Management of Pruritus in Chronic Liver Disease

Bhalerao, Angeline; Mannu, Gurdeep

doi:10.1155/2015/295891

Cited by 30 publications

(19 citation statements)

References 34 publications

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“…Support for this theory comes from the fact that application of bile acids to the skin causes itch 7 , 8 and one study has suggested that cholestatic pruritus is mediated by the bile acid-activated receptor, the G-protein-coupled receptor, TGR5, expressed by peptidergic neurons of mouse dorsal root ganglia and spinal cord 10 . It is well known that pruritus can be profoundly debilitating; orthotopic liver transplantation may be the only option for severe and intractable pruritus 11 . Further investigations are warranted into the causative mechanism and optimal treatment of cholestatic pruritus.…”

Section: Introductionmentioning

confidence: 99%

Manual acupuncture relieves bile acid-induced itch in mice: the role of microglia and TNF-α

Lee¹,

Lin²,

Hung³

et al. 2018

Int. J. Med. Sci.

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Pruritus, or itch, is a frequent complaint amongst patients with cholestatic hepatobiliary disease and is difficult to manage, with many patients refractory to currently available antipruritic treatments. In this study, we examined whether manual acupuncture (MA) at particular acupoints represses deoxycholic acid (DCA)-induced scratching behavior and microglial activation and compared these effects with those induced by another pruritogen, 5'-guanidinonaltrindole (GNTI, a kappa opioid receptor antagonist). MA at Hegu (LI4) and Quchi (LI11) acupoints significantly attenuated DCA- and GNTI-induced scratching, whereas no such effects were observed at the bilateral Zusanli acupoints (ST36). Interestingly, GNTI-induced scratching was reduced similarly by both MA and electroacupuncture (EA) at the LI4 and LI11 acupoints. MA at non-acupoints did not affect scratching behavior. Intraperitoneal injection of minocycline (a microglial inhibitor) reduced GNTI- and DCA-induced scratching behavior. In Western blot analysis, subcutaneous DCA injection to the back of the neck increased spinal cord expression of ionized calcium-binding adapter molecule 1 (Iba1) and tumor necrosis factor-alpha (TNF-α) as compared with saline injection, while MA at LI4 and LI11 reduced these DCA-induced changes. Immunofluorescence confocal microcopy revealed that DCA-induced Iba1-positive cells with thicker processes emanated from the enlarged cell bodies, while this effect was attenuated by pretreatment with MA. It is concluded that microglia and TNF-α play important roles in the itching sensation and MA reduces DCA-induced scratching behavior by alleviating spinal microglial activation. MA may be an effective treatment for cholestatic pruritus.

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Section: Introductionmentioning

confidence: 99%

Manual acupuncture relieves bile acid-induced itch in mice: the role of microglia and TNF-α

Lee¹,

Lin²,

Hung³

et al. 2018

Int. J. Med. Sci.

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“…In our case, UDCA was not successful, and neither was the insertion of an NB tube. NB tubes have been used with success in severe cholestasis but mainly in the context of congenital aetiologies and in particular in those with low GGT cholestasis 17. Our patient had a low normal GGT level initially, a typical feature of congenital cholestasis, hence an NB tube insertion was attempted while the genetic results were pending.…”

Section: Discussionmentioning

confidence: 95%

Successful liver transplantation for drug-induced vanishing bile duct syndrome

et al. 2020

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Drug-induced cholestasis has a wide range of clinical presentations, and in a small number of patients, it can progress to severe ductopenia. A 63-year-old woman was referred to our department with progressive cholestasis and hyperbilirubinaemia following a course of flucloxacillin. Despite the comprehensive laboratory, imaging and genetic investigations, no other cause for the cholestasis was demonstrated. Sequential liver biopsies confirmed the development of vanishing bile duct syndrome. She developed significant cachexia and pruritus that did not respond to medical therapy, and hence she was listed for liver transplantation. She underwent liver transplantation 6 months after the initial drug-induced injury. She has remained well with good graft function at 1-year follow-up. The case highlights an extreme form of drug-induced ductopenia and underscores the need for meticulous hepatology input and consideration of liver transplantation in some patients.

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“…Pruritus can be a severe, debilitating symptom of PBC, and can be exacerbated by treatment with OCA 19 20. If the pruritus is not well managed, treatment of PBC can be challenging; in some patients, pruritus can be an impediment to the effective use of OCA 22.…”

Section: Managing Pruritus In Patients With Pbcmentioning

confidence: 99%

“…Patients with PBC may be asymptomatic or present with a variety of symptoms, most commonly fatigue and/or pruritus 2 17. Pruritus, or itchy skin, affects up to 70% of patients with PBC and can interfere with daily life; because it is often worse at night, pruritus may prevent or disrupt sleep, increasing fatigue and affecting patient quality of life (QoL) 18–20. PBC-related pruritus often manifests in the limbs, causing itch on the palms and feet, as well as on the arms and legs 19.…”

Section: Introductionmentioning

confidence: 99%

“…It can range from mild to severe and can intensify in warmer temperatures 19. Of note, up to three-quarters of patients affected by PBC-related pruritus report this symptom prior to diagnosis 20 21. In some patients, OCA treatment is associated with increased pruritus, which may be managed with lifestyle changes and a variety of treatments 22.…”

Section: Introductionmentioning

confidence: 99%

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Practical strategies for pruritus management in the obeticholic acid-treated patient with PBC: proceedings from the 2018 expert panel

Pate

Gutierrez²,

Frenette

et al. 2019

BMJ Open Gastroenterol

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Background and aimsThis article provides expert guidance on the management of pruritus symptoms in patients receiving obeticholic acid (OCA) as treatment for primary biliary cholangitis (PBC). PBC is a chronic, autoimmune cholestatic liver disease that affects intrahepatic bile ducts. If not adequately treated, PBC can lead to cholestasis and end-stage liver disease, which may require transplant. Timely treatment is therefore vital to patient health. Pruritus is a common symptom in patients with PBC. Additionally, the use of OCA to treat PBC can contribute to increased pruritus severity in some patients, adding to patient discomfort, decreasing patient quality of life (QoL), and potentially affecting patient adherence to OCA treatment.MethodsIn May 2018, a group of physician experts from the fields of gastroenterology, hepatology, and psychiatry met to discuss the management of pruritus in OCA-treated patients with PBC. Recognizing the importance of optimizing treatment for PBC, these experts developed recommendations for managing pruritus symptoms in the OCA-treated PBC patient based on their experience in clinical practice.ResultsThese recommendations include a comprehensive list of management strategies (including over-the-counter, prescription, and alternative therapies), guidance on titration of OCA to minimize pruritus severity, and an algorithm that outlines a practical approach to follow up with patients receiving OCA, to better assess and manage pruritus symptoms.ConclusionsPruritus associated with OCA therapy is dose dependent and often manageable, and with the proper education and tools, most pruritus cases can be effectively managed to minimize treatment discontinuation.

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Management of Pruritus in Chronic Liver Disease

Cited by 30 publications

References 34 publications

Manual acupuncture relieves bile acid-induced itch in mice: the role of microglia and TNF-α

Manual acupuncture relieves bile acid-induced itch in mice: the role of microglia and TNF-α

Successful liver transplantation for drug-induced vanishing bile duct syndrome

Practical strategies for pruritus management in the obeticholic acid-treated patient with PBC: proceedings from the 2018 expert panel

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