Liver transplantation for intractable pruritus is contraindicated before an adequate trial of opiate antagonist therapy.

A woman with stage III (pre-cirrhotic) primary biliary cirrhosis was referred for liver transplantation because of intractable pruritus. Oral administration of 50 mg naltrexone precipitated a severe opioid withdrawal-like reaction. Subsequently, when oral naltrexone therapy was reintroduced following a cautious infusion of naloxone, no reaction occurred and the pruritus resolved completely. Liver transplantation should not be considered for apparently intractable pruritus of cholestasis before an adequate trial of opiate antagonist therapy.