Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial

Proteomic Biomarkers of Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease, which can lead to adverse fetal outcomes, including preterm labor and intrauterine death. The pathogenesis of ICP is still unclear. We hypothesized that pathological index leads to abnormal placenta changes in ICP. Investigation of these differences in protein expression in parallel profiling is essential to understand the comprehensive pathophysiological mechanism underlying ICP. The present study screened differentially expressed proteins (DEPs) as novel diagnostic markers for ICP. Proteomic profiles of placental tissues from 32 ICP patients and 24 healthy volunteers (controls) were analyzed. Our founding was valid by following western blotting and immunohistochemistry staining, respectively. The association of the key protein expression with clinicopathological features of ICP was further analyzed. A total of 178 DEPs were identified between the ICP and control groups. Functional enrichment analysis showed these proteins were significantly enriched in the PPAR singling pathway by KEGG and PPARα/RXRα activation by IPA. Apolipoprotein A2 (APOA2) was the only upregulated protein, which uniquely identified in ICP groups and related to both pathways. Validation of western blotting and immunohistochemical staining analysis showed significantly higher APOA2 expression in the ICP group than in the control group. Furthermore, the expression of APOA2 is associated with clinicopathological features in ICP groups. Receiver operating characteristic (ROC) curve analyses showed that the AUC of APOA2 was 0.8984 (95% confidence interval (CI): 0.772-1.000). This study has identified up-regulated APOA2 associated with PPAR singling pathway and PPARα/RXRα activation in ICP. Thus, APOA2 may be involved in ICP pathogenesis, serving as a novel biomarker for its diagnosis.

Gradual dosing of ursodeoxycholic acid in mothers with intrahepatic cholestasis of pregnancy may improve composite neonatal outcome

INTRODUCTION AND OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) is often accompanied by fetal and maternal complications.

MATERIALS AND METHODS

Retrospective review of the clinical course of women with ICP and their neonates treated at our medical center over a 10-year period. Special attention was paid to the maternal and neonatal response to 2 different modes of ursodeoxycholic acid (UDCA) administration.

RESULTS

Neonates of mothers with high total bile acid levels had a poorer composite neonatal outcome. Twenty-seven women who presented at an advanced stage of their pregnancies did not receive UDCA. UDCA was administered in 2 modes: either a full dose at admission (76 women) or a gradually increasing dose until the desired dosage was reached (25 women). The mean gestational age at delivery for the 94 neonates that were exposed to full UDCA dose was the lowest (36±2.3 weeks for the full dose, 37±1.4 weeks for the 30 neonates from the gradually increasing dose, 38±1.6 weeks for the 29 neonates from the no treatment group, p<0.001). The group of neonates that were exposed to full UDCA dose had the highest rate of unfavorable composite neonatal outcome (53% for full dose, 30% for gradually increasing dose, 24% for the no treatment group, p=0.006).

CONCLUSIONS

Compared to the administration of a full UDCA dose, the administration of a gradually increasing dose of UDCA may be associated with a greater gestational age at delivery and fewer events of unfavorable composite neonatal outcomes. These novel findings should be retested prospectively in a large cohort of patients.

Targeting bile salt homeostasis in biliary diseases

PURPOSE OF REVIEW

Advances in the understanding of bile salt synthesis, transport and signalling show the potential of modulating bile salt homeostasis as a therapeutic strategy in cholestatic liver diseases. Here, recent developments in (pre)clinical research in this field is summarized and discussed.

RECENT FINDINGS

Inhibition of the apical sodium-dependent bile salt transporter (ASBT) and Na + -taurocholate cotransporting polypeptide (NTCP) seems effective against cholestatic liver diseases, as well as Farnesoid X receptor (FXR) agonism or a combination of both. While approved for the treatment of primary biliary cholangitis (PBC) and intrahepatic cholestasis of pregnancy (ICP), ursodeoxycholic acid (UDCA) has retrospectively shown carefully promising results in primary sclerosing cholangitis (PSC). The side chain shortened derivate norUDCA is of further therapeutic interest since its mechanisms of action are independent of the bile salt transport machinery. In the pathogenesis of sclerosing cholangiopathies, a skewed T-cell response with alterations in gut microbiota and bile salt pool compositions are observed. In PSC pathogenesis, the bile salt receptor Takeda G-protein-coupled receptor 5 (TGR5) in cholangiocytes is implicated, whilst in immunoglobulin G4-related cholangitis the autoantigens annexin A11 and laminin 511-E8 are involved in protecting cholangiocytes.

SUMMARY

Modulating bile salt homeostasis has proven a promising treatment strategy in models of cholestasis and are continuously being further developed. Confirmatory clinical studies are needed in order to assess the proposed treatment strategies in patients allowing for a broader therapeutic arsenal in the future.

[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP).

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10μmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99μmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99μmol/L is below 100μmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low).

CONCLUSION

Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Simultaneous determination of UDCA and its major metabolites in human plasma with surrogate matrix by a rapid and specific LC-MS/MS method

A rapid, convenient, and specific liquid chromatography-tandem mass spectrometry method was developed and validated for the simultaneous quantification of ursodeoxycholic acid (UDCA), and its major metabolites, glycoursodeoxycholic acid (GUDCA) and tauroursodeoxycholic acid (TUDCA) in human plasma. Methanol was chosen as surrogate matrix for preparation the calibrators to establish calibration curves. Isotope internal standard was used for each analyte. After plasma samples were deproteinized with methanol, the post-treatment samples were analyzed on a ZORBAX SB-C18 column (2.1 × 50 mm, 1.8 μm) with 2 mM ammonium acetate and acetonitrile as mobile phase at a flow rate of 0.5 mL/min. Detection was performed on a triple quadrupole mass spectrometer operating in multiple reaction monitoring (MRM) employing negative ESI interface using API5500 triple quadrupole tandem mass spectrometer system, with the transitions set at m/z 391.4 → m/z 391.4, m/z 448.3 → m/z 73.9, m/z 498.4 → m/z 80.1, m/z 395.3 → m/z 395.3, m/z 453.3 → m/z 74.0, and m/z 503.2 → m/z 79.9 for UDCA, GUDCA, TUDCA, UDCA-d4, GUDCA-d5, and TUDCA-d5, respectively. The calibration curve ranges were 5.00-2500 ng/mL for UDCA and GUDCA and 0.500-250 ng/mL for TUDCA. The intra- and inter-day precision was within 7.00% in terms of relative standard deviation (RSD%) and the accuracy within 11.75% in terms of relative error. The selectivity, sensitivity, extraction recovery, matrix effect, dilution reliability, and stability were within the acceptable range. The method was successfully applied to a pharmacokinetic study in 12 healthy Chinese volunteers after oral administration of 250 mg UDCA.

Bile Acids-A Peek Into Their History and Signaling

Bile acids wear many hats, including those of an emulsifier to facilitate nutrient absorption, a cholesterol metabolite, and a signaling molecule in various tissues modulating itching to metabolism and cellular functions. Bile acids are synthesized in the liver but exhibit wide-ranging effects indicating their ability to mediate organ-organ crosstalk. So, how does a steroid metabolite orchestrate such diverse functions? Despite the inherent chemical similarity, the side chain decorations alter the chemistry and biology of the different bile acid species and their preferences to bind downstream receptors distinctly. Identification of new modifications in bile acids is burgeoning, and some of it is associated with the microbiota within the intestine. Here, we provide a brief overview of the history and the various receptors that mediate bile acid signaling in addition to its crosstalk with the gut microbiota.

Intrahepatic cholestasis of pregnancy: from an obstetrician point of view

Intrahepatic cholestasis of pregnancy (ICP) is the commonest among the specific dermatoses of pregnancy. The disease is characterised by intense pruritus and specifically by elevated bile acid levels and owing to the rarity of data published in this context, the disease carries a great challenge in both diagnosis and management. The disease is associated with significant maternal as well as perinatal adverse effects, hence, this article aims at improving the knowledge of the women's health carers with the up-to-date and evidence-based, whenever possible, recommendations while managing patients with ICP.

Serum microRNAs as non-invasive diagnostic biomarkers for intrahepatic cholestasis of pregnancy

OBJECTIVES

Intrahepatic cholestasis of pregnancy (IHCP) causes itching, preterm birth, and stillbirth. However, there is no accurate diagnostic method for IHCP. Currently, circulating microRNAs (miRNAs) have become candidate biomarkers for the diagnosis of multiple diseases. Here, we investigated the diagnostic value of miRNAs in IHCP and aimed to predict the molecular mechanism of IHCP pathogenesis.

METHODS

We analyzed differentially expressed miRNAs in both women with IHCP and normal pregnant women. The selected candidate miRNAs were validated in 46 IHCP cases and 46 normal pregnant subjects, and we constructed receiver operator characteristic curves of miRNAs. Pearson correlations between levels of total bile acid (TBA) and differentially expressed miRNAs were also calculated. In addition, we clustered functionally significant biological pathways using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses.

RESULTS

The expression levels of 13 miRNAs were remarkably upregulated while the other 35 miRNAs were significantly downregulated, in women with IHCP (P≤0.05) when compared with healthy pregnant women. The areas under the curves of miRNA-7706, miRNA-877-3p, and miRNA-128-3p were higher than 0.90, indicating more reliable diagnosis of IHCP. The Pearson analysis showed that the levels of these miRNAs were positively correlated to TBA level. Additionally, the results of bioinformatics analysis revealed that the differentially expressed miRNAs mainly influenced fatty acid biosynthesis, the endoplasmic reticulum ubiquitin ligase complex, and the p53, and mammalian target of rapamycin (mTOR) and AMP-activated protein kinase (AMPK) signaling pathways.

CONCLUSION

The panel of three-miRNAs (miRNA-7706, miRNA-877-3p, and miRNA-128-3p) may be a useful noninvasive diagnostic biomarker of IHCP.

Comprehensive analysis of placental gene-expression profiles and identification of EGFR-mediated autophagy and ferroptosis suppression in intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) was the most common liver disease specific to pregnancy. The symptoms of ICP were maternal pruritus and increased bile acid level in serum which was related to preterm birth, fetal distress, meconium-stained amniotic fluid and stillbirth. However, the mechanism of ICP progression on fetal development remained obscure. Sequencing data of 2 normal placenta samples and 4 intrahepatic cholestasis samples during pregnancy was analyzed by GEO2R. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were used for analysis of differentially expressed genes. MCODE - A plug-in of Cytoscape was used for molecular complex detection. STRING, Cytoscape, GeneMANIA, NetworkAnalyst, TransmiR, JASPAR, DGIdb and DrugBank were used in this study. Furthermore, histopathological and cell experiments were used to verify our results. Our study identified the key KEGG pathway and four MCODEs which were closely with ICP development, further, sorted by degree centrality, we showed top 30 genes from 7209 differential genes, such as TP53, SRC, EGFR, ESR1, IL10, CD8A, MAPK3, PTPRC, EGF, KIT, ITGAM, LEP and CSF2, etc. Moreover, these hub genes participated in JAK-STAT3 signaling pathway and STAT1/3 regulated these genes expression in a direct way or miRNA-mediated manner. Drug-target analysis about up-regulated genes among hub genes showed that these genes contained multiple drug action site. Furthermore, hub gene-EGFR was associated with destroyed autophagy and ferroptosis. In conclusion, our study analyzed key genes and pathways in ICP development. JAK-STAT3 pathway and EGFR might be a potential target for ICP therapy.

Intrahepatic cholestasis of pregnancy - Time to redefine the reference range of total serum bile acids: A cross-sectional study

Objective

To establish pregnancy‐specific reference ranges for fasting and postprandial total serum bile acid (TSBA) concentrations.

Design

Cross‐sectional study.

Setting

Tertiary‐care university hospital.

Population

Healthy pregnant women at term admitted to the Obstetrics Department over a period of 1 year. Exclusion criteria were an established diagnosis of intrahepatic cholestasis of pregnancy (ICP) or any coexisting condition of increased risk for ICP.

Methods

Both fasting (after 8–14 h of fasting) and postprandial (2 h after meal) TSBA concentrations were measured in 612 women (with 528 fasting samples and 377 postprandial samples) by automated enzymatic spectrophotometric assay.

Main outcome measures

Fasting and postprandial TSBA concentrations in 612 women.

Results

Reference intervals of 4.4–14.1 μmol/L for fasting TSBA and 4.7–20.2 μmol/L for postprandial TSBA were established. The postprandial values were significantly higher than the fasting values, with a median increase of 1.0 μmol/L (p < 0.0001). A correlation between fasting TSBA concentrations and postprandial concentrations was found, as well as correlations with fetal sex, parity and assisted reproductive technologies. A seasonal pattern was noticed for both fasting and postprandial TSBA, with the highest values measured in the winter season (p < 0.01 and 0.02, respectively)

Conclusions

Normal pregnancy is associated with mild hypercholanaemia, and therefore a higher threshold should be considered for the diagnosis of ICP. We suggest using the upper reference limits observed in our healthy pregnant population (14 μmol/L for fasting TSBA and 20 μmol/L for postprandial TSBA). As the fasting measurement is more specific for the diagnosis, and the postprandial measurement is essential for the assessment of severity, it is recommended to measure both values rather than use random sampling.

Tweetable abstract

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Linked article: This article is commented on by Ovadia et al., pp. 1897–1898. in this issue. To view this minicommentary visit https://doi.org/10.1111/1471‐0528.17171

Intrahepatic cholestasis of pregnancy: Case series of a rare disease in an African setting

Intrahepatic cholestasis of pregnancy commonly presents in the second and third trimester with unexplained pruritus sine materia, abnormal liver function tests, and/or elevated serum total bile acid concentration. Its incidence ranges from less than 1% to 27.6%, with Araucana Indians from Chile being the highest affected. Intrahepatic cholestasis of pregnancy complicates pregnancy, hence influencing its outcomes. Our series involves three cases of pruritus in pregnancy ending with one elective cesarean delivery and two emergency cesarean deliveries without any significant complications to babies as well as immediate resolution of maternal symptoms. High index of suspicion for intrahepatic cholestasis of pregnancy is of paramount importance among clinicians even in primary care setup. Prompt treatment and intervention will prevent poor perinatal outcome.

Analysis of CYP27A1 mutations in Han Chinese women with intrahepatic cholestasis of pregnancy

OBJECTIVE

To explore the cytochrome P450 family 27 subfamily A member 1 (CYP27A1) gene mutations in Chinese women with intrahepatic cholestasis of pregnancy (ICP) and the correlation between CYP27A gene mutations and BA (bile acid) level changes.

METHODS

In this study, the entire coding region of the CYP27A1 gene was sequenced in 151 Han Chinese women with ICP and 1029 matched samples, and the pathogenicity of identified CYP27A1 gene mutations was judged through evolutionary conservation analysis, computational analysis and protein structure modeling. Finally, we verified the relationship between gene mutations and total serum bile acid (TBA) and cholesterol (CHOL) levels through experiments in cell culture.

RESULTS

We identified five heterozygous CYP27A1 missense mutations in five ICP samples. Three online tools, Polyphen-2, MutationTaster and SIFT, predicted that the five CYP27A1 mutations were pathogenic. Furthermore, all five mutations caused marked protein structural changes. Experiments in cells showed that the intracellular and medium levels of TBA in the mutant groups were lower than those in the wild-type group, while the CHOL levels were higher in all mutants except for the R158H mutant.

CONCLUSIONS

CYP27A1 mutations are associated with the levels of TBA and CHOL, suggesting that CYP27A1 mutations contribute to abnormal total cholesterol and BA levels, which leads to ICP.

Intrahepatic cholestasis of pregnancy: dilemma in diagnosis and management

OBJECTIVE

To determine the obstetrical outcomes of women delivered for the diagnosis of intrahepatic cholestasis of pregnancy (ICP).

METHODS

Retrospective study of singleton pregnancies diagnosed with ICP between 1 May 2014 and 31 December 2017. Population was analyzed based on bile acids: normal (<10 µmol/L), mild (10 to 40 µmol/L), moderate-severe (>40 µmol/L), and not obtained. Receiver operating characteristic curves established critical values for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) to predict elevated bile acids. Statistical analyses included χ² for categorical variables and ANOVA for continuous variables. All tests used a 2-sided α level of significance of .05.

RESULTS

Bile acids were normal in 39 (45.9%) women, 30 (35.3%) had mild cholestasis, 10 (11.8%) had moderate-severe cholestasis and not obtained for six (7%) women. Gestational diabetes was more common in mild cholestasis (p = .03). There were no differences in demographics, clinical presentation, obstetric interventions and neonatal outcomes. Bile acids took 5-6 days to result. Rate of labor inductions was high in all groups. Postpartum complications occurred in four women in the normal group and in one woman in the mild cholestasis group. Five (12.8%) neonates in the normal group, six (20%) in the mild group, and one (10%) in the severe group were admitted to the NICU. There was no fetal asphyxia, no 5-minute Apgar score <7, and no perinatal deaths. An AST of 27.5 IU/L (p = .002) with sensitivity of 81% and specificity of 76%, and an ALT of 26.7 IU/L (p = .004) with sensitivity of 78% and specificity of 68% predicted elevated bile acids. Improving the sensitivity of AST and ALT to 95%, the ROC curve identified an AST of 62 IU/L with a specificity, positive and negative predictive values of 32, 58 and 86%, respectively; and an ALT of 106 IU/L with a specificity, positive and negative predictive values of 27, 57 and 83%, respectively.

CONCLUSIONS

ICP should not be presumed in patients with pruritus. This practice may lead to early term delivery and associated complications.

Intrahepatic Cholestasis of Pregnancy: Toward Improving Perinatal Outcome

Intrahepatic cholestasis of pregnancy (ICP) is associated with poor perinatal outcomes in some women such as preterm delivery and fetal demise. Ursodeoxycholic acid (UDCA) is the main therapeutic agent for ICP, but recent evidence failed to show an impact on most perinatal outcomes. Our objective is to summarize the latest evidence in the management of ICP, with a focus on perinatal outcome. We propose a practical approach that combines pharmacotherapy with biochemical and fetal testing, as well as delivery planning.

Redox-Dependent Effects in the Physiopathological Role of Bile Acids

Bile acids (BA) are recognized by their role in nutrient absorption. However, there is growing evidence that BA also have endocrine and metabolic functions. Besides, the steroidal-derived structure gives BA a toxic potential over the biological membrane. Thus, cholestatic disorders, characterized by elevated BA on the liver and serum, are a significant cause of liver transplant and extrahepatic complications, such as skeletal muscle, central nervous system (CNS), heart, and placenta. Further, the BA have an essential role in cellular damage, mediating processes such as membrane disruption, mitochondrial dysfunction, and the generation of reactive oxygen species (ROS) and oxidative stress. The purpose of this review is to describe the BA and their role on hepatic and extrahepatic complications in cholestatic diseases, focusing on the association between BA and the generation of oxidative stress that mediates tissue damage.

Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.

[Intrahepatic cholestasis of pregnancy]

Die Schwangerschaftscholestase („intrahepatic cholestasis of pregnancy“, ICP) ist die häufigste schwangerschaftsspezifische Lebererkrankung. Das Leitsymptom Juckreiz sowie eine begleitende Serumkonzentrationserhöhung von Gallensäuren und/oder der Alaninaminotransferase (ALT) sind wegweisend in der Diagnosestellung. Die mütterliche Prognose ist gut. Das fetale Outcome ist abhängig von der Gallensäurenkonzentration. Die ICP ist dabei sowohl mit Frühgeburt als auch mit intrauterinem Fruchttod (IUFT) assoziiert. Dieser ist Folge einer akuten fetalen Asphyxie, nicht einer chronischen uteroplazentaren Dysfunktion. Ein prädiktives Monitoring, z. B. durch Kardiotokographie (CTG) oder Ultraschall gibt es nicht. Eine medikamentöse Therapie mit Ursodeoxycholsäure (UDCA) bessert den Juckreiz, aber beeinflusst das fetale Outcome nicht nachweislich. Eine Entbindungsindikation ist in Abhängigkeit von Gallensäurenkonzentration und Gestationsalter gegeben. In Folgeschwangerschaften besteht ein hohes Wiederholungsrisiko.

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial

OBJECTIVE

To evaluate whether a particular group of women with intrahepatic cholestasis of pregnancy (ICP), based on their presenting characteristics, would benefit from treatment with ursodeoxycholic acid (UDCA).

DESIGN

Secondary analysis of the PITCHES trial (ISRCTN91918806).

SETTING

United Kingdom.

POPULATION OR SAMPLE

527 women with ICP.

METHODS

Subgroup analyses were performed to determine whether baseline bile acid concentrations or baseline itch scores moderated a woman's response to treatment with UDCA.

MAIN OUTCOME MEASURES

Bile acid concentration and itch score.

RESULTS

In women with baseline bile acid concentrations less than 40 μmol/l, treatment with UDCA resulted in increased post-randomisation bile acid concentrations (geometric mean ratio 1.19, 95% CI 1.00-1.41, P = 0.048). A test of interaction showed no significance (P = 0.647). A small, clinically insignificant difference was seen in itch response in women with a high baseline itch score (-6.0 mm, 95% CI -11.80 to -0.21, P = 0.042), with a test of interaction not showing significance (P = 0.640). Further subgroup analyses showed no significance. Across all women there was a weak relationship between bile acid concentrations and itch severity.

CONCLUSIONS

There was no subgroup of women with ICP in whom a beneficial effect of treatment with UDCA on bile acid concentration or itch score could be identified. This confirms that its routine use in women with this condition for improvement of bile acid concentration or itch score should be reconsidered.

TWEETABLE ABSTRACT

PITCHES: No group of women with ICP has been found in whom UDCA reduces bile acid concentrations or pruritus.