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JEFFREY J. CIES, PHARM.D., BCPS, is Pediatric Clinical Pharmacy Specialist, Department of Pharmacy, Temple University Children’s Medical Center, Philadelphia, PA. JOHN N. GIAMALIS, B.S.PHARM., is Pediatric Clinical Pharmacy Specialist, Alfred I. duPont Hospital for Children, Nemours Children’s Clinic, Wilmington, DE.

Address correspondence to Dr. Cies at the Department of Pharmacy, Temple University Children’s Medical Center, 3509 North Broad Street, Philadelphia, PA 19140 (jeffrey.cies{at}tuhs.temple.edu).

Purpose. The treatment of cholestatic pruritus in children is reviewed. Summary. Cholestasis is characterized by an accumulation of substances that are normally secreted in the bile. Pruritus is a well-known feature of chronic cholestasis in both adults and children and has been reported as the most incapacitating symptom in children with chronic liver disease. Traditional agents, such as antihistamines, are typically ineffective as monotherapy in controlling cholestatic pruritus. As a result, clinicians have looked to other agents, such as rifampin, phenobarbital, ursodiol, opioid antagonists, and bile-binding resins, for attaining better control of pruritic symptoms. Each agent demonstrates different levels of efficacy in pediatric and adult literature. There are no guidelines or algorithms to guide therapy with these agents for children. As a result, an agent should be selected based on the patient’s concurrent diseases and current medication regimen. Cholestyramine and ursodiol are both safe and inexpensive, with documented efficacy for cholestatic pruritus in children. Because cholestatic pruritus is likely a result of multiple mechanisms, combination therapy with agents that have differing mechanisms of action might be beneficial and could capitalize on potential synergy between the agents used. Future therapy for cholestatic pruritis may include serotonin antagonists, selective serotonin-reuptake inhibitors, and leukotriene antagonists. Conclusion. Depending on the underlying disease state resulting in cholestasis, phenobarbital, ursodiol, bile sequestering agents, and opioid antagonists appear to be most effective for treating pruritus related to intrahepatic cholestasis. Alternatively, rifampin appears to be the only agent with reported treatment efficacy for pruritus related to extrahepatic cholestasis. Index terms: Anticonvulsants; Antidepressants; Antihistamines; Antilipemic agents; Antituberculars; Bile acid resins; Bile acids; Cholestasis; Cholestyramine; Costs; Leukotriene antagonists; Mechanism of action; Opiate antagonists; Pediatrics; Phenobarbital; Pruritus; Rifampin; Toxicity; Ursodiol