Cholestatic itch in patients with liver disease
For management of cholestatic itch in the palliative care setting, see Cholestatic itch in palliative care. For management of itch due to intrahepatic cholestasis of pregnancy, see Intrahepatic cholestasis of pregnancy.
Itch can be a debilitating symptom in some patients with cholestatic liver disease, regardless of its aetiology. Optimal treatment of the underlying cause of cholestatic liver disease is the most effective therapy. General skin care measures (eg wearing loose-fitting clothing, use of emollients and soap substitutes) may also be helpful.
For adults with cholestatic itch, if symptoms do not improve, consider:
colestyramine 4 to 16 g orally, daily (in up to four divided doses). itch, cholestatic colestyramine
All other drugs should be taken at least 1 hour before, or 4 to 6 hours after colestyramine.
If colestyramine is ineffective, add:
ursodeoxycholic acid 13 to 15 mg/kg orally, daily (in a single or divided dose)12. itch, cholestatic ursodeoxycholic acid
Ursodeoxycholic acid can paradoxically worsen itch in some patients.
Colestyramine and ursodeoxycholic acid should not be taken at the same time of day because they bind together in the intestine, significantly reducing the absorption of ursodeoxycholic acid.
If itch persists despite treatment with colestyramine and ursodeoxycholic acid, rifampicin may be beneficial—seek expert advice. Monitor liver biochemistry in patients taking rifampicin because it can cause liver injury.
Other drugs that have been used for cholestatic itch include sertraline, opioid antagonists (naltrexone, naloxone), pregabalin and antihistamines; however, data on their effectiveness are limited and they should only be prescribed in specialist centres. Severe, refractory itch may be an indication for liver transplant.