Tips for Controlling Pruritus Berheктиcum Capitis, a Common Scalp Condition
Primary Biliary Cholangitis (PBC) is a condition that can cause fatigue and brain fog, and one of its most distressing symptoms is the itch known as "cholestatic pruritus." This itch is a result of bile duct disease.
Healthcare providers manage PBC itch using a stepwise approach, starting with less intensive therapies and moving on to more intensive ones as needed.
Ursodeoxycholic acid (UDCA) is a first-line treatment for PBC. It improves bile flow and reduces bile acid toxicity, helping to slow disease progression and partially alleviate itch indirectly by lessening bile acid buildup.
Obeticholic acid, on the other hand, is used when UDCA alone is insufficient. It activates the FXR receptor in the liver, reducing bile acid synthesis and accumulation to prevent bile buildup that can cause itch. However, it's important to note that Obeticholic acid can make itch worse in some people with PBC.
Antihistamines are sometimes prescribed to relieve itching symptomatically, although histamine is not the primary cause of itch in PBC. These provide symptomatic relief rather than addressing bile acid toxicity.
Ileal bile acid transporter (IBAT) inhibitors, such as linerixibat, block bile acid reabsorption in the gut, increasing bile acid excretion in feces. This reduces circulating bile acids, which are thought to cause itch, thus directly targeting the pruritus mechanism. IBAT inhibitors are a newer class of medication undergoing clinical trials for PBC, aiming to reduce the amount of bile in the body and potentially lessen itch.
Bile acid sequestrants, such as cholestyramine, bind bile acids in the intestine to prevent reabsorption, reducing bile acid levels linked to itch.
PPAR agonists are a recent class shown to help reduce itching by modulating liver metabolism and inflammation, though the exact mechanism on itch is under study.
Other emerging drugs, including NOX inhibitors like setanaxib and newer second-line agents such as elafibranor and seladelpar, are under investigation for their ability to improve liver function and potentially reduce itch, mostly through anti-inflammatory and metabolic effects rather than direct anti-itch action.
Naltrexone, an opioid antagonist, is a 3rd-line agent used to counteract central opioid pathways related to itching in PBC.
It's worth noting that the itch associated with PBC is often worse at night and is not associated with a rash or allergies. It typically affects the palms of hands and soles of feet, but can be all over.
Rifampicin is a 3rd-line agent for managing PBC itch, acting as a potent enzyme inducer that reduces circulating pruritogens like bile.
IBAT inhibitors have been approved for use in other pediatric bile duct diseases, such as Alagille's syndrome.
It's important to remember that everyone's response to these treatments can vary, and it's crucial to discuss treatment options with a healthcare provider.
In summary, the main strategy is to reduce bile acid accumulation or modulate liver inflammation to alleviate pruritus. Traditional therapies like UDCA and obeticholic acid improve bile flow and reduce bile acid levels, while new treatments like IBAT inhibitors directly increase bile acid excretion to lessen itch. Symptomatic relief with antihistamines may be used adjunctively.
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