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Cholestatic Pruritus

CME

The Impact of Cholestatic Pruritus in PBC

Physicians: Maximum of 0.75 AMA PRA Category 1 Credit™

Released: June 18, 2024

Expiration: June 17, 2025

Christopher L. Bowlus
Christopher L. Bowlus, MD
CME/CE Information

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Symptoms Experienced by People With PBC1-5

Pruritus is one of the most common symptoms that people with PBC experience; up to 70% of patients with PBC will report pruritus of varying degrees from mild to debilitating and severe, similar to the frequency and variability of the symptoms of fatigue and brain fog.

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Cholestatic Pruritus

Cholestatic pruritus is defined as itch due to cholestasis—impairment or interruption in the flow of bile. This can occur in patients with or without jaundice.

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Conditions Associated With Cholestatic Pruritus6-8

Although cholestatic pruritus is common in PBC, it also occurs in several other cholestatic diseases, including enterohepatic cholestasis of pregnancy and other conditions that cause interruption of bile flow.

We do see itch in other chronic liver diseases, such as chronic viral hepatitis and cirrhosis, but the frequency and intensity of pruritus in these other disease states tends to be much less than in PBC.

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Mechanisms of Cholestatic Pruritus9,10

The mechanism of cholestatic pruritus is not completely understood. The theory is that the pruritus is due to a pruritogen (or pruritogens) that activates different neural pathways, leading to the sensation of itch and the behavior of scratching, but the exact pruritogen (or pruritogens) is not clear.

Bile acids have long been the proposed pruritogen, but the correlation between serum levels of bile acids and severity of pruritus is not that strong, making us think other pruritogens may be involved.

The pruritogens may be acting directly at the level of the skin and the neural receptors at the skin, sending a signal up the spinal cord and into the brain, signaling the itch sensation.

Other actors in the spinal cord, such as opioid receptors, or within the brain, such as serotonin receptors, may be responsible for creating the itch sensation.

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Health Utility of Cholestatic Pruritus

The burden of cholestatic pruritus on patients with PBC is substantial.11

It has been associated with significant impairment of health-related quality of life, and the degree of its negative impact has been shown to be comparable to the level of impairment in patients with severe Parkinson’s disease.11,12 It is a symptom whose impact we should not dismiss.

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Impact of Pruritus on Quality of Life13,14

The symptoms of pruritus and fatigue are interrelated.

Pruritus, particularly that which is moderate to severe, can lead to sleep deprivation because pruritus tends to be worse at night. This can then lead to worsening fatigue, which can cause or exacerbate depression and an inability to do one’s work or activities of daily living, which can lead to further sleep deprivation. In some cases, it can lead to suicidal ideation.

Understanding and treating PBC-related pruritus can have positive impacts on other symptoms that our patients with PBC experience.

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