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Therapeutic Approach

Patients with hepatobiliary diseases with and without cholestasis experience frequently excruciating pruritus. Acquired (eg, primary biliary cholangitis and primary sclerosing cholangitis) and congenital diseases (such as Alagille syndrome) as well as intrahepatic cholestasis of pregnancy are commonly associated with pruritus, but other hepatic disorders may also lead to pruritus. Pruritus begins on normal appearing skin usually on the palms and soles, but may affect the whole body in the course of the disease. Excoriations, lichenification of the skin, and pruriginous lesions may develop due to scratching. Therapeutically, several pharmacological and procedural options are currently available; however, high-quality clinical trials are still scarce. The European Association for the Study of the Liver (EASL) recommends cholestyramine as first-line treatment for cholestatic itch, followed by rifampicin as a second-line option. Oral or intravenous opiate antagonists (naltrexone, naloxone) are regarded as third-line agents, while sertraline constitutes a further therapy option. See Table 20-1.

Table 20-1Cholestatic Pruritus Treatment Table

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