Moderate to Severe Pruritus (Skin Itching) in Large Duct Primary Sclerosing Cholangitis

In patients with large duct primary sclerosing cholangitis (PSC), pruritus reaching moderate to severe intensity requires systematic pharmacological management. Before escalating treatment, relevant bile duct strictures should be excluded as a cause of progressive itching.

Clinical scenario: Large duct PSC with moderate to severe skin itching (pruritus) requiring structured, stepwise pharmacological treatment.

Third-line approach: When earlier pharmacological options have not achieved adequate symptom control, an oral opioid antagonist may be considered — introduced with particular caution at a very low starting dose. The complete structured regimen, including sequencing and monitoring guidance, is available via the link below.

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References

Pharmacological treatment of moderate to severe pruritus in sclerosing cholangitis with bezafibrate or rifampicin is recommended.
It is recommended to exclude relevant bile duct strictures in large duct sclerosing cholangitis as the cause of progressive pruritus.
As third-line treatment, the oral opioid antagonist naltrexone may still have a role, but starting at very low doses (12.5 mg) is recommended to avoid early side effects resembling an opioid withdrawal syndrome.

DOI: 10.1016/j.jhep.2022.05.011

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