How To Manage PBC Itch

When you’re living with primary biliary cholangitis (PBC), you know well that fatigue and brain fog often come with the territory.

And for a lot of people, a nagging, distracting and downright frustrating itchiness is right up there with chief complaints.

But what can you do about PBC itch? Can you make it stop?

Yes, for a lot of people, the itch can be managed. And it can help you live a better life.

We talked with hepatologist Muyiwa Awoniyi, MD, PhD, about how to manage itching when you’re living with PBC.

PBC and itching: Why it happens

“Pruritus” is the medical term for itchy skin.

And while things like dry skin or hives can cause itching, the itch associated with PBC is different. ”Cholestatic pruritus” is the medical name for itchy skin that’s a result of bile duct disease.

PBC itch typically affects the palms of your hands and the soles of your feet. But it can also be all over. And it’s often worse at night. It’s not associated with a rash or allergies either.

The exact mechanism behind the itch is rather complicated. But essentially, having PBC causes a backup of bile in your body. And that buildup can trigger a reaction that irritates your peripheral nerves.

“The peripheral nerves then send sympathetic signals to the brain and trigger itch,” Dr. Awoniyi explains.

What can be done for PBC itch?

Living with a relentless itch can make it tough to sleep — and get through your day. And the extent of your itch may not necessarily jibe with the severity of your PBC disease progression.

“Comorbid symptoms like itch can be really hard on people living with PBC,” Dr. Awoniyi acknowledges. “Oftentimes, how we measure severity of disease doesn’t match the extent to which symptoms like itch or fatigue affect your life. But the good news is that we’ve made good headway on managing PBC-related itch.”

Home remedies like lotion or ice aren’t likely to make a dent in this kind of itching. But there are a number of medications that a healthcare provider can prescribe that can get to the root of the itch and make it stop. And some of them can also help manage your disease overall.

Healthcare providers use a stepwise approach to managing PBC itch. That means they move on to more intensive therapies only as needed. That helps to manage your condition, while putting your safety and comfort first.

Dr. Awoniyi describes some of the most common PBC itch-management medications.

Cholestyramine

1st-line agent

Cholestyramine binds bile acids in the gut, which reduces circulating levels that contribute to PBC itch. It may cause some gastrointestinal (GI) discomfort and must be taken separately from other medications, as it can interfere with absorption. “If you decrease the bile load, you, hopefully, will decrease the itching,” Dr. Awoniyi explains.

Rifampicin

2nd-line agent

Rifampicin acts as a potent enzyme inducer that helps reduce circulating “pruritogens,” like bile. It does this by changing liver enzyme activity. It requires careful monitoring and may be suitable if bile acid sequestrants like cholestyramine aren’t effective for you.

Naltrexone

3rd-line agent

Naltrexone is an opioid antagonist that helps to counteract the central opioid pathways that are related to itching. This medication is introduced very slowly at first, and the dose will be increased gradually. That helps to minimize side effects, such as GI discomfort or mood changes.

SSRIs

4th-line agent

Selective serotonin reuptake inhibitors (SSRIs) are commonly used in the treatment of depression. But they also can be a benefit for people with PBC itch.

What do depression medications have to do with PBC itch?

“SSRIs work in the same (serotonergic) pathway in your brain the excess bile that leads to itching when you have PBC,” Dr. Awoniyi points out. “SSRIs in some people can help to block the signals that trigger itch.”

If your healthcare provider recommends SSRIs for your PBC itch, it’s not that they’re not diagnosing you with depression. It’s simply that the medication, while most commonly used for depression, can also reduce your itching.

But the trouble with SSRIs may be that it can take a strong dose to affect your itch. If you’re prescribed an SSRI, don’t be surprised if the recommended dosage is upwards of 100 milligrams a day. The mood-altering effects may not be tolerable in some people.

Ileal bile acid transporter (IBAT) inhibitor

Clinical trial intervention

IBAT inhibitors are a newer class of medication that may be used to help reduce the amount of bile in your body. They do that by keeping it from being reabsorbed.

Less bile can mean less itch.

These medications are currently undergoing clinical trials for people with PBC. But they have been approved in other pediatric bile duct disease, such as Alagille’s syndrome.

PPAR agonists

Some of the newest medications for PBC have also been shown to manage the condition overall and help with itchiness.

Other treatments for PBC include ursodeoxycholic acid (UDCA), which isn’t known to help with itchy skin, and obeticholic acid (OCA), which can make itch worse.

PPAR antagonists may be an option for some people to both reduce itching and manage PBC.

“Just a few years ago, we didn’t have much that could reliably help people dealing with PBC itch,” Dr. Awoniyi notes. “IBAT inhibitors and PPAR agonists are newer medications that have really been making a big difference for our patients’ quality of life.”

If you’re dealing with itchiness as a result of PBC, talk with a healthcare provider. They can help you find the strategy that will work best for you.