The Evolution of Pruritus Management for People with Primary Biliary Cholangitis

Abstract

Primary biliary cholangitis (PBC) is a progressive, immune-mediated liver disease that can be chronic and, in some cases, fatal. Cholestatic pruritus is a common symptom of PBC; however, it is consistently underassessed and undertreated. The pruritus can be moderate to severe, and persistent over years. Patients can experience changes in severity over the course of the day, with pruritus often being most troublesome in the evening and at night. Occurrence is associated with sleep disturbance, leading to daytime fatigue and mood disorders, as well as having a huge impact on health-related quality of life (HRQoL). Assessment of cholestatic pruritus should be carried out by healthcare professionals (HCP) at every consult with a patient with PBC to ascertain occurrence, severity, and the effect on HRQoL. Severity assessment can be carried out using a simple 0–10 numerical rating, or visual analogue scale, and the patient’s quality of life can be assessed with more involved measures, such as the PBC-40 tool. Patients can also track changes in symptoms over time on dedicated phone apps, and share these data at consults. Treatment for PBC is primarily with ursodeoxycholic acid (UDCA); however, this drug has not been shown to significantly improve cholestatic pruritus. Guidelines recommend anion-exchange resins as first-line treatment for pruritus, with pregnane X receptor agonists, oral opiate antagonists, and selective serotonin reuptake inhibitors also suggested as second/third-line treatment. Of note though, few of these have been specifically licensed for cholestatic pruritus and clinical trial data supporting their use remain limited. Other measures include training patients to stop the itch-scratch-itch cycle and the use of moisturising and/or cooling creams. At the American Association for the Study of Liver Diseases (AASLD) 2023 Liver Meeting in Boston, Massachusetts, USA, two HCPs with expertise in PBC, along with a patient representative, discussed these aspects of cholestatic pruritus, and how patients with this symptom can be recognised, assessed, and helped.