Are Clinicians Ready for Safe Use of Stratified Therapy in Primary Biliary Cholangitis (PBC)? A Study of Educational Awareness

Dig Dis Sci. 2018 Oct;63(10):2547-2554. doi: 10.1007/s10620-018-5074-8. Epub 2018 May 8.


Background: Primary Biliary Cholangitis (PBC, formerly cirrhosis), is a chronic cholestatic liver disease which until spring 2016 had a single licensed therapy, Ursodeoxycholic acid (UDCA). Approximately 30% of patients do not respond to UDCA, and are high-risk for progressing to end stage liver disease, transplantation or death. A new era of stratified medicine with second-line therapies to treat high-risk disease is emerging, with the first such second-line agent obeticholic acid recently receiving FDA and EMA approval and entering practice. Recent experience in the USA of inappropriate use and associated deaths has highlighted concerns as to whether clinicians have the knowledge to implement second-line therapies appropriately and safely.

Methods: Online survey of knowledge regarding optimal PBC management in Gastroenterologists and Hepatologists in the USA; the first 100 completed responses from each group used for analysis.

Results: 80% of Hepatologists felt they were highly competent in their understanding of the importance of early diagnosis and early UDCA therapy in PBC compared with 65% of gastroenterologists. However, only 36% of Hepatologists and 30% of gastroenterologists felt competent at assessing response to UDCA. Competence in knowledge (mode of action, efficacy, and side effects) of second-line therapies and enrollment into trials was low among both groups.

Conclusion: Significant knowledge gaps in clinicians managing PBC presents a problem in optimizing care. It is perhaps not surprising that knowledge of emerging second-line therapies is low, however more concerning is sub-optimal use of UDCA in real-life practice and the lack of confidence at assessing treatment response which should be a routine part of clinical practice to assess risk of disease progression and will be key in delivering stratified medicine.

Keywords: Cholestatic liver disease; Clinical pharmacology; Health economics; Primary biliary cholangitis/cirrhosis; Statistics.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Chenodeoxycholic Acid / adverse effects
  • Chenodeoxycholic Acid / analogs & derivatives*
  • Cholagogues and Choleretics / therapeutic use
  • Clinical Competence / statistics & numerical data*
  • Disease Progression
  • Early Diagnosis
  • Gastroenterologists / education
  • Gastroenterologists / statistics & numerical data*
  • Humans
  • Liver Cirrhosis, Biliary / diagnosis
  • Liver Cirrhosis, Biliary / drug therapy*
  • Risk Factors
  • Ursodeoxycholic Acid / therapeutic use


  • Cholagogues and Choleretics
  • obeticholic acid
  • Chenodeoxycholic Acid
  • Ursodeoxycholic Acid