LETTER
Pruritus Associated with Cholestatic Liver Disease
Y. Horsmans, MD, and
A.P. Geubel, MD
15 October 1996 | Volume 125 Issue 8 | Page 701
TO THE EDITOR:
Pruritus is a frequent complication of cholestatic liver disease. The disorder may be disabling, especially in patients with primary biliary cirrhosis. The mechanism of pruritus remains unknown. Treatments proposed to relieve pruritus include bile acid-sequestering resin, phenobarbital, rifampicin, and naloxone [1, 2]. All of these drugs are associated with a highly variable response rate, with some patients having a poor or no response. We report an impressive effect of grapefruit juice in the treatment of severe pruritus.
Five patients with primary biliary cirrhosis were treated using grapefruit juice (600 mL daily) to relieve severe pruritus. All patients responded poorly or not at all to bile acid-sequestering resin, phenobarbital, or rifampicin. Pruritus resolved within 24 to 48 hours after administration of grapefruit juice. The effect of the juice was clearly dose-dependent, and pruritus returned shortly after grapefruit juice was withdrawn. A similarly favorable effect was seen in a patient whose pruritus was due to severe cholestatic hepatitis secondary to clavulanic acid and amoxicillin hepatotoxicity. In this case, severe pruritus was unaltered by the administration of cholestyramine and cetirizine dihydrochloride. In contrast, intake of grapefruit juice did not relieve pruritus that occurred during the course of chronic hepatitis C and without cholestasis in three patients.
This observation, although preliminary, strongly suggests that grapefruit juice may have a potent antiprurogenic effect. This impressive effect was only seen in the presence of cholestasis. Because grapefruit juice contains flavonoids, which have been shown to inhibit cytochrome P-450 enzymes belonging to families 1A, 2A, and 3A [3-5], it is tempting to speculate that the metabolism of putative prurigeneous substances released by the liver could be modulated by flavonoids.
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Author and Article Information
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Louvain Medical School, 1200 Brussels, Belgium
1. Jones EA, Bergasa NV. The pruritus of cholestasis. From bile acids to opiate agonists. Hepatology. 1990; 11:884-7.
2. Bergasa NV, Talbot TL, Alling DW, Schmitt JM, Walker EC, Baker BL, et al. A controlled trial of naloxone infusions for the pruritus of chronic cholestasis. Gastroenterology. 1992; 102:544-9.
3. Fuhr U, Klittich K, Staib AH. Inhibitory effect of grapefruit juice and its bitter principal, naringenin on CYP1A2 dependent metabolism of caffeine in man. Br J Clin Pharmacol. 1993; 35:431-6.
4. Merkel U, Sigusch H, Hoffman A. Grapefruit juice inhibits 7-hydroxylation of coumarin in healthy volunteers. Eur J Clin Pharmacol. 1994; 46:175-7.
5. Yee GC, Stanley DL, Pessa LJ, Dalla Costa T, Beltz SE, Ruiz J, et al. Effect of grapefruit juice on blood cyclosporin concentration. Lancet. 1995; 345:955-6.
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