
- Endogenous opioids: a possible contributor to cholestatic pruritus 3, 6
- Autotaxin: an enzyme that produces lysophosphatidic acid, a potential pruritogen in cholestasis 3, 6
- Lysophosphatidic acid: a potent neuronal activator and potential pruritogen in pruritus of cholestasis 6