Guide to treatments for itching and fatigue with primary biliary cholangitis (PBC)

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

Most people don’t have symptoms when they’re first diagnosed with primary biliary cholangitis (PBC) — a progressive autoimmune condition that damages bile ducts in the liver. However, the majority of people go on to develop symptoms within two decades of diagnosis.

The two most common PBC symptoms are fatigue and itching, according to Mayo Clinic expert and liver specialist Kymberly D. Watt, M.D. These symptoms may sound mild, but depending on the severity, they can range from frustrating to debilitating.

Treatments that address the symptoms of a disease rather than the underlying cause are especially important when it comes to managing PBC and simply enjoying day-to-day life.

Below, Dr. Watt goes over everything you need to know about itching and fatigue, including your treatment options.

Understanding fatigue and itching with PBC

Fatigue is often the most challenging symptom for people with PBC. An estimated 80% of people develop this symptom at some point in their disease. However, researchers don’t yet fully understand why or how fatigue develops with PBC, so there are limited options when it comes to effectively targeting and treating this symptom. Medications such as antidepressants and stimulants, for example, have been studied but are ineffective for treating fatigue.

In addition, Dr. Watt says itching often goes hand-in-hand with chronic exhaustion. “People who have trouble with itchy skin tend to have poor sleep, and not surprisingly, poor sleep worsens all other symptoms of PBC, in particular fatigue,” says Dr. Watt. Itching — which is especially common at night for many people with PBC — has been associated with sleep deprivation, depression and social isolation. In short, itching and fatigue can form a frustrating feedback loop. For many people with PBC, these symptoms can significantly lower their overall quality of life.

According to Dr. Watt, the first line of defense against PBC symptoms is treating the underlying condition through medication. “Fatigue is exceedingly hard to treat other than treating the underlying disease,” Dr. Watt says. “Itching can get better by improving underlying disease, but it still may also require additional medications or treatment to achieve better management.”

Typically, the gold standard for PBC treatment is ursodeoxycholic acid (UDCA), a medication that can slow the progression of inflammation and scarring. Most commonly, people take UCDA every day in pill form. If your body doesn’t respond to UCDA after 6 to 12 months, your healthcare team may recommend adding additional medications, such as obeticholic acid (Ocaliva), seladelpar (Livdelzi), elafibranor (Iqirvo) or fenofibrate (Lipofen, Triglide). If you have advanced PBC, your healthcare team also may discuss liver transplantation.

Specific treatments for PBC fatigue and itching

In addition to first line treatments for PBC, a number of additional strategies can help you manage your PBC symptoms, says Dr. Watt, including:

Medication.

There are a number of prescription options to help target and relieve itch, including antibiotics such as rifampin (Rimactane), certain selective serotonin reuptake inhibitors (SSRIs) and opioid antagonists. As always, speak with your healthcare team to determine the best option for you.

Antihistamines.

Antihistamines are often used to treat common allergy symptoms, such as runny nose, watery eyes and sneezing. But Dr. Watt says antihistamines can also help improve both sleep and itching. Consider trying diphenhydramine (Benadryl) or loratadine (Alavert, Claritin) or discussing prescription options with your healthcare team.

Topical lotions.

Topical lotions and ointments applied directly to the skin also can bring itch relief, according to Dr. Watt. Products that include menthol or other cooling agents, in particular, can be simple, cheap and effective.

Consider mindfulness.

“Practices such as meditation or yoga also may help some people manage both fatigue and itch,” says Dr. Watt. Meditation, in particular, has been shown to boost mood and concentration and improve insomnia, sleep quality and stress. Next time you are having trouble falling asleep or are feeling overwhelmed by your symptoms, consider taking a few minutes to practice mindfulness. You might focus on your breathing, take a short, intentional walk, or use your senses to notice and accept your environment.

Avoid tight clothing.

Though it sounds simple, paying attention to your wardrobe choices can have a big impact on the severity of itching. Rather than choosing tight, structured or form-fitting clothing, Dr. Watt advises wearing loose clothing to avoid skin irritation.

Emphasize good sleep hygiene.

Perhaps unsurprisingly, practicing good sleep habits may help you manage fatigue. Stick to a regular bedtime, avoid light and sound before bed, and set up a comfortable, dark environment in your bedroom. It’s also a good idea to avoid screen time an hour before bed. Better yet, leave your phone charging in a different room at night. If you still can’t fall asleep, try getting out of bed for some light stretching, a brief meditation or another relaxing activity that can help you fall asleep. Staying active during the day also can help get you tired for bed at night. And as a bonus, physical movement can help keep your mind off itching, says Dr. Watt.

Work with your healthcare team to manage PBC

Learning to live with a chronic condition like PBC and manage symptoms can certainly take a toll. But there are options.

If you are having difficulty managing fatigue and itching — or any other symptoms of PBC — don’t go it alone. Talk with your healthcare team about your options and develop a treatment plan that works.

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

Relevant reading

Back and Neck Health

Back and neck pain are common complaints. When you think of all of the work that your back and neck do each day — constantly moving, bending and twisting as you go about your day-to-day activities — it’s not surprising that problems develop. But just as doing too much can…