Treatment of cholestatic pruritus in children

[Guest guest]

American Journal of Health-System Pharmacy, Vol. 64,

Issue 11, 1157-1162

Copyright © 2007 by American Society of Health-System Pharmacists

Treatment of cholestatic pruritus in children

J. Cies and N. Giamalis

JEFFREY

J. CIES, PHARM.D., BCPS, is Pediatric Clinical Pharmacy Specialist, Department

of Pharmacy, Temple University Children’s Medical Center, Philadelphia, PA. JOHN N. GIAMALIS,

B.S.PHARM., is Pediatric Clinical Pharmacy Specialist, Alfred I. duPont Hospital for

Children, Nemours Children’s Clinic, Wilmington, DE.

Purpose. The treatment of cholestatic

pruritus in children is reviewed.

Summary. Cholestasis is

characterized by an accumulation of substances that are normally

secreted in the bile. Pruritus is a

well-known feature of chronic cholestasis in both

adults and children and has been reported as the most incapacitating

symptom in children with chronic liver disease. Traditional

agents, such as antihistamines, are typically ineffective as monotherapy in controlling cholestatic

pruritus. As a result, clinicians have

looked to other agents, such as rifampin, phenobarbital, ursodiol,

opioid antagonists, and bile-binding resins, for

attaining better control of pruritic

symptoms. Each agent demonstrates different

levels of efficacy in pediatric and adult literature. There

are no guidelines or algorithms to guide therapy with these agents

for children. As a result, an agent should be selected

based on the patient’s concurrent diseases and current medication

regimen. Cholestyramine and ursodiol are both safe and inexpensive, with

documented efficacy for cholestatic pruritus in

children. Because cholestatic

pruritus is likely a result of multiple mechanisms, combination

therapy with agents that have differing mechanisms of action might

be beneficial and could capitalize on potential synergy between the

agents used. Future therapy for cholestatic pruritis may include

serotonin antagonists, selective serotonin-reuptake inhibitors, and leukotriene antagonists.

Conclusion. Depending on the underlying disease state resulting in

cholestasis, phenobarbital,

ursodiol, bile sequestering agents, and opioid antagonists appear to be most effective for treating

pruritus related to intrahepatic cholestasis. Alternatively, rifampin

appears to be the only agent with reported treatment efficacy for

pruritus related to extrahepatic cholestasis.

Barb in Texas - Together in the Fight, Whatever it Takes!

Son Ken (33) UC 91 - PSC 99 Listed 7/21 @ Baylor Dallas