Treatment of primary sclerosing cholangitis

Meta-analysis: ursodeoxycholic acid for primary sclerosing cholangitis

BACKGROUND

There is no satisfactory medical treatment for patients with primary sclerosing cholangitis. There are conflicting data regarding the clinical benefit of high doses of ursodeoxycholic acid (UDCA) in primary sclerosing cholangitis.

AIM

To evaluate using meta-analysis, if UDCA (standard or high-dose) is useful in primary sclerosing cholangitis.

METHODS

We searched MEDLINE using the textwords 'PSC', 'treatment', 'UDCA' and retrieved all abstracts from the major Gastroenterology and Liver meetings. We included randomised clinical trials comparing standard or high-dose of UDCA (>15 mg/kg body weight per day) vs. placebo or no intervention. End-points: mortality or liver transplantation, pruritus, fatigue, cholangiocarcinoma and histological progression.

RESULTS

We identified eight randomised clinical trials comprising 567 patients. Five used standard doses and three high doses of UDCA. There was no significant difference in mortality [OR, 0.6 (95% CI, 0.4-1.4)], in pruritus [OR, 1.5 (95% CI, 0.3-7.2)], in fatigue [OR, 0.0 (95% CI, 0.1-7.7)], in cholangiocarcinoma [OR, 1.7 (95% CI, 0.6-5.1)] and in histology stage progression [OR, 0.9 (95% CI, 0.34-2.44)]. No differences were found in the subgroup analyses.

CONCLUSION

Neither standard nor high-dose UDCA influence favourably the progression of primary sclerosing cholangitis.

An update on primary sclerosing cholangitis

PURPOSE OF REVIEW

Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree complicated by cirrhosis and cholangiocarcinoma. It is immune mediated, although the precise aetiology remains unknown.

RECENT FINDINGS

The research into aetiology, genetic associations, pathogenesis, epidemiology, diagnosis of cholangiocarcinoma and medical treatments are discussed.

SUMMARY

Multiple gene polymorphisms and human leucocyte antigen haplotype associations with primary sclerosing cholangitis have been investigated. Common inflammatory bowel disease associated polymorphisms and ulcerative colitis associated human leucocyte antigen haplotypes are not associated with primary sclerosing cholangitis. Biliary epithelial cells may mediate their own destruction by exaggerating innate and adaptive immune responses to bacterial products in the liver. The natural history of large and small duct primary sclerosing cholangitis has been reviewed. Positron emission tomography may be a useful adjunct to current imaging modalities in the pretransplant assessment of patients to exclude cholangiocarcinoma. Ursodeoxycholic acid remains the most studied medical treatment for primary sclerosing cholangitis; pilot studies suggest a possible role for tacrolimus and silymarin, however further studies are required.

Update on the treatment of the pruritus of cholestasis

The pruritus of cholestasis is a difficult clinical problem to manage. It can be severe and interfere with sleep. Clinical behavioral studies have confirmed that the pruritus is mediated at least in part by endogenous opioids. Other neurotransmitter systems may be involved in the mediation of pruritus. Work continues to identify the mechanisms that mediate the pruritus and to develop specific drugs to treat this often maddening symptom.