Cholestatic itch in palliative care
For patients with palliative care needs, the most effective treatment for cholestatic itch is endoscopic or percutaneous biliary drainage or stenting to relieve the obstruction. If such treatment is not possible or appropriate, drug therapy may be tried in addition to general skincare measuresKouwenhoven, 2017Siemens, 2016Yosipovitch, 2010. Suitable regimens are:
1rifampicin 150 mg orally, at night; increase if necessary and as tolerated to 150 mg twice daily after 1 week or sooner if itch is severe. Maximum daily dose 600 mgScottish Palliative Care Guidelines, 2020 Howard, 2015Wilcock A, 2020 rifampicin
OR
1sertraline 50 mg orally, daily; increase if necessary and as tolerated up to 100 mg daily after 2 weeksMayo, 2007Scottish Palliative Care Guidelines, 2020. sertraline
If itch persists despite the above therapy, see Undifferentiated or other causes of itch in palliative care for management.
Colestyramine has been used for cholestatic itch, but it is poorly tolerated and evidence to support its use in palliative care is limited. Ondansetron is no longer recommended. Gabapentin and pregabalin are not beneficial for cholestatic itch; gabapentin may even worsen it.
Ultraviolet B phototherapy can be effective for cholestatic itch but the burden of treatment is significant (administered 3 times a week) and ongoing therapy becomes impractical at the end of lifeDecock, 2012.
For other aspects of palliative care for patients with liver disease, see Principles of palliative care for patients with chronic liver disease.