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

2. 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

3. 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.
Kaplan, et al. Am J Gastroenterol May; 102(5):

4. Burden of Pruritus Emotional Economic (job related) Sleep
Psychological

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

6. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

7. 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

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

9. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

10. 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

11. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

12. 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

13. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

14. 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

15. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

16. 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

17. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

18. 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

19. Treatment Options Cholestyramine Ursodeoxycholic acid Rifampicin
Naltrexone
Sertraline
Alternative treatments

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

21. Thank you!