Dr. Richard Thompson: The investigation of pruritus really starts in a non-hepatology environment. The majority of people that are being seen by doctors with pruritus are not being seen by hepatologists. The reflex that most people think about is to liver function tests, which is usually transaminases and bilirubin, for instance. They may not be abnormal significantly in all these cases.

Dr. Robert Gish: So when I'm thinking about itch, this word pruritus, I'm really thinking in these patients, what's going on in their liver, in their liver cells? And to do that, I need this special genetics panel, because the genetics panel tells me where they have a variant. Then, in many patients, not everybody, there's an increase in bile acids. Bile acids are part of this cholestatic process. Bile acids are another type of liver function test. And the bile acids build up either in the liver, cause damage, build up in the bloodstream, in the body, contributing to or causing itching. And that really puts a whole envelope around the patient.

It's very interesting in the clinic environment to bring the patient into the room, or we enter the room, and we say, "Hello, how are you? How are you doing?" The patient says, "Fine." We say, "Oh, they're fine," so then we can just dig into lab tests or something else. See even the patient minimizes the impact of their disease because they don't want to bother the physician, the provider, the APPs that we work with.

There’s sort of this interaction between the patient and the providers where patients are often not forthcoming about what's really bothering them. They also suppress. I had a patient in clinic recently. I was asking about itching. He said, "I don't have any itching," while he's actively scratching himself right in front of me. I turned to his spouse and said, "What's really going on at home with itching?" And she said, "Oh, he's terrible. He's itching all night. He sleeps in a separate room." Yet the patient told me 2 minutes earlier he had no itching. So there's a lot of suppression that goes on also. You might even call it denial.

Dr. Richard Thompson: So I think doctors can be guilty of dismissing it and minimizing it. Patients can feel slightly embarrassed because to say, "I've got itch," doesn't sound like it's a big problem to many people. The truth is that some of these patients have got such severe pruritus that it is a big problem.