Sep 15, 2026 · 15 min · 9 segments
How can clinicians better recognize and manage itching and fatigue in primary biliary cholangitis (PBC)? In this podcast, hepatology clinicians from RUSH University Medical Center discuss the impact…
Nancy RoweGuest
Allison MoserHost
So ursodeoxycholic acid is our first-line therapy, but it can sometimes worsen pruritus.
And I will often tell my patients that because especially if you were itchy to start out with, you know, and maybe we dose increased or they're just now starting on an agent, I want to make sure that they have realistic expectations, that they know they can call me, but that also, you know, they don't stop a therapy that might be important for them just because we've not warn them adequately on how they're going to feel.
Historically, we thought that bile acids was the primary driver of itch, but now we know that there are multiple pathways involved, LPA, neural pathways as well, as well as bile acid signaling.
And this kind of explains why lowering bile acids just doesn't necessarily help eliminate itch, which is one of the frustrating things about PPC pruritus, that the severity of itch doesn't always correlate with the severity of disease.
Do you think understanding these mechanisms have changed the way that we think about treating itch in our patients?
I think that the most important reason that this is impactful is that a one-size-fits algorithm is not going to be a good fit for the patients in front of you.
And we know that when you look at the guidelines and it says that cholestyramine might be first-line therapy, it's not going to work in all of your patients.
And it does have a little bit of difficulty in that it can't be used with other medicines close to it.
But more importantly, you need to empower your patient to recognize that if this medicine isn't working, we're going to give it a certain period of time.
And then we're going to switch to something that might have a different mechanism of action.
And that's why when you're looking at the tools in front of you, although we often will use a lot of creams, the goal isn't always the same.
You might be using something lubricating to prevent dry skin as an exacerbation, or you might be using something like a lidocaine-based to help deaden the nerves sensation, or you might be using Sarno, which is that tar-based cream.
So a lot of the things that you're going to use have different mechanisms which really impact all those various putrogens.
So ursodeoxycholic acid is our first-line therapy, but it can sometimes worsen pruritus.
And I will often tell my patients that because especially if you were itchy to start out with, you know, and maybe we dose increased or they're just now starting on an agent, I want to make sure that they have realistic expectations, that they know they can call me, but that also, you know, they don't stop a therapy that might be important for them just because we've not warn them adequately on how they're going to feel.
Historically, we thought that bile acids was the primary driver of itch, but now we know that there are multiple pathways involved, LPA, neural pathways as well, as well as bile acid signaling.
And this kind of explains why lowering bile acids just doesn't necessarily help eliminate itch, which is one of the frustrating things about PPC pruritus, that the severity of itch doesn't always correlate with the severity of disease.
Do you think understanding these mechanisms have changed the way that we think about treating itch in our patients?
I think that the most important reason that this is impactful is that a one-size-fits algorithm is not going to be a good fit for the patients in front of you.
And we know that when you look at the guidelines and it says that cholestyramine might be first-line therapy, it's not going to work in all of your patients.
And it does have a little bit of difficulty in that it can't be used with other medicines close to it.
But more importantly, you need to empower your patient to recognize that if this medicine isn't working, we're going to give it a certain period of time.
And then we're going to switch to something that might have a different mechanism of action.
And that's why when you're looking at the tools in front of you, although we often will use a lot of creams, the goal isn't always the same.
You might be using something lubricating to prevent dry skin as an exacerbation, or you might be using something like a lidocaine-based to help deaden the nerves sensation, or you might be using Sarno, which is that tar-based cream.
So a lot of the things that you're going to use have different mechanisms which really impact all those various putrogens.
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