From the Guidelines
The most effective treatment for pruritus in cholestatic liver disease is bezafibrate, which has been shown to alleviate moderate to severe itch in people with primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) treated with ursodeoxycholic acid (UDCA) 1.
Treatment Options
- Bezafibrate is recommended 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 and strong additive anticholestatic effects in combination with UDCA 1.
- Rifampicin is considered a second-line treatment, but it may induce drug-induced hepatitis after 4-12 weeks in up to 12% of cholestatic patients, and its use should be monitored closely 1.
- Cholestyramine, a non-absorbable anion exchange resin, is no longer recommended as a first-line treatment due to limited evidence for its effectiveness in sclerosing cholangitis and potential interference with the absorption of other medications, such as UDCA 1.
Key Considerations
- Pruritus can significantly impair quality of life in patients with cholestatic liver disease, and effective treatment is essential to alleviate symptoms and improve patient outcomes.
- The molecular pathogenesis of cholestatic pruritus is not fully understood, but recent studies have shed light on the potential mechanisms involved, including the role of the ileal apical sodium bile salt transporter (ASBT) and selective PPARα or PPARδ agonists 1.
- Novel medical antipruritic strategies, such as non-absorbable inhibitors of ASBT and selective PPARα or PPARδ agonists, may offer alternative treatment options in the future, but further research is needed to determine their effectiveness and tolerability.
From the Research
Allergic Reactions
- Anaphylaxis is characterized by the sudden onset of acute allergic symptoms involving two or more organ systems 2
- The incidence of anaphylactic reactions has increased in recent years, with most frequent elicitors being food, insect venom, or drugs 2, 3
- Allergic reactions are graded into four groups according to the classification by Ring and Messmer, with grade I being cutaneous symptoms only and grade IV being cardiovascular shock and cardiac and/or respiratory arrest 2, 3
Treatment of Allergic Reactions
- The treatment of allergic reactions should be guided by the severity of the reaction, with initial treatment including an intramuscular epinephrine injection into the lateral thigh 2, 3
- Additionally, patients should receive intravenous antihistamines and corticosteroids, and oral antihistamines and corticosteroids should be prescribed for self-treatment in the case of an allergic emergency 2
- Adrenaline can also be nebulized or given intravenously in severe cases, and fluid resuscitation with balanced electrolyte solutions and high-flow oxygen are also fundamental 3
Diagnosis and Management
- A reliable diagnostic marker for anaphylaxis is elevated serum tryptase, and symptoms usually affect four organ systems: skin, gastrointestinal tract, respiratory tract, and cardiovascular system 3
- Post-crisis management includes patient education, allergy identification, and an emergency kit with an adrenaline auto-injector 3
- Emergency physicians should have a good understanding of various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment 4