From the Guidelines
For biliary-related mild pruritus, I recommend starting with bezafibrate as the first-line treatment, given its clear-cut benefit in alleviating moderate to severe itch in people with primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) as shown in the FITCH trial 1. This approach prioritizes the most recent and highest quality evidence, which suggests that bezafibrate is effective in treating cholestasis-associated pruritus with minimal side effects. The management of biliary-related pruritus involves a stepwise approach, considering the severity of symptoms and the patient's response to treatment. Key considerations include:
- Bezafibrate as the first-line pharmacological treatment for moderate to severe pruritus in PSC and other forms of fibrosing cholangiopathy, due to its sustained antipruritic effect under cholestatic conditions 1.
- Rifampicin as a potential second-line treatment, given its effectiveness in reducing hepatic pruritus, although it requires monitoring for hepatotoxicity and may induce drug-induced hepatitis in some patients 1.
- Naltrexone as a third-line option, starting at low doses to avoid side effects, for patients who do not respond to first-line treatments 1.
- General recommendations for patients suffering from cholestasis-associated pruritus include using emollients, avoiding hot baths or showers, and keeping nails shortened to prevent skin damage from scratching 1. It is crucial to address the underlying biliary condition for long-term management of pruritus, and patients should be monitored closely for any changes in their condition or response to treatment. Given the potential for significant improvement in quality of life with effective management of pruritus, it is essential to prioritize treatments with the strongest evidence base, such as bezafibrate, and to consider the potential risks and benefits of each treatment option 1.
From the FDA Drug Label
Cholestyramine for Oral Suspension, USP powder, is indicated for the relief of pruritus associated with partial biliary obstruction Cholestyramine resin has been shown to have a variable effect on serum cholesterol in these patients. In patients with partial biliary obstruction, the reduction of serum bile acid levels by cholestyramine resin reduces excess bile acids deposited in the dermal tissue with resultant decrease in pruritus
The management option for biliary-related mild pruritus (itching) is Cholestyramine. It is indicated for the relief of pruritus associated with partial biliary obstruction and works by reducing serum bile acid levels, which in turn decreases the excess bile acids deposited in the dermal tissue, resulting in a decrease in pruritus 2.
From the Research
Management Options for Biliary-Related Mild Pruritus
The management of biliary-related mild pruritus involves a stepwise approach, with various treatment options available. The following are some of the management options:
- First-line treatment: Cholestyramine is considered a first-line treatment for cholestatic pruritus 3, 4, 5
- Second-line treatment: Rifampicin, naltrexone, and sertraline are considered second-line treatments for cholestatic pruritus 3, 4, 5
- Alternative treatments: Bezafibrate and ileal bile acid transporter inhibitors represent promising future anti-pruritic treatment options 4, 5
- Supportive therapy: Nutritional rehabilitation with supplement of fat-soluble vitamins and calcium, as well as biliary diversion surgery, may be necessary in some cases 6
- Experimental treatments: Novel drugs are currently being developed for the management of cholestatic itching, with ongoing translational and clinical research 3, 5
Treatment Guidelines
International societies, such as the AASLD and EASL, recommend a stepwise approach for the management of cholestatic itch 3. The treatment guidelines include:
- Assessment of pruritus severity
- Treatment with specific drug therapies in line with current practice guidelines
- Consideration of novel therapeutic targets, such as KOR agonists, PPAR agonists, and ileal bile acid transporter inhibitors 4
- Liver transplantation may be considered in cases of refractory pruritus affecting the quality of life or those with end-stage liver disease 6, 5