Pruritus is common in PBC, PSC, intrahepatic cholestasis of pregnancy and hepatitis C virus infection. We usually attribute the symptom to accumulation of bile salts in the plasma and tissues of patients, however, there may be other causes. These include excess endogenous opioid production, as well as the presence of lysophosphatidic acid (LPA- a potent neuronal activator) and autotaxin (the enzyme responsible for the formation of LPA).
These other pathways may explain with cholestyramine does not work for all patients. That said, let’s review the treatment options and their side effect profile:
1. Cholestyramine- nausea, bloating, constipation.
1a. Sarna Anti-itch Lotion- none I can think of…
2. Rifampicin- acute hepatitis (10-15%)
3. Opioid antagonists (naloxone, naltrexone)- withdrawal-like symptoms
4. Sertraline- dry mouth, anxiety, drowsiness, nausea, constipation.