Intractable pruritus in cholestatic jaundice: Treatment by plasma-exchange and plasma-perfusion

Plasmapheresis for Refractory Pruritus due to Drug-Induced Cholestasis

“…More invasive measures like plasmapheresis and extracorporeal liver dialysis with molecular adsorbent recirculating system (MARS) have been used effectively in cases of severe refractory pruritus not amenable to conventional management [4, 5, 6, 7, 8, 9, 10, 14, 15]. There have been only 2 reports in the literature of intractable pruritus due to drug-induced cholestasis managed by extracorporeal albumin dialysis using MARS but none with plasmapheresis [14, 15].…”

“…Bile salts, endogenous opioids, serotonin, and lysophosphatidic acid have been implicated in the pathogenesis of pruritus [2, 3]. Plasmapheresis has been described in the literature as a safe and rapidly effective treatment for intractable pruritus due to cholestasis of PBC, PSC, and ICP [4, 5, 6, 7, 8, 9, 10]. We report a case of refractory pruritus due to drug-induced cholestasis, not improved with withdrawal of the offending drug, managed effectively by plasmapheresis.…”

Critical updates in the 7th edition of the American Society for Apheresis guidelines

“…Treatment with cholestyramine reduces pruritic stimulus, whereas treatment with the latter three modulates signaling of itching/pain . Stents can be placed to enhance drainage, or TPE can be performed in patients that are unresponsive to medications . In the severest cases, liver transplantation may be considered …”

Plasma separation and anion adsorption transiently relieve intractable pruritus in primary biliary cirrhosis

“…Current therapeutic interventions for cholestatic pruritus are thus directed towards elimination or inactivation of putative peripheral pruritogens by anion exchange resins such as cholestyramine and colestipol or enzyme-inducing agents such as rifampicin or modulation of altered central neurotransmission by opioid or serotonin receptor antagonists [3]. In patients who do not respond to medical therapies, invasive procedures, such as nasobiliary drainage or partial external diversion of bile [4][5][6][7], ileal diversion [8], hemodialysis [9], charcoal hemoperfusion [10], plasmapheresis and plasma perfusion [11][12][13], and extracorporeal albumin dialysis [14,15] have been tried in small numbers of patients.…”