AASLD and AGA set out six recommendations for primary biliary cholangitis

The American Association for the Study of Liver Diseases and the American Gastroenterological Association have issued a joint guideline on primary biliary cholangitis (PBC), built on systematic reviews of six priority questions using GRADE. Published in Hepatology on 22 October 2026.

The six recommendations cover: testing PBC-specific antinuclear antibodies when antimitochondrial antibodies are negative but PBC is suspected; ursodeoxycholic acid (UDCA) as first-line therapy; liver stiffness measurement for prognosis; PPAR agonists for patients with an inadequate response to, or intolerance of, UDCA; linerixibat for moderate to severe cholestatic pruritus; and UDCA after liver transplantation to reduce recurrence.

The shift is towards risk-based escalation: measure response to UDCA, use stiffness to judge risk, and add second-line therapy early when response is incomplete. Certainty ranged from moderate to very low.

Availability of the newer second-line agents and linerixibat in India is limited or unknown. UDCA, liver stiffness and antibody testing are widely accessible.

• Test PBC-specific antinuclear antibodies when antimitochondrial antibodies are negative but cholestasis suggests PBC
• Start ursodeoxycholic acid as first-line therapy, dosed by weight
• Assess biochemical response to UDCA at about 12 months
• Use liver stiffness measurement to stratify risk
• Refer patients with an inadequate response for second-line therapy

Why it matters

PBC care is moving from one drug for everyone to measured response and early escalation.

Don't overread it

Several recommendations rest on low or very low certainty evidence.

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