Treatment of itching associated with intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy: an evaluation of obstetric management in German maternity units

Purpose

Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse fetal and neonatal outcome. Evidence for improvement by obstetric management is sparse. Common international guidelines recommend induction of labor before term, however, they differ in recommendations of monitoring the disease and time point of active management. So far, an official guideline for treatment and management of ICP in Germany does not exist. This study aims to compile common practice and policy in obstetric management of ICP in German maternity units. The objective is to gather obstetricians’ opinion on management of ICP, and to estimate the need for standardization of current practice in Germany on the background of existing evidence.

Methods

A questionnaire focusing on indications for interventions was developed including fourteen multiple-choice questions comprising the areas of diagnostic criteria, laboratory testing, fetal monitoring, treatment, and delivery timing. The survey was sent to 699 maternity clinics and was distributed to participants of the annual congress hosted by the German society of perinatal medicine (DGPM). Collected data were summarized and evaluated in relation to available evidence and existing guidelines. Descriptive statistics and Fisher's exact test were used.

Results

334 completed questionnaires returned corresponding to a response rate of 48.1%. Coinciding with existing international guidelines, 48.8% of the participants acknowledge bile acid concentrations above 10 µmol/L to be indicative of ICP. 85.0% of obstetricians recommend antenatal testing with cardiotocography, exceeding common standards of maternity policy guidelines; 50.3% execute active management in ICP-affected pregnancies as they generally recommend a delivery between 37 + 0 and 38 + 6 weeks of gestation. Although recent studies evinced a risk of stillbirth in ICP-affected pregnancies not until a bile acid concentration of > 100 µmol/L, 22.2% of the respondents recommend delivery before 37 + 0 weeks of gestation due to raised bile acids of 40–99 µmol/L.

Conclusions

Opinions on the management of ICP in German maternity units differ widely and partly deviate by large from international standards. Reasons for this may be the lack of a national guideline and the low awareness due to the rarity of the disease on the one hand and the very slow dynamics in evidence generation and thus the uncertainty about the actual risks and optimal management on the other. The present data highlight the need for further research and clinical guidelines to standardize and optimize treatment based on the best available evidence.

MRGPRX4 is a bile acid receptor for human cholestatic itch

Patients with liver diseases often suffer from chronic itch, yet the pruritogen(s) and receptor(s) remain largely elusive. Here, we identify bile acids as natural ligands for MRGPRX4. MRGPRX4 is expressed in human dorsal root ganglion (hDRG) neurons and co-expresses with itch receptor HRH1. Bile acids elicited Ca²⁺ responses in cultured hDRG neurons, and bile acids or a MRGPRX4 specific agonist induced itch in human subjects. However, a specific agonist for another bile acid receptor TGR5 failed to induce itch in human subjects and we find that human TGR5 is not expressed in hDRG neurons. Finally, we show positive correlation between cholestatic itch and plasma bile acids level in itchy patients and the elevated bile acids is sufficient to activate MRGPRX4. Taken together, our data strongly suggest that MRGPRX4 is a novel bile acid receptor that likely underlies cholestatic itch in human, providing a promising new drug target for anti-itch therapies.

Management of intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease during pregnancy, characterized by otherwise unexplained pruritus in late second and third trimester of pregnancy and elevated bile acids and/or transaminases. ICP is associated with an increased risk of adverse perinatal outcomes for the fetus and the later development of hepatobiliary disease for the mother. Bile acids should be monitored throughout pregnancy since fetal risk is increased at serum bile acids >40 µmol/l. Management of ICP consists of treatment with ursodeoxycholic acid, which reduces pruritus. Early elective delivery is common practice but should be performed on an individualized basis as long as strong evidence supporting this practice is lacking. Mothers should be followed-up for normalization of liver function tests 6-12 weeks after delivery. Future research in large-scale studies is needed to address the impact of ursodeoxycholic acid and early elective delivery on fetal outcome.

Sulfotransferase genes: regulation by nuclear receptors in response to xeno/endo-biotics

Pregnane X receptor (PXR) and constitutive active/androstane receptor (CAR), members of the nuclear receptor superfamily, are two major xeno-sensing transcription factors. They can be activated by a broad range of lipophilic xenobiotics including therapeutics drugs. In addition to xenobiotics, endogenous compounds such as steroid hormones and bile acids can also activate PXR and/or CAR. These nuclear receptors regulate genes that encode enzymes and transporters that metabolize and excrete both xenobiotics and endobiotics. Sulfotransferases (SULTs) are a group of these enzymes and sulfate xenobiotics for detoxification. In general, inactivation by sulfation constitutes the mechanism to maintain homeostasis of endobiotics. Thus, deciphering the molecular mechanism by which PXR and CAR regulate SULT genes is critical for understanding the roles of SULTs in the alterations of physiological and pathophysiological processes caused by drug treatment or environmental exposures.

Specific Pregnancy Dermatoses in 1430 females from Northern India

BACKGROUND

The specific dermatoses of pregnancy represent a heterogenous group of ill-defined pruritic skin diseases, unique to pregnancy and post partum period.

OBJECTIVE

The aim of our study was epidemiological and clinical evaluation of various specific dermatoses of pregnancy.

METHODS

All patients visiting our antenatal clinic were screened for various pruritic skin conditions and those with specific pregnancy dermatoses were identified and evaluated.

RESULTS

Out of 1430 patients screened, nearly 5% (70 cases) patients had specific dermatoses of pregnancy. Intra hepatic cholestasis was the commonest specific pregnancy dermatoses.

CONCLUSION

Specific dermatoses of pregnancy can be diagnosed primarily on the basis of clinical features. All of these, except intra hepatic cholestasis, do not have any effect on normal course of pregnancy.

Dexamethasone in the treatment of obstetric cholestasis: A case series

Twelve women with obstetric cholestasis were given dexamethasone after failure to respond to ursodeoxycholic acid. Clinical improvement was achieved in eight cases, without complete resolution of symptoms. Biochemical response was achieved in seven cases. All but two cases had good correlation between clinical and biochemical response. Women of Asian and South American origin were more likely to respond to dexamethasone than Caucasians. There were no reported maternal or fetal side-effects. However, the subsequent consequences of dexamethasone treatment for the mother and fetus have not been thoroughly evaluated. Therefore, even in Asian and South American women, larger studies of dexamethasone are required before this treatment can be recommended as a universally safe and effective treatment for obstetric cholestasis.

Intrahepatic cholestasis of pregnancy in women with a multiple pregnancy: an analysis of risks and pregnancy outcomes

OBJECTIVE

This study was conducted to assess the incidence and perinatal outcomes of multiple pregnancies complicated by intrahepatic cholestasis of pregnancy in an urban population.

METHODS

We performed a retrospective chart review of all multiple gestation deliveries at our institution between January 2004 and December 2005. Antepartum and delivery data were collected for all patients. Symptoms and treatment were also abstracted for patients in whom intrahepatic cholestasis was diagnosed. We used the Student two-tail t test and Fisher exact test to examine the differences between multiple gestation pregnancies with and without cholestasis of pregnancy.

RESULTS

Data were available for 263 multiple pregnancies. The incidence of cholestasis was 4.2% (11/263), with a mean onset at 29.4 weeks. There were no differences in mean gestational age at delivery, preterm delivery rate, meconium histiocytosis, incidence of preeclampsia, or incidence of postpartum hemorrhage between women with and those without cholestasis. There were no intrauterine fetal deaths in the cholestasis group.

CONCLUSION

Women with multiple gestations complicated by cholestasis of pregnancy do not have increased adverse perinatal outcomes. The absence of unexplained fetal demise may be a result of routine delivery before 40 weeks' gestation in multiple pregnancies.

Intrahepatic cholestasis of pregnancy-current achievements and unsolved problems

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disorder. Maternal effects of ICP are mild; however, there is a clear association between ICP and higher frequency of fetal distress, preterm delivery, and sudden intrauterine fetal death. The cause of ICP remains elusive, but there is evidence that mutations in genes encoding hepatobiliary transport proteins can predispose for the development of ICP. Recent data suggest that ursodeoxycholic acid is currently the most effective pharmacologic treatment, whereas obstetric management is still debated. Clinical trials are required to identify the most suitable monitoring modalities that can specifically predict poor perinatal outcome. This article aims to review current achievements and unsolved problems of ICP.

Phenobarbital Confers its Diverse Effects by Activating the Orphan Nuclear Receptor Car

In the early 1960s, phenobarbital (PB) was shown to induce hepatic drug metabolism and the induction was implicated in the molecular mechanism of drug tolerance development. Since then, it has become evident that PB not only induces drug metabolism, but also triggers pleiotropic effects on liver function, such as cell growth and communication, proliferation of the endoplasmic reticulum, tumor promotion, glucose metabolism, steroid/thyroid hormone metabolism, and bile acid synthesis. Upon activation by PB and numerous PB-type inducers, the nuclear receptor CAR mediates those pleiotropic actions by regulating various hepatic genes, utilizing multiple regulatory mechanisms.

Gastrointestinal medications in pregnancy

Management of the pregnant patient presents unique challenges to the treating physician. Current Food and Drug Administration classifications do not necessarily reflect clinical experience or recent literature. Ideally, one should use the lowest-risk drug possible, with attention to the appropriate level of efficacy for the patient's condition, the stage of pregnancy and dose adjustment. Every treatment decision should be fully discussed with the patient and a multidisciplinary team that should include the obstetrician and, if appropriate, the paediatrician. This review will cover the medications commonly used to treat gastrointestinal disease. The majority of medications can be categorised as 'low risk' or 'should be avoided'. The following medications should never be used during pregnancy due to the clear risk of teratogenicity or adverse events: bismuth, castor oil, sodium bicarbonate, methotrexate, ribavirin, doxycycline, tetracycline, and thalidomide.

Intrahepatic cholestasis of pregnancy: review of the literature and evaluation of current evidence

OBJECTIVE

To provide an overview of the epidemiology, etiology, pathogenesis, diagnosis, and management of intrahepatic cholestasis of pregnancy.

METHODS

We searched the Medline and PubMed database using the key words intrahepatic cholestasis of pregnancy, obstetric cholestasis, diagnosis, management, and complications.

RESULTS

Intrahepatic cholestasis of pregnancy, or obstetric cholestasis, is a liver condition that develops during pregnancy. It is associated with increased perinatal morbidity and mortality. Pruritus and risk of postpartum hemorrhage are the main causes of maternal morbidity. Intrahepatic cholestasis of pregnancy is a diagnosis of exclusion. The current management policies depend on regular fetal and maternal monitoring and delivery at fetal maturity. The analysis of the quality of previous studies provided in this review highlights the areas of deficiency in evidence-based knowledge of this subject.

CONCLUSIONS

More research is required into the etiology, pathogenesis, and monitoring modalities that can specifically predict fetal outcome in intrahepatic cholestasis of pregnancy. Clinical trials are required to identify the most suitable drugs for treatment.

Short communication: Consensus on the management of obstetric cholestasis: National UK survey

An anonymous questionnaire was sent to the lead consultant obstetricians and the midwives in charge of the antenatal clinics of all maternity units in UK to determine their current views on the diagnosis and management of obstetric cholestasis (OC). The response rate was 60%. Management policies were broadly similar and consistent with those recommended in the current literature. However, the survey highlighted areas for improvement. Based on the findings of this survey, a consensus view of the management of OC in UK is achievable.

Pediatric median neuropathy due to pruritus in Alagille syndrome

Median entrapment neuropathy or carpal tunnel syndrome is uncommon in children. The majority of cases are related to genetic conditions which result in skeletal dysplasia or altered connective tissue characteristics, direct injury to the median nerve caused by intensive sports or trauma, or hereditary neuropathy with liability to pressure palsies. This report describes a 10-year-old patient with Alagille syndrome who presented with poor fine motor skills because of an entrapment neuropathy of the median nerve at the wrist. This condition was probably caused by intermittent external compression at the wrists due to years of rubbing both wrists and hands to relieve pruritus. To our knowledge, median neuropathy has never been associated with Alagille syndrome, although severe pruritus is considered a major symptom and many patients exhibit widespread scratching and rubbing.

American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on February 22, 2006 and by the AGA Institute Governing Board on April 20, 2006.

Ursodeoxycholic acid treatment of vanishing bile duct syndromes

Vanishing bile duct syndromes (VBDS) are characterized by progressive loss of small intrahepatic ducts caused by a variety of different diseases leading to chronic cholestasis, cirrhosis, and premature death from liver failure. The majority of adult patients with VBDS suffer from primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). Ursodeoxycholic acid (UDCA), a hydrophilic dihydroxy bile acid, is the only drug currently approved for the treatment of patients with PBC, and anticholestatic effects have been reported for several other cholestatic syndromes. Several potential mechanisms of action of UDCA have been proposed including stimulation of hepatobiliary secretion, inhibition of apoptosis and protection of cholangiocytes against toxic effects of hydrophobic bile acids.

Efficacy and safety of ursodeoxycholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy

BACKGROUND & AIMS

Treatment of intrahepatic cholestasis of pregnancy with ursodeoxycholic acid appears promising, but data are limited so far. The aim of this randomized study was to evaluate the efficacy and safety of ursodeoxycholic acid in comparison with cholestyramine.

METHODS

Eighty-four symptomatic patients with intrahepatic cholestasis of pregnancy were randomized to receive either ursodeoxycholic acid, 8-10 mg/kg body weight daily (n = 42), or cholestyramine, 8 g daily (n = 42), for 14 days. The primary end point was a reduction of pruritus by more than 50% after 14 days of treatment as evaluated by a pruritus score. Secondary end points were outcome of pregnancy, reduction of serum aminotransferase activities and serum bile acid levels, and drug safety. Intention-to-treat analysis was applied.

RESULTS

Pruritus was more effectively reduced by ursodeoxycholic acid than cholestyramine (66.6% vs 19.0%, respectively; P < .005). Babies were delivered significantly closer to term by patients treated with ursodeoxycholic acid than those treated with cholestyramine (38.7 +/- 1.7 vs 37.4 +/- 1.5 weeks, respectively, P < .05). Serum alanine and aspartate aminotransferase activities were markedly reduced by 78.5% and 73.8%, respectively, after ursodeoxycholic acid, but by only 21.4%, each, after cholestyramine therapy (P < .01 vs ursodeoxycholic acid). Endogenous serum bile acid levels decreased by 59.5% and 19.0%, respectively (P < .02). Ursodeoxycholic acid, but not cholestyramine was free of adverse effects.

CONCLUSIONS

Ursodeoxycholic acid is safe and more effective than cholestyramine in intrahepatic cholestasis of pregnancy.

An itching and excoriated dermatosis during intrahepatic cholestasis of pregnancy

A 35-year-old woman at 30th gestation week of her second pregnancy presented to our department with a 2-month history of intense and generalized pruritus. She had a spontaneous abortion 1 year earlier. Itching initially presented during nighttime and localized on lower limbs and after became continuous, diffuse, and associated with excoriations due to scratching. The patient was previously treated with oral corticosteroids (25 mg/d) in a gynecological department with temporary response. On our examination, she presented linear excoriations with hemorrhagic crusts localized on the trunk, buttocks, and upper and lower limbs. Biopsy specimen from the lesional area of the right buttock submitted for routine histology documented a mild perivascular and interstitial infiltrate of lymphocytes and monocytes with rare eosinophils on superficial dermis. Indirect and direct immunofluorescence (performed on perilesional skin) were negative. Laboratory investigations revealed microcytic anemia (hemoglobin 7.5 g/dL; medium corpuscular volume 61.7 fl), erythrocyte sedimentation rate (21 mm) and serum bile acid levels (18.3 nmol/L; normal values 1.00-8.90) increase. On the basis of clinical, serological, and histological findings, we diagnosed an itching dermatosis during an intrahepatic cholestasis of pregnancy. We treated the patient with ursodeoxycholic acid (600 mg) and topical corticosteroids with gradual resolution of itching. Furthermore, she delivered a healthy boy at 39th gestation week with normal birth weight and normal Apgar score.

The constitutive androstane receptor and pregnane X receptor function coordinately to prevent bile acid-induced hepatotoxicity

A double null mouse line (2XENKO) lacking the xenobiotic receptors CAR (constitutive androstane receptor) (NR1I3) and PXR (pregnane X receptor) (NR1I2) was generated to study their functions in response to potentially toxic xenobiotic and endobiotic stimuli. Like the single knockouts, the 2XENKO mice are viable and fertile and show no overt phenotypes under normal conditions. As expected, they are completely insensitive to broad range xenobiotic inducers able to activate both receptors, such as clotrimazole and dieldrin. Comparisons of the single and double knockouts reveal specific roles for the two receptors. Thus, PXR does not contribute to the process of acetaminophen hepatotoxicity mediated by CAR, but both receptors contribute to the protective response to the hydrophobic bile acid lithocholic acid (LCA). As previously observed with PXR (Xie, W., Radominska-Pandya, A., Shi, Y., Simon, C. M., Nelson, M. C., Ong, E. S., Waxman, D. J., and Evans, R. M. (2001) Proc. Natl. Acad. Sci. U. S. A. 98, 3375-3380), pharmacologic activation of CAR induces multiple LCA detoxifying enzymes and provides strong protection against LCA toxicity. Comparison of their responses to LCA treatment demonstrates that CAR predominantly mediates induction of the cytochrome p450 CYP3A11 and the multidrug resistance-associated protein 3 transporter, whereas PXR is the major regulator of the Na+-dependent organic anion transporter 2. These differential responses may account for the significant sensitivity of the CAR knockouts, but not the PXR knockouts, to an acute LCA dose. Because this sensitivity is not further increased in the 2XENKO mice, CAR may play a primary role in acute responses to this toxic endobiotic. These results define a central role for CAR in LCA detoxification and show that CAR and PXR function coordinately to regulate both xenobiotic and bile acid metabolism.

Cholestatic syndromes

Further insights into the cellular and molecular mechanisms underlying hepatobiliary transport function and its regulation now permit a better understanding of the pathogenesis and treatment options of cholestatic liver diseases. Identification of the molecular basis of hereditary cholestatic syndromes will result in an improved diagnosis and management of these conditions. New insights into the pathogenesis of extrahepatic manifestations of cholestasis (eg, pruritus) have facilitated new treatment strategies. Important new studies have been published about the pathogenesis, clinical features, diagnosis, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, drug-induced cholestasis, and viral cholestatic syndromes.

Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (or obstetric cholestasis) is a liver disorder that occurs in late pregnancy. Despite the potential adverse maternal and fetal/neonatal outcomes, cholestasis of pregnancy is often neglected and treated expectantly. More research is needed to improve the molecular and genetic understanding of the disease and to define a safe and effective medical treatment that improves clinical outcome. Ursodeoxycholic acid is considered to be a safe treatment option in the third trimester, but further randomized controlled trials are needed before ursodeoxycholic acid treatment can be generally recommended. Ursodeoxycholic acid is preferentially administered to patients with severe cholestasis (onset before week 33 or serum bile acid levels > 70 mmol/L) or to patients with a history of sudden fetal death, while maintaining close obstetric and regular biochemical surveillance (transaminases, bilirubin, and bile acid levels). Ursodeoxycholic acid can decrease pruritus and ameliorate liver tests, but effects on obstetric complications are ambiguous. S-Adenosylmethionine, dexamethasone, and cholestyramine can provide some relief of itching. Because none of these drugs have been shown to be harmful to mother or fetus, the individual woman and her clinician may decide whether to try one of the treatments described.