From the FDA Drug Label
ASK A DOCTOR BEFORE USE IF YOU HAVE liver or kidney disease. Your doctor should determine if you need a different dose. The FDA drug label does not answer the question.
From the Research
For hepatic itch (pruritus associated with liver disease), antihistamines are generally ineffective, and a stepwise approach starting with cholestyramine, followed by rifampicin, naltrexone, and sertraline is recommended. According to the most recent and highest quality study 1, the pathophysiology of pruritus in cholestatic liver disorders is complex and involves multiple mediators, including lysophosphatidic acid (LPA) and its synthetizing enzyme autotaxin (ATX). The study suggests that conventional therapies, such as cholestyramine, rifampicin, naltrexone, and sertraline, have a favorable adverse events profile and are effective in a proportion of patients.
Treatment Options
- Cholestyramine is considered first-line treatment for cholestatic pruritus, as recommended by international societies like the AASLD and EASL 1.
- Rifampicin is a potent antipruritic agent that has been shown to reduce autotaxin transcription in vitro and is effective in treating cholestatic itch 2.
- Naltrexone, an opioid antagonist, is also used to treat cholestatic pruritus, and its safety and efficacy have been evaluated in several studies, including a retrospective review of inpatients who received naltrexone for cholestatic pruritus 3.
- Sertraline, a serotonin reuptake inhibitor, is another option for treating cholestatic pruritus, as recommended by evidence-based guidelines 2.
Important Considerations
- Antihistamines, such as hydroxyzine, cetirizine, and loratadine, are generally ineffective in treating hepatic itch, as they only address the histamine pathway, and hepatic itch involves multiple pathways beyond histamine, including bile acids and opioid receptors 4.
- Experimental and invasive procedures, such as UVB phototherapy, extracorporeal albumin dialysis, and nasobiliary drainage, should be reserved for refractory pruritus 2.
- Liver function tests should be monitored regularly when using medications like rifampicin, as they can affect liver function 5.
Recommendations
- Consult with a healthcare provider before starting any medication, especially with liver disease, as dosage adjustments may be necessary.
- Consider adding cholestyramine, rifampicin, or naltrexone under medical supervision if antihistamines do not provide adequate relief, as these target other mechanisms of hepatic pruritus.