Background Cholestatic itch is caused by intra-hepatic liver diseases such as primary biliary cirrhosis, and extra-hepatic obstruction of the biliary tree, often caused by tumours. The pathophysiology of cholestatic itch is complex and no single treatment has proved definitive. Naltrexone is an opioid receptor antagonist, which reduces central opioidergic tone, believed to be raised in patients with cholestatic pruritis.

Aim To review and assess the efficacy of oral naltrexone for the treatment of cholestatic itch.

Methods Search of electronic databases, grey literature, clinical trials registries and handsearching for studies including naltrexone for cholestatic itch. Full papers were obtained if relevant and studies graded.

Results 13 papers were included in the analysis, including 3 randomised controlled trials, 1 controlled clinical trial, 1 open-label pilot study, 7 case reports and 1 retrospective notes review. All studies found naltrexone to be effective in relieving pruritis. In all 5 studies performing statistical analysis, naltrexone significantly reduced pruritis compared to baseline. 37% of patients reported side effects, notably opioid withdrawal-type reactions and recurrence of previous pain, from all pathologies.

Conclusions Oral naltrexone therapy helps relieve cholestatic itch and although it should be used with caution in patients using exogenous opioids for analgesia, it should be considered when treating refractory pruritis in patients with end-stage liver disease.