Management of pruritus of PBC/biliary tract obstruction

Pruritus associated with cholestasis secondary to primary biliary cirrhosis is managed with the following:

• as first line treatment - cholestyramine, 4-8 g daily, taken at least 1 hour before or 4-6 hours after other medication (1). Cholestyramine may reduce the absorption of vitamin D and so worsen osteomalacia.
• Rifampicin should be considered as a second-line treatment option although discolouration of urine, tears and other body secretions is seen during treatment (1).
• Naltrexone is regarded as the third line treatment option
• for patients who are resistant to above treatment methods, Sertraline may be used as fourth line treatment (1).

Use of ursodeoxycholic acid (UDCA) has been beneficial in cholestatic itch due to intrahepatic cholestasis of pregnancy (1).

Cholestyramine may reduce the absorption of vitamin D and so worsen osteomalacia. Consider UV light treatment or plasmapheresis, which also benefits xanthomata and xanthomatous neuropathy.

Cholestatic itch due to obstructive bile duct lesions is managed with either endoscopic, radiological or surgical correction treatment (1).

Reference:

• (1) European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol. 2009;51(2):237-67