Sep 15, 2026 · 15 min · 7 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
I also think it's really important when patients make drug changes, so ursodeoxycholic acid is our first line of 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, um, you know, and maybe we've dose increased or they're just now starting on an agent, I wanna make sure that they have realistic expectations, that they know they can call me, but that also, um, you know, they don't stop a therapy that might be important for them just because we've not warned them adequately on how they're gonna feel.
Um, historically, we thought that bile acids was the primary driver of itch, but now we know that there are multiple pathways involved, LPA, n- uh, neural pathways as well, as well as bile acid signaling.
Um, and this kind of explains why lowering bile acids does, doesn't necessarily help eliminate itch, which is one of the frustrating things about PBC 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 gonna work in all of your patients, and it does have a little bit of, um, 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 gonna give it a certain period of time, and then we're gonna 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, um, help, you know, deaden the nerves sensation.
So a lot of the things that you're gonna use have different mechanisms which really impact all those various pruritus.
I also think it's really important when patients make drug changes, so ursodeoxycholic acid is our first line of 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, um, you know, and maybe we've dose increased or they're just now starting on an agent, I wanna make sure that they have realistic expectations, that they know they can call me, but that also, um, you know, they don't stop a therapy that might be important for them just because we've not warned them adequately on how they're gonna feel.
Um, historically, we thought that bile acids was the primary driver of itch, but now we know that there are multiple pathways involved, LPA, n- uh, neural pathways as well, as well as bile acid signaling.
Um, and this kind of explains why lowering bile acids does, doesn't necessarily help eliminate itch, which is one of the frustrating things about PBC 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 gonna work in all of your patients, and it does have a little bit of, um, 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 gonna give it a certain period of time, and then we're gonna 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, um, help, you know, deaden the nerves sensation.
So a lot of the things that you're gonna use have different mechanisms which really impact all those various pruritus.
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