What is the treatment for itching due to cirrhosis?

Management of Pruritus in Cirrhosis

Rifampicin should be considered as first-line treatment for pruritus in patients with cirrhosis, starting at 150 mg twice daily and potentially increasing to 600 mg twice daily as needed. 1

Pathophysiology and Clinical Presentation

Pruritus is a common and distressing symptom in patients with cirrhosis and cholestatic liver diseases. It typically:

• Worsens in the evenings and early night
• Often affects the palms and soles, but can be generalized
• May present with hyperpigmented and excoriated skin, particularly on hands and feet
• When accompanied by fatigue, may indicate more aggressive liver disease 1, 2

The pathogenesis is complex and not fully understood, involving bile salt accumulation, opioid system dysregulation, and other mediators 3.

Treatment Algorithm

First-line Treatment:

• Rifampicin: Start at 150 mg twice daily, can increase to 600 mg twice daily 1
  • Strong evidence from meta-analyses of RCTs supports its efficacy 1
  • Monitor for hepatotoxicity with regular liver function tests
  • Warn patients about discoloration of secretions (urine, tears)
  • Hepatotoxicity may occur in up to 12% of cholestatic patients after 2-3 months 1

Second-line Treatment:

• Cholestyramine: 9 g daily orally 1, 4
  • Binds bile salts in the gut lumen, preventing absorption
  • Take separately from UDCA (minimum 4 hours apart) to prevent binding and loss of efficacy 1
  • Poor palatability can be addressed by flavoring with fruit juice 1
  • Limited evidence base but widely used historically 1

Third-line Treatment:

• Sertraline: 75-100 mg daily orally 1
  • Limited evidence from small trials but generally well-tolerated
  • Side effects include dry mouth 1

Fourth-line Treatment:

• Opioid antagonists: Naltrexone 50 mg daily or nalmefene 1
  • Start at low dose to avoid opiate withdrawal-like reactions
  • May cause ongoing pain sensitivity issues and reduced pain threshold
  • Consider IV naloxone induction to minimize withdrawal symptoms 1

Fifth-line Options:

• Topical tacrolimus ointment 1
• Systemic dronabinol or phenobarbitone 1
• UV phototherapy - experimental but accessible 1, 5
• Plasmapheresis or albumin exchange - for extreme cases 1

Important Considerations

1. Avoid gabapentin for hepatic pruritus - evidence does not support its use 1

2. Sedative antihistamines should be avoided long-term except in palliative care due to potential dementia risk 1

3. Monitor liver function regularly when using rifampicin due to potential hepatotoxicity 1

4. For intractable pruritus unresponsive to medical therapy:

   • Consider experimental approaches like nasobiliary drainage or MARS (molecular absorbance recirculating system) 1
   • Liver transplantation may be considered for persistent and intractable pruritus 1

5. Patient education about the fluctuating nature of cholestatic pruritus (both within the day and over longer periods) is important 1

6. Combination therapy may be beneficial in some cases, such as phototherapy with low-dose cholestyramine 5

The management of pruritus in cirrhosis requires a systematic approach with careful monitoring of treatment efficacy and side effects. Rifampicin has the strongest evidence base and should be considered first-line therapy, with other agents added in a stepwise manner as needed.