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Use of Butorphanol as Treatment for Cholestatic Itch

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Abstract

Background

Pruritus is a debilitating symptom of cholestatic diseases such as primary biliary cholangitis and primary sclerosing cholangitis and often results in major reduction in quality of life for afflicted patients. Classic treatment options for the treatment of cholestatic pruritus include antihistamines, bile acid resins, serotonin reuptake inhibitors, and mu-opioid antagonists. Unfortunately, these drugs are not always successful in treating pruritus of cholestasis and may be associated with adverse effects. Recent advances in our understanding of itch pathophysiology have led to the use of butorphanol, a kappa-opioid agonist and mu-opioid antagonist, for the treatment of various forms of pruritus. Reports of butorphanol to treat cholestatic itch specifically are rare.

Aims

To better understand the role of butorphanol in the treatment of cholestatic pruritus, including characterization of its side effect profile.

Methods

We present a case series of eight adult patients with cholestatic disease who were treated with butorphanol in hopes of alleviating intractable pruritus. Patients were identified through a clinical data request form serviced by University of Miami Information Technology.

Results

Five out of eight patients (62.5%) reported successful reductions in itch severity after treatment with butorphanol, two patients reported no (or transient) change in itch severity, and one patient reported a paradoxical increase in itching. Side effects included somnolence, sedation, nausea, vomiting, and dizziness.

Conclusions

Butorphanol was safe and leads to clinically significant symptomatic improvement. Clinicians should be aware of butorphanol as an off-label treatment option for pruritus of cholestasis. Further studies are needed to better characterize the effect of butorphanol on cholestatic itch.

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Authors and Affiliations

Authors

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Correspondence to Cynthia Levy.

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Conflicts of interest

CL received consulting fees from CymaBay, Genfit, Pliant, Shire, GSK, Mirum, TARGET PharmaSolutions and Cara Therapeutics, research grants from CymaBay, Intercept, Genfit, Shire, GSK, Cara Therapeutics, TARGET PharmaSolutions, Novartis, Durect, Enanta, Genkyotex, Gilead, Alnylam, and Mitsubishi. CL is an associate editor for Liver Transplantation, committee participant at ABIM and receives royalties from Up-to-Date. GY reports grants and personal fees from Sanofi Regeneron, personal fees from TREVI, grants and personal fees from Pfizer, personal fees from Galderma, grants from Sun Pharma, grants and personal fees from Kiniksa, grants and personal fees from Menlo, personal fees from Eli Lily, grants and personal fees from Novartis, personal fees from Bellus, grants and personal fees from Leo, outside the submitted work. RSG has no conflicts of interest to disclose.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Golpanian, R.S., Yosipovitch, G. & Levy, C. Use of Butorphanol as Treatment for Cholestatic Itch. Dig Dis Sci 66, 1693–1699 (2021). https://doi.org/10.1007/s10620-020-06392-2

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  • DOI: https://doi.org/10.1007/s10620-020-06392-2

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