Sertraline as a first-line treatment for cholestatic pruritus

Abstract

Pruritus is frequently the most debilitating symptom of cholestatic liver diseases. Moreover, existing therapies are often ineffective. Recent small, retrospective case series reports suggest that serotonin reuptake inhibitors can improve pruritus. This study was undertaken to establish the dose of sertraline and to evaluate its efficacy for cholestatic pruritus. Twenty one subjects with chronic pruritus due to liver disease (including primary biliary cirrhosis, primary sclerosing cholangitis, chronic hepatitis C, and postnecrotic cirrhosis) initially underwent an open-label, dose escalation to determine the dose with optimal efficacy and tolerability. After a washout period, 12 of the subjects entered a randomized, double-blind, placebo-controlled trial. Participants quantified their pruritus using a 0-10 visual analog scale, and pruritus was assessed for distribution, timing, degree of disability, and physical evidence of scratching. The optimum sertraline dose (75-100 mg/day) was well tolerated. In the controlled portion of the study, itch scores improved in patients taking sertraline, but worsened in patients taking placebo (P ‫؍‬ 0.009). Changes in itch distribution, duration, direction, and physical evidence of scratching paralleled changes in the visual analog pruritus score. Conclusion: Sertraline seems to be an effective, well-tolerated treatment for pruritus due to chronic liver disease. These results suggest that serotonergic pathways are important in the perception of itch. (HEPATOLOGY 2007;45:666-674.)

Advances in Pathogenesis and Management of Pruritus in Cholestasis

“…The selective serotonin uptake inhibitor sertraline (75-100 mg/day) can be administered as fourth-line therapy. A single placebo-controlled crossover trial [94] and a case series [95] reported moderate antipruritic effects. Coadministration of several drugs at the same time is not recommended due to the risk of drug-drug interactions.…”

Sertraline is an effective management option for cholestatic pruritus

“…Mayo's study also analyzed a secondary outcome measure and discussion about depression with SSRI use, while Zyclicz did not. 4,8 The Browning trial was excluded for two reasons: inadequate patient demographics and retrospective nature of study. 1 Only primary biliary cholangitis (PBC) was included in Browning's study, while PBC, primary sclerosing cholangitis (PSC), and Hepatitis C Virus (HCV) cirrhosis were included in Mayo's study.…”

Pruritus

“…Sertraline was reported to relieve pruritus of cholestasis in a controlled study [57]. Other centrally acting medications including the noradrenergic and serotoninergic antidepressant mertazapine, have been reported to relieve this type of pruritus in a small heterogeneous group of patients with malignancy and uremia [8] and in patients with nocturnal itch from skin diseases [8].…”