The American Gastroenterological Association and the American Association for the Study of Liver Diseases convened a joint panel, using systematic reviews and GRADE, to address six priority questions in adults with primary biliary cholangitis. The guideline was published on 1 November.
The six recommendations cover: using PBC-specific antinuclear antibodies when PBC is suspected but antimitochondrial antibodies are negative; ursodeoxycholic acid as first-line therapy; liver stiffness measurement for prognosis; PPAR agonists for patients with an inadequate response to, or intolerance of, UDCA; linerixibat, an ileal bile acid transporter inhibitor, for moderate to severe pruritus; and UDCA after liver transplantation to reduce recurrence. Certainty of evidence ranged from moderate to very low.
The guideline's thrust is risk-based escalation: diagnose early, optimise UDCA, assess response and stiffness, and add second-line therapy for those not responding. That framework applies everywhere, even where newer agents are unavailable.
In India, PPAR agonists licensed for PBC and linerixibat have limited availability. Ensuring UDCA is correctly dosed by weight and response is reassessed is the step most clinics can take now.
- Test PBC-specific antinuclear antibodies when PBC is suspected but antimitochondrial antibodies are negative.
- Start ursodeoxycholic acid as first-line therapy in all patients with PBC, dosed by weight.
- Assess biochemical response to UDCA and use liver stiffness to stratify risk.
- Consider a PPAR agonist, where available, for inadequate response or intolerance to UDCA.
- Consider UDCA after liver transplantation for PBC to reduce recurrence.
Why it matters
It turns PBC care into a structured, risk-based pathway rather than UDCA alone indefinitely.
Don't overread it
Several recommendations rest on low or very low certainty evidence.
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