Given the multitude of proposed pathways for cholestatic pruritus, there are numerous therapeutic agents that are being used to treat pruritus, but with very limited success. Given the impact of pruritus on quality of life, finding an effective agent to control this symptom is an active area of research with a number of clinical trials evaluating novel agents. Below, we will discuss evidence behind the various available treatment options for cholestatic pruritus and review emerging therapies.
Bile Acid Resins
Bile acid resins are the first-line therapy often used for patients experiencing cholestatic pruritus per the American Association for the Study of Liver Disease’s (AASLD) PSC and PBC management guidelines [
41]. This class of medications works by binding bile acids which creates an insoluble compound that cannot be reabsorbed in the ileum and is excreted as waste with feces. This decreases the buildup of serum bile acids, preventing excess bile acids from translocating to the skin which theoretically decreases activation of TGR5, preventing skin irritation and pruritus [
42].
Cholestyramine is a bile acid resin that is commonly used to treat pruritus due to the availability of evidence on its efficacy from randomized control trials. Two large, randomized control trials (RTC) were done in 1984 that evaluated cholestyramine at doses of 4 g twice a day and 3 g three times a day. Both of these trials found that pruritus was significantly decreased compared to the placebo based on cumulative pruritus scores. Based on these findings, cholestyramine has been used since and is currently the first-line therapy [
43,
44].
However, since the publication of these two large RCTs, a different RCT was published in 2010 that examined the use of colesevelam on cholestatic pruritus. This study found that colesevelam decreased serum bile acid levels but did not actually demonstrate a reduction in pruritus among the 38 participants. Both the placebo group (36%) and the treatment group (35%) had similar percentages of participants reaching the primary endpoint of a 40% reduction in visual analogue scale score [
45]. It should also be noted that cholestyramine is often not well tolerated due to its side effects of constipation and bloating. Furthermore, if not taken correctly, it can decrease the absorption of other medications, which limits its usability.
Rifampin
Rifampin is one alternative therapy for pruritus refractory to cholestyramine and other agents. While initially used as a medication for tuberculosis, it has also been discovered to decrease pruritus. The mechanism is thought to be secondary to rifampin’s interaction with PXR. By activating PXR, there is a reciprocal decrease of ATX in hepatocytes. This means there is decreased production of LPA and decreased activation of calcium channels (TRPA1 and TRPV1) leading to decreased axon stimulation and decreased pruritus [
46].
Rifampin has multiple studies that support its use for cholestatic pruritus. The first study that supported rifampin was in 1988 and consisted of only 9 patients with PBC who were treated with varying doses. Rifampin was also administered with cholestyramine in this study and 8 out of 9 patients reported preferring rifampin use for pruritus control as opposed to the placebo. After this initial evidence, two other trials were done in 1991 and 1992 that showed a significant decrease in pruritus with rifampin. Most recently, in 2006, a meta-analysis was done of the 5 randomized clinical trials that tested rifampin and found that 77% of patients using rifampin reported a decrease in symptoms [
47‐
52]. Given these findings, rifampin has been shown to decrease pruritus in patients with cholestatic pruritus and is an appropriate agent for treatment.
It is important to note that rifampin can be hepatotoxic in some patients. Based on current studies, it carries an incidence of 7.3% and can cause a 10–20% increase in serum aminotransferance levels [
53,
54]. As a result, it is important to monitor patients for drug-induced hepatitis while they are on this medication. It is also recommended to start patients at a dose of 150 mg/day and slowly increase the dose every 2 weeks if the hepatic panel at that time interval has not worsened.
Naltrexone (Mu-Opioid Receptor Antagonist)
Naltrexone is another alternative option in the treatment of cholestatic pruritus. It works by blocking the mu-opioid receptor. An increase in mu-opioid receptor activation is thought to worsen pruritus, so a decrease would likely help alleviate pruritus. Naltrexone also blocks the kappa-opioid receptor but to a much lesser extent. Since pruritus is purported to be a result of the ratio of MOR being elevated compared to KOR, by lowering the ratio pruritus is improved [
55].
The earliest study that supported the use of naltrexone was in 1988 and examined the use of naltrexone in a group of 11 patients with PBC that noted improvement in pruritus, fatigue, and also plasma bilirubin. After this study, there were three additional clinical trials done in the 1990s that showed naltrexone improved pruritus in patients with cholestasis, further supporting its use. Naltrexone also has the most recent controlled clinical trial done out of the first three agents used for pruritus, with a study done in 2006 that showed significant improvement in pruritus. However, this study also showed that naltrexone was associated with increased side effects of withdrawal reaction, gastrointestinal distress, and insomnia, which were self-limited. Given these findings, naltrexone is an appropriate therapy to reduce cholestatic pruritus but it is important to keep in mind the side effects from its usage [
28,
56‐
59].
Peroxisome Proliferator-Activated Receptor (PPAR) Agonists
PPAR agonists are a newer drug class being evaluated to treat PBC and shown to also improve pruritus and patients’ quality of lives based on emerging evidence. Over the past decade, there have been multiple new agents in this class that have been introduced and others currently in clinical trials that show promising results. PPAR has multiple subtypes. These include PPAR-alpha, which is found in multiple tissues including skeletal muscles and liver and is involved in bile acid metabolism. PPAR-gamma is found in adipose and colonic tissue and is involved in increasing fatty acid storage and PPAR-delta is ubiquitously expressed and is involved in increased fatty acid oxidation. The FXR gene is known to produce more PPAR-alpha which results in more secretion of bile acids from the liver and stimulates bile acid detoxification through the CYP3A4 pathway. In a mouse model, it was found that the direct injection of PPAR-alpha into mouse tissue caused decreased bile acid synthesis as well [
60].
Medications included in this class are bezafibrate (PPAR-alpha, delta, gamma agonist), fenofibrate (PPAR-alpha agonist), elafibranor (PPAR-alpha and delta agonist), and seladelpar (PPAR-delta) which are been evaluated in the treatment of PBC. This class has been shown to be anti-fibrotic and anti-inflammatory and also has anti-cholestatic benefits.
Bezafibrate, a fibrate which is not available in the USA, but is a second-line treatment agent recommended by the European Association for Study of Liver Disease (EASL) for cholestatic pruritus in Europe following cholestyramine. It works by pan-activating PPARs and is shown to normalize alkaline phosphatase (ALP) in 67% of patients with PBC with incomplete biochemical response or intolerant to UDCA in a phase 3 clinical trial in Europe, the BEZURSO study. It also showed improvements in pruritus, fatigue, and liver stiffness but no significant difference in quality-of-life scores [
61]. It has also been examined as a treatment for cholestatic pruritus. Recently, the FITCH trial, a double-blind placebo-controlled trial, showed evidence in support for bezafibrate for the treatment of pruritus. The trial found that patients with PSC and PBC with moderate to severe itching had reduced morning and evening intensity of pruritus and improved 5D-itch scores with the use of bezafibrate compared to placebo [
62]. Fibrates as a class are known to cause transient mild transaminitis in some cases, mild rise in creatinine, and risk of rhabdomyolysis. However, these side effects are not common and caution should be exercised in those patients with chronic kidney disease (CKD) [
63]. There is also emerging data on the anticholestatic and antipruritic benefit for fenofibrates (PPAR-alpha), available in the USA, in patients with PBC. A recent meta-analysis found significant decreases in ALP, gamma-glutamyl transferase (GGT), and pruritus in patients with PBC [
64].
Elafibranor acts on both PPAR-alpha and gamma as an agonist. It has a phase 2 clinical trial in PBC patients who have failed ursodeoxycholic acid (UDCA) therapy. The study has found that patients had decreased pruritus over a 12-week period of using the medication [
65]. In addition to the phase 2 study, recently, the ELATIVE phase 3 trial, a year-long double-blinded placebo-controlled trial looked at 161 patients and found that elafibranor normalized ALP in 15% of patients compared to 0% in the placebo group at 52 weeks. Elafibranor did show reductions in pruritus at week 52 in PBC-40 Itch and 5D itch scales that were statistically significant (
p = 0.0070 and 0.0199, respectively) However, with the WI NRS there was no significant improvement [
66].
Seladelpar, a selective PPAR-delta agonist, is another agent in investigation for the management of PBC and cholestatic pruritus. Recent data from phase 2 and phase 3 clinical trials support its efficacy in PBC. Seladelpar works by activating the PPAR-delta pathway. This causes a decrease in CYP7A1. As mentioned above, CYP7A1 is involved in bile acid synthesis. By decreasing the level of CYP7A1, bile acid synthesis is decreased, leading to less bile acid deposit in tissues and circulating in serum, resulting in decreased pruritus [
67].
The first trial for Seladelpar was a double-blind, randomized control phase 2, proof of concept clinical trial. This study was done in 2017 and conducted over a 12-week period using various doses of the medication. In this study, no significant decrease in pruritus was observed [
68]. In 2022, a second phase 2 randomized control study was done that looked at patients over a 52-week-period and found a decrease in pruritus at 5 and 10 mg doses of the medication [
69]. Over this past year, there have also been two phase 3 studies that have been published with encouraging data. The ENHANCE trial, a phase 3, double-blind, randomized, and placebo-controlled study that evaluated 240 patients over 1 year showed a 30% improvement in ALP and pruritus with a dose of 10 mg [
70]. In another phase 3 trial, the RESPONSE study, a placebo-controlled trial, found that patients treated with seladelpar had a decrease of the numerical rating scale (NRS) for pruritus of 3.2 compared to only 1.7 for the placebo group (
p < 0.005) [
71].
Based on this data, in addition to effective treatments for PBC, seladelpar and elafibranor may add a viable pharmaceutical option to treat pruritus in patients with PBC.
Ileal Bile Acid Transporter (IBAT) Inhibitors
Over the past decade, new targets of cholestatic pruritus have been explored. One of these new targets is the ileal bile acid transporter inhibitors. As discussed above, the main mechanism of bile acid synthesis includes the transportation of bile acid intermediates into the small bowel, where they are converted into bile acids by gut flora. They are then reabsorbed into the bloodstream through ileal transporters and sent back into the hepatobiliary system [
72].
Therefore, one of the newer approaches has been to target the source of re-uptake at the ileum itself. Currently, there are four drugs approved or being studied, maralixibat, odevixibat, linerixibat, and volixibat. Maralixibat has multiple randomized control trials in progress, including a phase 2 study for pruritus in PBC. It has also received first approval recently for use in cholestatic pruritus in patients with PFIC and Alagille syndrome [
73].
Odevixibat has also shown evidence as a promising agent in the treatment of cholestatic pruritus. In a phase 3 clinical trial for patients with PFIC and Alagille syndrome, published in 2022, over half the patient population reported a decrease in pruritus. However, this trial also found that many patients suffered side effects of frequent diarrhea and bowel movements [
74]. Currently, it has been approved for patients older than 12 months with Alagille syndrome.
Linerixibat has one ongoing investigation assessing its efficacy for cholestatic pruritus in patients with PBC. The GLISTEN study is currently in phase 3, with published data from its phase 2 study (GLIMMER) that showed doses of linerixibat at 40 mg, 90 mg, and 180 mg daily significantly decreased itch over the 12-week treatment period from patients with moderate to severe itching (NRS > 4/10) in all quality-of-life domains in the PBC-40 questionnaire [
75].
Volixibat is another agent that is currently under investigation to treat pruritus associated with PSC and PBC. It is currently in phase 2 randomized double-blind placebo-controlled studies, called VANTAGE for PBC and VISTAS for PSC which are actively enrolling patients [
76].
The IBAT class represents a recent advance in treatment and likely has a promising future as a therapeutic option in a wider range of patients with cholestatic itch and could improve quality of life.
IL-31 As a Targeted Pathway
In the recent discovery of the IL-31 and FXR pathway, coupled with the 2023 study by Xu et al., IL-31 presents a promising new target for new pharmaceutical interventions for cholestatic pruritus. Currently, there are medications developed for atopic dermatitis and psoriasis that target the IL-31 pathway [
77]. It is possible that future studies explore the use of these medications in patients with cholestatic pruritus. Another interesting discovery published in June of 2023 in the phase 3 ENCHANCE trail showed that seladelpar, a PPAR-agonist, decreased serum IL-31 levels and decreased pruritus [
78]. Given the purported link between PPAR and FXR, it is possible that seladelpar is dampening the stimulation of FXR, causing decreased production of IL-31 and consequently decreasing pruritus. Given these recent discoveries, the IL-31 pathway presents an exciting opportunity for future targeted therapies.
Other Approaches
While these pharmacologic approaches to cholestatic pruritus are available, there are other approaches to consider as well, such as topical over-the-counter agent and for refractory cases, plasmaphoresis, molecular adsorbent recirculating system (MARS), and transplant. Topical emollients have long been used to help with pruritus. Regular application with emollients that contain 1–2% menthol is currently recommended as a general approach to pruritus [
79]. Another approach is plasmapheresis, which involves the removal of pruritogens from plasma that can improve symptoms in severe cases. Currently, this approach has few case reports in pregnant patients with cholestatic pruritus [
80]. Another approach is the molecular adsorbent recirculating system (MARS), where albumin dialysis is done to remove pruritogenic molecules that are bound to albumin. This therapy functions in a similar fashion to plasmaphoresis and has limited data. Finally, in severe cases, a liver transplantation can be done if there is access to a liver transplant and has shown to be highly effective in patients with refractory disease [
81].