Table 2

Pragmatic drug approaches to the medical management of cholestatic pruritus in the absence of clinical trial opportunities for patients

AgentDoseAdditional notes
Cholestyramine4 g/day to a maximum of 16 g/day as toleratedMust be given 2–4 hours before or after UDCA (usually give UDCA at night)
Pharmacy advice to avoid interactions with concomitant medications
Suggest give at breakfast time (an hour before or after eating) if gallbladder in situ; rarely much incremental benefit beyond 8–12 g/day, or tolerance
Mixing with orange squash and leaving in fridge overnight improves palatability
Gastrointestinal (GI) symptoms: constipation
Rifampicin300–600 mg/dayRisk of hepatotoxicity – need regular monitoring, start at 150 mg once to twice daily then titrate upwards as per symptoms and lung function test (LFT) monitoring. Maximum 600 mg daily
Check LFTs in 2–4 weeks; caution in advanced liver disease; consider vitamin K supplementation if icteric
Gabapentin*Dose titrate as normalDose titrate according to side effects and efficacy
Naltrexone*50 mg/day (normal maximum dose, although higher doses have been used in the specialist clinic setting)Start at 12.5 mg/day and titrate slowly to avoid withdrawal symptoms
Some patients require an intravenous induction stage
Sertraline*100 mg/dayTitrate dose to symptoms and as tolerated
Needs interaction at the primary/secondary care interface; change over if on alternative antidepressant
  • *Beyond the routine first- and second-line use of cholestyramine and rifampicin, the choice of other agents is frequently based on an individual clinician’s experience and preference.