Why are Bile Acid Sequestrants not preferred in the management of cholestatic pruritus in the palliative population?

Varying aetiology (pruritus might not be attributed to increased circulating bile acids only and other pathways are involved),

unfavourable side effect profile (especially Constipation and bloating),

practical issues (powder requiring dilution – volume of administration, multiple doses),

tendency for drug-drug interactions,

a delayed onset of action and

presence of better alternatives
preclude their use in the palliative population.

References

Kuiper, E. M. M., van Erpecum, K. J., Beuers, U., & van Buuren, H. R. (2010). The potent bile acid sequestrant colesevelam is not effective in cholestatic pruritus: Results of a randomized, double-blind, placebo-controlled trial. Hepatology, 52(4), 1334–1340. https://doi.org/10.1002/hep.23831

Tandon, P., Rowe, B. H., Vandermeer, B., Bain, V. G., & Montori, V. M. (2007). The efficacy and safety of treatments for patients with cholestatic pruritus: A systematic review and meta-analysis. The American Journal of Gastroenterology, 102(7), 1528–1536. https://doi.org/10.1111/j.1572-0241.2007.01224.x

Beuers, U., Kremer, A. E., Bolier, R., & Elferink, R. P. J. O. (2014). Pruritus in cholestasis: Facts and fiction. Hepatology, 60(1), 399–407. https://doi.org/10.1002/hep.26909

European Association for the Study of the Liver. (2009). EASL clinical practice guidelines: Management of cholestatic liver diseases. Journal of Hepatology, 51(2), 237–267. https://doi.org/10.1016/j.jhep.2009.04.009

Weisshaar, E., Szepietowski, J. C., Dalgard, F. J., et al. (2019). European guideline on chronic pruritus. Acta Dermato-Venereologica, 99(5), 469–506. https://doi.org/10.2340/00015555-3164

Twycross, R., Wilcock, A., & Howard, P. (Eds.). (2020). Palliative Care Formulary (6th ed.). Nottingham, UK: Palliativedrugs.com Ltd.