What is the treatment for intrahepatic cholestasis of pregnancy (ICP)?

From the Guidelines

The primary treatment for intrahepatic cholestasis of pregnancy (ICP) is ursodeoxycholic acid (UDCA), typically prescribed at 10-15 mg/kg/day divided into 2-3 doses, as recommended by the most recent and highest quality study 1. This medication helps reduce bile acid levels, improve liver function, and decrease itching. Treatment should begin as soon as ICP is diagnosed and continue until delivery. Key aspects of ICP management include:

• Regular monitoring of bile acid levels and liver function tests, typically every 1-2 weeks
• Fetal monitoring, with increased surveillance after 34 weeks
• Delivery timing, with many providers recommending delivery between 36-38 weeks to reduce stillbirth risk, and earlier delivery considered for severe cases with very high bile acid levels UDCA works by replacing toxic bile acids, protecting liver cells, and improving bile flow, addressing the underlying pathophysiology of bile acid accumulation that causes maternal symptoms and poses risks to the fetus. In addition to UDCA, other treatments may be considered, such as:
• Antihistamines like diphenhydramine (25-50 mg every 4-6 hours) or hydroxyzine (25 mg every 6-8 hours) for relief from itching
• Topical anti-itch creams with menthol or calamine for temporary comfort
• Cholestyramine (8-16 g/day) as a second-line agent, although it is less effective and can interfere with vitamin absorption. The most recent guidelines from the European Association for the Study of the Liver 1 and the Society for Maternal-Fetal Medicine 1 support the use of UDCA as the first-line treatment for ICP, and recommend individualized management based on serum bile acid levels and fetal monitoring. Overall, the goal of ICP management is to reduce the risks of stillbirth, preterm birth, and other adverse outcomes, while also alleviating maternal symptoms and improving quality of life.

From the Research

Treatment Options for Intrahepatic Cholestasis of Pregnancy (ICP)

• Ursodeoxycholic acid (UDCA) is considered the first-line treatment for ICP, as it has been shown to improve maternal symptoms and biochemical tests 2, 3, 4, 5.
• UDCA monotherapy is recommended due to its efficacy, cost-effectiveness, and convenience 2.
• The optimal dosage of UDCA for ICP treatment has not been established, but low doses (300-450 mg/day) have been shown to be effective in improving biochemical markers and clinical symptoms 3.
• S-adenosylmethionine (SAMe) has also been used in combination with UDCA, but its effectiveness is still being studied 2.
• Treatment with UDCA should be initiated as soon as possible after diagnosis to minimize the risk of adverse pregnancy outcomes 4, 5.

Management of ICP

• Pregnant women with severe ICP should be managed in a perinatal center with close interdisciplinary monitoring and treatment involving perinatologists and hepatologists 4.
• Delivery may be considered at 37 weeks' gestation due to the increased risk of stillbirth in women with ICP 5.
• Fetal surveillance and monitoring of liver function tests are crucial in managing ICP 3, 5.

Pharmacological Management

• The goal of pharmacological treatment is to improve maternal symptoms and biochemical alterations, and to reduce fetal adverse events 6.
• UDCA treatment has been shown to improve maternal pruritus symptoms and biochemical tests, but its effect on fetal outcomes is still being studied 2, 3, 5.