Cholestasis in infancy. A review

Treatment of cholestatic pruritus in children

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 pruritus 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.

Effect of ursodeoxycholic acid therapy on hepatic function in children with intrahepatic cholestatic liver disease

BACKGROUND

Ursodeoxycholic acid (UDCA) has been shown to improve pruritus, alanine aminotransferase (ALT), and cholesterol levels in children with intrahepatic cholestatic liver disease. However, the effect of UDCA on quantitative tests of hepatic function in children is uncertain.

METHODS

A 2.5-year, open label, crossover study, was designed to determine the effect of UDCA (15-20 mg/kg per day for 12 months, off for 6 months, and on again for 12 months) on clinical symptoms, biochemical test results, galactose and caffeine elimination half-lives (t1/2), and quantitative hepatic scintigraphy in 13 subjects aged 13.1 +/- 2.1 years (10 of whom completed the entire study), with intrahepatic cholestasis.

RESULTS

Pruritus improved with UDCA in the 6 patients with pruritus on entry into the study. At 12 months, there was a significant decline in ALT, gamma-glutamyl transpeptidase, and plasma levels of copper and manganese, with no further decline in these levels at 24 months. There were no changes in bilirubin or cholylglycine levels. After therapy was discontinued at 12 months, UDCA was restarted within 1 month in 9 of 12 patients in response to a doubling of ALT (n = 6) or worsening pruritus (n = 3). Galactose t1/2 increased after 12 months, with no further increases after 24 months of UDCA therapy, whereas caffeine t1/2 did not change. There were no significant changes in hepatic scintigraphy throughout the study.

CONCLUSIONS

These data suggest that although UDCA therapy improves pruritus and results in a reduction in ALT and gamma-glutamyl transpeptidase, UDCA therapy did not improve quantitative measures of hepatic function in children with intrahepatic cholestasis.