Managing the Itch Alok Vij, MD Department of Dermatology Cleveland Clinic Foundation June 24, 2017

Disclosures I have no financial relationships with any company I do discuss off-label use of medications I do discuss branded over-the-counter products

Symptoms in PSC Symptom Frequency Fatigue 50-75% Pruritus 40-70% Jaundice 9-69% Abdominal pain 16-60% Weight loss 10-34% Fevers and chills 5-28% Hyperpigmentation 25% None 15-55% Itching, or pruritus, is one of the most common symptoms in PSC, more common than jaundice, abdominal pain, weight loss. https://www.nature.com/ajg/journal/v102/n5/full/ajg2007195a.html Kaplan, et al. Am J Gastroenterol. 2007 May; 102(5): 1042-9.

Burden of Pruritus Emotional Economic (job related) Sleep Psychological

Why do I itch? Histamine (?) Bile acids Endogenous opioids Serotonin Autotaxin

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Sensitive Skin Care Bathe with warm instead of hot water “Sensitive skin” soaps with no fragrance, dyes, preservatives Dove Sensitive Skin, Vanicream, Cetaphil Gentle Cleansing Antibacterial Bar Shorter rather than long showers Moisturize before your skin dries Aveeno, Eucerin, Cerave Break the “itch-scratch” cycle Sarna, Gold Bond, Aveeno Skin Relief

Antihistamines Topical or oral antihistamines aren’t very effective for managing the itch of PSC Sedating antihistamines like diphenhydramine (Benadryl) are helpful for sleep

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Cholestyramine Binds with bile salts in the intestine to prevent re-absorption of bile salts Reduces the amount of circulating bile salts Start with one dose twice a day and increase to a max of six doses a day All other medications should be taken one hour before and four hours after taking

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Ursodeoxycholic acid One of the most commonly used medications for PSC Reduces absorption of cholesterol, stimulates bile secretion Useful (safe) in pregnancy Urso might not be as helpful for itching as we previously thought

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Rifampicin Activate pregnane X receptors (PXRs), which increase excretion and metabolism of bile acids Inhibits activation of autotaxin pathway May work better when used with urso Changes metabolism of other medications, so those doses may have to be adjusted Need to monitor blood work, especially liver and kidney tests

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Naltrexone Blocks itch signals in brain by blocking an opioid receptor Can also block the effect of opioid pain medications “Low dose naltrexone” is a hot topic in dermatology and deserves further study for itch Doses low enough not to interfere with pain medications

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Sertraline “Selective serotonin reuptake inhibitor” (SSRI), one class of anti-depressant Serotonin is a neuroendocrine hormone synthesized in the brain and GI tract In liver diseases, enhanced release of serotonin in the brain causes itching and fatigue Altering effect of serotonin changes perception of itch

Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin Naltrexone Sertraline Alternative treatments

Alternative treatments MEDICATIONS NON MEDICATIONS Gabapentin Dronabinol Aprepitant Yin chen hao (wormwood or Artemisia capillaris) Exercise Capsaicin Accupuncture

Thank you!