Treatment for primary biliary cholangitis (PBC) needs to be personalized when the first standard medicine does not work well enough, according to a recent review published in the journal Hepatology.
The first treatment for PBC is a medicine called ursodeoxycholic acid (UDCA). It helps patients live longer without needing a liver transplant and is generally considered very safe. However, UDCA doesn’t work well for everyone.
For patients who do not respond to UDCA alone, second-line treatment options are available, such as elafibranor and seladelpar, both approved by the FDA for PBC. (The first second-line therapy approved for PBC, obeticholic acid, was withdrawn from the U.S. market in September 2025 due to safety concerns.) Some doctors also use off-label drugs such as fenofibrate or bezafibrate. These therapies may help slow disease progression and improve symptoms like itching, which can greatly affect daily life.
However, scientists still do not know which second-line therapy works best overall. “At present, the lack of comparative effectiveness data precludes ranking these options,” the review’s authors said. Because of this, doctors must choose a therapy based on a patient’s individual case, such as their age, disease stage, symptoms, other medical conditions they have, other medicines they are taking, personal preferences, and drug availability and affordability.
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Not all patients can safely use the currently available second-line therapies. For example, none are recommended for people with decompensated cirrhosis (an advanced stage of liver disease marked by the deterioration of liver function) or those who develop PBC again after a liver transplant. Future studies should focus on finding effective treatment options for those who currently have none, the review authors said.
Researchers are now studying new approaches, including combining multiple medicines and testing drugs called ileal bile acid transporter (IBAT) inhibitors, which reduce bile acid build-up in the body and may lead to improvements in itching and liver health.
The review’s authors emphasize that personalized care begins with careful testing at the start of treatment, including liver blood tests and checks for liver scarring (fibrosis). Ongoing monitoring helps doctors see whether the disease is improving or getting worse.
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