From the Guidelines
Treatment for mild sclerosing cholangitis should prioritize managing symptoms and slowing disease progression, with a focus on improving quality of life and reducing morbidity and mortality. The primary goal is to alleviate symptoms such as pruritus, which can significantly impact quality of life. According to the most recent and highest quality study, bezafibrate is recommended as the first-line pharmacological treatment for moderate to severe pruritus in sclerosing cholangitis 1. This is based on the results of the FITCH trial, which showed a clear benefit of bezafibrate in alleviating moderate to severe itch in people with primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) treated with ursodeoxycholic acid (UDCA) 1.
Key considerations for managing mild sclerosing cholangitis include:
- Using emollients to prevent dryness of skin
- Avoiding hot baths or showers
- Using cooling gels (e.g., menthol gels) for affected skin areas
- Keeping nails shortened
- Considering bezafibrate as the first-line treatment for pruritus, with rifampicin as a potential second-line option 1
- Regular monitoring with liver function tests every 3-6 months to track disease progression
It is essential to note that the evidence for the antipruritic effectiveness of anion exchange resins, such as cholestyramine, is limited in sclerosing cholangitis, and they may impair the absorption of various medications, including UDCA 1. Therefore, bezafibrate is the preferred treatment option for pruritus in mild sclerosing cholangitis, due to its sustained antipruritic effect and strong additive anticholestatic effects in combination with UDCA 1.
From the Research
Treatment for Mild Sclerosing Cholangitis
The treatment for mild sclerosing cholangitis, specifically primary sclerosing cholangitis (PSC), is primarily focused on managing symptoms and slowing disease progression.
- Ursodeoxycholic acid (UDCA) is widely used to improve biochemical parameters of cholestasis and is considered safe at low doses 2, 3, 4, 5.
- High-dose UDCA treatment may improve serum liver tests but does not improve survival and is associated with increased rates of serious adverse events 6.
- Endoscopic interventions, such as balloon dilatation, biopsy, and brush cytology, are limited to clinically relevant strictures 4, 5.
- Liver transplantation is considered for end-stage liver disease with decompensation, although PSC can recur in up to 38% of patients 5.
Ongoing Research and Future Directions
Several novel therapeutic strategies are being developed, including:
- Apical sodium-dependent bile acid transporter and ileal bile acid transporter inhibitors
- Integrin inhibitors
- Peroxisome proliferator-activated receptor agonists
- CCL24 blockers
- Recombinant FGF19
- CCR2/CCR5 inhibitors
- Farnesoid X receptor bile acid receptor agonists
- Nor-ursodeoxycholic acid
- Manipulation of the gut microbiome, including faecal microbiota transplantation 5.