Pruritus hepatic L29.8

The triggering pruritogen has not yet been clearly identified. There are a number of indications that doubt a direct connection between bile salts and pruritus. A correlation between pruritus intensity and bile salt concentrations could not be proven. Nor between pruritus and the extent of cholestasis. The atiopathogenetic role of endogenous opioids, histamine, autotaxin and lysophosphatidic acid is discussed.

Menthol, Polidocanol: The external therapy approaches are generally not very successful. Cooling ointments containing water, shaking mixtures or even gels with added menthol (e.g. Menthol-Creme 5%) and Polidocanol (e.g. Thesit, Optiderm, R200 R197 ) are able to slightly reduce itching.

Capsaicin: Occasionally good results can be achieved with an ointment containing capsaicin. Capsaicin is a relatively uncomplicated extract of cayenne pepper. The ointment is applied several times a day; start with a 0.025% concentration, later gradually increase to 0.075% capsaicin R036. Only low concentrations should be used in sensitive areas such as the face. Cold showering also relieves itching.

In primary biliary cirrhosis, good effects of codeine (4-hourly 20 mg p.o.) have been described (elevated plasma levels of endogenous opioids play a role in pruritus in primary biliary cirrhosis; codeine inhibits this mechanism).

Exchange resins: Some patients respond to therapy with the anion exchange resin colestyramine. (e.g. Quantalan: Dosage: 4 portions of 4g (max. 16g/day) spread over the day, to be taken before meals). Exchange resins are non-absorbable alkaline macromolecules that bind anions, amphiphilic substances such as bile salts in the intestinal lumen.

Opioid receptor antagonists: The efficacy of the opioid receptor antagonists naloxone and naltrexone (12.5-50mg/day p.o.) has been demonstrated in studies.

Rifampicin: Also effective is the use of the antibiotic rifampicin (300-600mg/day) - which acts as a ligand of the nuclear pregnant/steroid X receptor.

Experimental: Lidocaine, phototherapy (UVA and UVB), plasmapheresis.

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