What is the treatment for pruritus (itching) secondary to liver cirrhosis?

Treatment of Pruritus Secondary to Liver Cirrhosis

Cholestyramine should be used as first-line therapy for pruritus secondary to liver cirrhosis due to its favorable safety profile, followed by rifampicin as second-line treatment if cholestyramine is ineffective or not tolerated. 1

Stepwise Treatment Algorithm

First-Line Treatment

• Cholestyramine 4g up to four times daily is the recommended first-line treatment for pruritus in liver cirrhosis 1
• Cholestyramine works by binding bile salts in the gut lumen, preventing their absorption in the terminal ileum 1
• Important: Cholestyramine should be taken separately from other medications (especially UDCA) by at least 4 hours to prevent binding and loss of efficacy 1
• Poor taste tolerance can be a problem, which may be addressed by flavoring with fruit juice 1

Second-Line Treatment

• Rifampicin is recommended as second-line therapy when cholestyramine fails or is not tolerated 1
• Start at 150mg daily with monitoring of liver function tests, and increase gradually to a maximum of 600mg daily if needed 1
• Rifampicin has strong evidence supporting its efficacy in reducing hepatic pruritus 1
• Important precautions:
  • Monitor for hepatotoxicity as drug-induced hepatitis has been reported in up to 12% of cholestatic patients after 2-3 months of treatment 1, 2
  • Inform patients about discoloration of urine, tears, and other body secretions 1

Third-Line Treatment

• Naltrexone (an oral opiate antagonist) at a dose of 50mg daily should be considered as third-line treatment 1
• Start at a low dose of 25mg to minimize opiate withdrawal-like reactions 1
• Naltrexone should only be considered after proven lack of efficacy, intolerance, or side effects with cholestyramine and rifampicin 1
• Long-term tolerability can be an issue, with many patients experiencing ongoing opiate withdrawal-like reactions or reduced threshold to pain 1

Fourth-Line Treatment

• Sertraline (75-100mg daily) may be considered for patients resistant to the above treatments 1
• Sertraline presumably acts by altering neurotransmitter concentrations within the central nervous system 1
• Side effects include dry mouth, which patients should be warned about 1

Additional Therapeutic Options for Refractory Cases

• For patients resistant to standard therapies, consider:
  • Selective serotonin reuptake inhibitors (SSRIs) other than sertraline 1
  • Experimental physical approaches in specialized centers:
    • Extracorporeal albumin dialysis 1
    • Plasmapheresis 1
    • Bile duct drainage 1
    • Ultraviolet (UV) light therapy 1
• Liver transplantation is highly effective for controlling cholestatic itch but should only be considered when all available interventions have proven ineffective 1

Treatments to Avoid or Use with Caution

• Gabapentin has been suggested but a small trial failed to show benefit over placebo; not recommended for hepatic pruritus 1
• Antihistamines have limited efficacy for cholestatic pruritus but may provide non-specific relief through sedative properties; they are not recommended as specific therapy but may be useful adjuncts for some patients 1, 3
• Ondansetron has shown inconsistent results in clinical trials and is not routinely recommended 1

Monitoring and Follow-up

• Use visual analogue scales to help assess response to interventions 1
• Monitor liver function tests regularly when using rifampicin due to risk of hepatotoxicity 2
• Evaluate for presence of dominant biliary strictures in patients with worsening pruritus, increasing bilirubin levels, or progressive bile duct dilation on imaging 3

Special Considerations

• In patients with obstructive jaundice, addressing the underlying obstruction (via ERCP with biliary drainage/stent placement) should be considered as part of the management approach 3
• For patients with primary biliary cirrhosis, ursodeoxycholic acid (UDCA) at 10-15 mg/kg/day is recommended for the underlying disease but may not directly improve pruritus 3