From the Guidelines
The primary treatment for cholestasis-associated itching in pregnancy is ursodeoxycholic acid (UDCA), which should be used as the first-line agent to alleviate maternal symptoms. This recommendation is based on the highest quality evidence available, including a study published in the American Journal of Obstetrics and Gynecology in 2021 1, which suggests that UDCA is effective in improving maternal symptoms and has no known adverse effects on the fetus. The typical starting dose for UDCA treatment is 10-15 mg/kg per day, divided into 2 or 3 daily doses, with a maximum dose of 21 mg/kg per day if necessary 1.
Key points to consider in the treatment of cholestasis-associated itching in pregnancy include:
- UDCA is the most commonly used treatment for intrahepatic cholestasis of pregnancy (ICP) and has been shown to improve maternal symptoms and laboratory abnormalities 1
- Alternative treatments, such as S-adenosyl-methionine and cholestyramine, may be considered for patients who cannot take UDCA or who have continued symptoms on the maximum dosage, but their effectiveness is limited 1
- Antihistamines, such as diphenhydramine or hydroxyzine, and topical treatments, such as calamine lotion or cool baths with colloidal oatmeal, may provide temporary relief but are not as effective as UDCA 1
- Close monitoring with twice-weekly non-stress tests after 32 weeks and consideration of early delivery at 36-37 weeks are recommended to reduce the risk of stillbirth 1
It is essential to note that the primary goal of treatment is to alleviate maternal symptoms and reduce the risk of adverse perinatal outcomes. UDCA has been shown to be effective in improving maternal symptoms, and its use is recommended as the first-line treatment for cholestasis-associated itching in pregnancy.
From the Research
Treatment for Cholestasis-Associated Itching in Pregnancy
The treatment for cholestasis-associated itching in pregnancy primarily involves the use of ursodeoxycholic acid (UDCA) due to its efficacy in improving symptoms and liver function tests. Key points regarding the treatment include:
- Ursodeoxycholic Acid (UDCA): UDCA has been shown to be effective in reducing pruritus and improving liver function tests in patients with intrahepatic cholestasis of pregnancy (ICP) 2, 3, 4, 5, 6.
- Dosage and Administration: The dosage of UDCA varies but is often administered at 300-450 mg/day or 4-6 mg/kg/day until delivery 2, or at 8-10 mg/kg body weight daily 5.
- Comparison with Other Treatments: UDCA has been compared to other treatments such as S-adenosylmethionine (SAMe) and cholestyramine, with UDCA showing superior efficacy in some studies 3, 5.
- Safety and Tolerance: UDCA is well-tolerated by pregnant women, with no significant fetal or neonatal side effects reported in the studies 4, 5.
- Predictive Factors for Response: Factors such as elevated ALT levels before treatment may predict a better response to UDCA therapy 6.
- Real-World Efficacy: In real-world conditions, UDCA therapy has been shown to improve pruritus and liver function tests in a significant proportion of patients with ICP 6.
Key Findings from Studies
- A study from 2016 found that low doses of UDCA improved biochemical markers and clinical symptoms in almost 90% of ICP patients 2.
- A 2015 study concluded that UDCA and SAMe are both effective and safe in the treatment of ICP, with UDCA monotherapy recommended as the first-line therapy due to its efficacy, cost-effectiveness, and convenience 3.
- A randomized controlled trial from 2014 demonstrated that UDCA improves maternal itching scores and liver function tests without interfering with fetoplacental estrogen production in patients with ICP 4.
- A 2005 study showed that UDCA is more effective than cholestyramine in reducing pruritus and serum bile acid levels, and is associated with fewer adverse effects 5.
- An observational study from 2017 supported the use of UDCA as first-line therapy in ICP, with improvement in pruritus and liver function tests observed in a majority of patients 6.