Treatment of ICP: UDCA

The most commonly used treatment in ICP is a drug called ursodeoxycholic acid (also known as urso, UDCA, Actigall and ursodiol). UDCA is a naturally occurring bile acid that is present in your body in very small amounts. It may sound contradictory that taking an additional bile acid will help, but UDCA is different from the other bile acids. It is most likely that it works by improving the flow of bile and reducing the passage of harmful bile acids across the placenta. Although UDCA is not licensed for use in pregnancy (as is the case for many drugs), PITCHES, the most recent trial of the drug, showed that it is safe for women to take.

But despite these findings some researchers still felt that UDCA was beneficial to take, and the most recent research from Ovadia et al (2021) showed that it can reduce the risk of spontaneous premature birth, particularly for those women with bile acids over 40 µmol/L. There are also some experts in ICP who still believe that UDCA could protect those unborn babies whose mothers have very high bile acid levels.

How does UDCA work?

There are different types of bile acids, some of which are more harmful than others if present in high concentrations in the blood. For pregnancies complicated by cholestasis the bile acids that are elevated in the blood are relatively harmful ones that can cause harm to liver cells (and potentially to the baby). When women take UDCA in pregnancy the composition of the bile acids changes – while UDCA is now raised in the blood, it is a non-harmful bile acid, and it causes the concentration of the harmful bile acids to decrease. Ovadia (2019) showed that when women take UDCA, around 60% of the total bile acid pool is UDCA, making the bile acid pool less toxic.

Can UDCA protect your baby?

Some researchers believe that bile acids may affect the baby’s heart by causing very subtle heart arrhythmias (irregular heartbeats) and have conducted experiments to try to show this. They have grown rodent heart cells in a petri-dish in order to study what happens if bile acids are added to the beating heart cells. They found that if a small amount of bile acids are dropped onto the cells they will begin to beat out of time, and after a while they will stop beating altogether. However, they discovered that if they add UDCA before the cells stop beating this can reverse the effect and the heart cells will all start to beat in time again. Of course, experiments in the lab aren’t going to mimic exactly what is happening in the womb, but for the researchers it has been convincing enough to think that bile acids could be the cause of risk and that ursodeoxycholic acid may have some protective properties for the baby. Research that was being conducted to investigate the impact of bile acids on the fetal heart has now been published.

Will UDCA improve or get rid of your itch?

Trials showed that women who take UDCA typically only see a partial improvement in their itch, and some see none at all. Interestingly, although bile acids have been associated with the itching in ICP for many years, more recent studies have identified that two other substances in the blood, lysophosphatidic acid (LPA) and sulfated progesterone metabolites, are also raised in the blood of women with ICP and are implicated as other links in the cause of the itching. It could be that finding different treatments to reduce these substances may help with the itch.

So should you take UDCA?

This is something for you to talk to your doctors about, but given the research to show that UDCA can reduce the risk of spontaneous premature birth, and that it may reduce the itch a little, on balance we would say that it is still worth considering until a better drug can be identified. If your bile acids are extremely high and you have seen that there are other drugs that can be tried (such as rifampicin), talk to them about this and perhaps show them some research papers, which you can download here.