What to prescribe for pruritus due to cirrhosis?

Management of Pruritus in Cirrhosis

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

Treatment Algorithm for Cirrhosis-Related Pruritus

First-Line Therapy

• Rifampicin: Start at 150 mg twice daily, can be increased to 600 mg twice daily 1
  • Monitor for hepatotoxicity with regular liver function tests 1
  • Warn patients about orange discoloration of secretions 1
  • Two meta-analyses of randomized controlled trials support rifampicin's efficacy in reducing hepatic pruritus 1
  • Caution: Hepatitis occurs in approximately 7.3% of patients treated with rifampicin for cholestatic liver disease 2

Second-Line Therapy

• Cholestyramine: 9 g daily orally 1
  • Acts by binding bile salts in the gut lumen 1
  • Evidence is limited but one small RCT showed benefit in 10 patients 1
  • Most effective when taken 30-60 minutes before and after meals 1

Third-Line Therapy

• Sertraline: 75-100 mg daily orally 1
  • Well tolerated according to one small RCT 1
  • For patients not responding to 50 mg daily, dose may be increased in 50 mg increments up to 200 mg daily 3
  • Gradual tapering over 10-14 days is recommended when discontinuing to avoid withdrawal symptoms 3

Fourth-Line Therapy

• Naltrexone: 50 mg daily orally 1
  • Opioid antagonists have more side effects than cholestyramine and rifampicin 1
  • Alternative: Nalmefene (0.25-1 mg/kg per day intravenously) 1

Fifth-Line Options

• Consider any of the following: 1
  • Systemic dronabinol
  • Phenobarbital
  • Propofol
  • Topical tacrolimus ointment
  • Newer agents targeting bile acid transport, autotaxin and lysophosphatidic acid metabolism

Important Considerations and Monitoring

• Do not use gabapentin for hepatic pruritus 1
• Ondansetron has conflicting evidence and cannot be routinely recommended 1
• Monitor liver function tests regularly in all patients with hepatic pruritus 1, 4
• Patients with significant hepatic impairment should be referred to a hepatology center 1
• Long-term rifampicin treatment has shown sustained relief of pruritus in PBC patients followed for up to 24 months 4

Potential Complications and Pitfalls

• Rifampicin-induced hepatitis: Can occur in approximately 7.3% of patients and may lead to impaired liver synthetic function requiring transplantation in severe cases 2
• Opioid antagonist side effects: These can be significant and may limit their use 1
• Medication adherence: Cholestyramine has poor palatability which may affect compliance 1
• Drug interactions: Rifampicin is a potent inducer of hepatic enzymes and may affect metabolism of other medications 5

Special Situations

• For patients with intractable pruritus despite medical therapy, consider referral for: 1
  • Extracorporeal dialysis techniques
  • Nasobiliary drainage
  • Liver transplantation evaluation

Remember that pruritus in cirrhosis can significantly impact quality of life and should be addressed promptly and aggressively with a stepwise approach to therapy.