Primary biliary cholangitis of the liver brings on severe itching

I am an 85-year-old female who has had primary biliary cirrhosis of the liver for many years. I have been on 300 mg of ursodiol taken three times a day for all those years, with no problems until now. I currently have severe itching all over my body. I am now taking 4 g of cholestyramine a day to relieve this terrible itching, but after two weeks, I am not feeling any relief. Will this medication work? If so, how long before it does?

Primary biliary cholangitis (many still refer to it by its former name, primary biliary cirrhosis, even though many people never get cirrhosis) is an autoimmune disease, where the body attacks the bile ducts, leading to cholestasis (the lack of movement of bile).

It is a rare disease, much more common in women and usually diagnosed in middle age. It can be found by screening labs or with symptoms of fatigue, jaundice or itching.

Ursodeoxycholine (Ursodiol), first identified in bears, has been the mainstay of treatment with PBC and has improved the prognosis of this condition. It is used to slow progression of the disease and prevent the need for liver transplantation by preventing cirrhosis.

Ursodeoxycholine by itself may not treat itching particularly well, and nearly 80% of people with PBC will develop itching by 10 years of having the condition. Most people do well with the cholestyramine you were given, although the dose necessary is sometimes a lot higher. The dose is usually increased over weeks, so when you go back to your liver specialist, they may increase the dose. Be sure not to take ursodeoxycholine near the time you take the cholestyramine.

There are other options, including rifampin and naltrexone, if the cholestyramine does not work for you. Also, the itching in PBC sometimes comes and goes for no apparent reason.

I'm curious about the effect of tart cherry juice on gout that you mentioned in a recent column. Any idea why? What's unique in tart cherry juice? Does non-tart cherry juice work? What about tart strawberry or apple juice?

There are several varieties of cherries, with most people being familiar with Bing and Rainier

cherries. Tart (Montmorency) cherries have been touted as having many health benefits, but regular cherries show a reduction in gout attacks. In the study, 10-12 cherries twice daily reduced gout attacks by 35%. (People with diabetes might not be appropriate for as much fruit intake.) Unfortunately, alcohol and meals prone to cause gout flare-ups (such as shellfish) make the cherry intake less effective.

A separate trial on tart cherry juice did not find a benefit in reducing gout risk. Gout is caused by deposition of uric acid crystals, and most medications to reduce gout attacks focus on reducing uric acid in the blood. But there seems to be something specific in cherries — a class of compounds called anthocyanins (found in cherries in high levels) are known to have anti-inflammatory effects. Other fruits, specifically strawberries, grapes and kiwi, were tested and did not have the beneficial effects on the blood uric acid level that cherries did.

Cherries are not as effective as prescription medication, such as allopurinol, but may be helpful in people with very mild disease or who aren't controlled with allopurinol.

Contact Dr. Roach at ToYourGoodHealth@med. cornell.edu.

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