What are the treatment options for cholestatic pruritus?

Answer

Cholestyramine is the first-line therapy, followed by rifampin and opioid antagonists. Ondansetron may also be tried. Cholestyramine has only been show effective in a few randomized studies, but this drug is thought to be helpful in relieving pruritus. Because of its low cost, it should be tried before more expensive treatments are considered.

Rifampin, a hepatic enzyme inducer, is effective for pruritus of cholestasis. Caution should be used in patients with preexisting liver disease because of possible hepatotoxicity.^{[44, 45]}

Opioid antagonists, including naloxone, may relieve pruritus, but intravenous administration limits its use outside the hospital setting. Oral naltrexone is also effective.^{[46, 47, 48, 49]}Oral nalmefene has been tested and is effective but may only be available in intravenous form.^[50]To prevent opioid withdrawal syndrome, low starting doses should be used. These drugs should not be used in patients in need of palliative opioid treatment. Butorphanol, which antagonizes the mu receptor but agonizes the kappa receptor, has been shown to be effective in suppressing cholestatic pruritus.^[42]

Ursodeoxycholic acid and S-adenosyl-L-methionine have both been reported to decrease pruritus in women with cholestasis of pregnancy, but ursodeoxycholic acid may improve fetal outcomes and biochemical serum markers.^{[51, 52]}

Extracorporeal albumin dialysis may be considered when severe pruritus is refractory to other therapies.^{[53, 54]}

Ondansetron has limited effectiveness and, because it relieves opioid-induced pruritus, it appears to affect opioid pathways.

Stanozolol relieves pruritus; however, it worsens cholestasis and is not recommended.

Removal of the offending agent should be initiated in patients with drug-induced cholestasis.

Other therapies that may be effective are thalidomide, infused propofol, serotonin-selective reuptake inhibitors, UV-B, phenobarbital, dronabinol, and bright-light therapy indirectly reflected toward the eyes.

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