Treatment of pruritus in cholestasis

Pruritus can be a major problem in patients with cholestasis especially those with primary biliary cirrhosis. The aetiology and pathophysiology of pruritus remain largely unknown. The treatment can be broadly divided into first and second line agents. Cholestyramine is the best first line drug and is believed to act as a bile salt binding agent reducing the body pool of bile acids. Antihistamines are also useful and much of their benefit is due to their sedative properties. Second line treatments include phenobarbitone, rifampicin, anabolic steroids, opioid antagonists, plasmaphoresis and ultraviolet phototherapy. However, the potential side-effects of some of these agents limit their use. Althought recent encouraging results have been reported with ursodeoxycholic acid which is thought to induce beneficial qualitative changes in the endogenous bile acid pool and reduce the concentration of toxic bile salts, further trials demonstrating its efficacy are awaited. It is likely that a better understanding of the complex mechanism of pruritus in cholestasis will help in the future development of effective antipruritic agents.