Obeticholic acid improves hepatic bile acid excretion in patients with primary biliary cholangitis

J Hepatol. 2021 Jan;74(1):58-65. doi: 10.1016/j.jhep.2020.07.028. Epub 2020 Jul 25.


Background & aims: Obeticholic acid (OCA) is an agonist of the nuclear bile acid receptor farnesoid X receptor, which regulates hepatic bile acid metabolism. We tested whether OCA treatment would influence hepatic transport of conjugated bile acids in patients with primary biliary cholangitis (PBC) who responded inadequately to treatment with ursodeoxycholic acid (UDCA).

Methods: Eight UDCA-treated patients with PBC with alkaline phosphatase ≥1.5 times the upper limit of normal range participated in a double-blind, placebo-controlled study. While continuing on UDCA, the patients were randomised to two 3-month crossover treatment periods with placebo and OCA, in random order, separated by a 1-month washout period without study treatment. After each of the two treatment periods, we determined rate constants for transport of conjugated bile acids between blood, hepatocytes, biliary canaliculi, and bile ducts by positron emission tomography of the liver using the conjugated bile acid tracer [N-methyl-11C]cholylsarcosine (11C-CSar). The hepatic blood perfusion was measured using infusion of indocyanine green and Fick's principle.

Results: Compared with placebo, OCA increased hepatic blood perfusion by a median of 11% (p = 0.045), the unidirectional uptake clearance of 11C-CSar from blood into hepatocytes by a median of 11% (p = 0.01), and the rate constant for secretion of 11C-CSar from hepatocytes into biliary canaliculi by a median of 73% (p = 0.03). This resulted in an OCA-induced decrease in the hepatocyte residence time of 11C-CSar by a median of 30% (p = 0.01), from group median 11 min to 8 min.

Conclusions: This study of UDCA-treated patients with PBC showed that, compared with placebo, OCA increased the hepatic transport of the conjugated bile acid tracer 11C-CSar, and thus endogenous conjugated bile acids, from hepatocytes into biliary canaliculi. As a result, OCA reduced the time hepatocytes are exposed to potentially cytotoxic bile acids.

Lay summary: Primary biliary cholangitis is a chronic liver disease in which the small bile ducts are progressively destroyed. We tested whether the treatment with obeticholic acid (OCA) would improve liver excretion of bile acids compared with placebo in 8 patients with primary biliary cholangitis. A special scanning technique (PET scan) showed that OCA increased the transport of bile acids from blood to bile. OCA thereby reduced the time that potentially toxic bile acids reside in the liver by approximately one-third.

Trial registration: ClinicalTrials.gov NCT03253276.

Keywords: Bile acid-binding proteins; Farnesoid X receptor; Intrahepatic cholestasis; Liver cirrhosis; Molecular imaging.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Alkaline Phosphatase / blood
  • Bile Acids and Salts / metabolism*
  • Bile Ducts, Intrahepatic* / diagnostic imaging
  • Bile Ducts, Intrahepatic* / physiopathology
  • Biological Transport / drug effects
  • Chenodeoxycholic Acid / administration & dosage
  • Chenodeoxycholic Acid / analogs & derivatives*
  • Chenodeoxycholic Acid / pharmacokinetics
  • Double-Blind Method
  • Female
  • Gastrointestinal Agents / administration & dosage
  • Gastrointestinal Agents / pharmacokinetics
  • Gastrointestinal Agents / pharmacology
  • Hepatocytes / pathology
  • Humans
  • Liver Cirrhosis, Biliary* / diagnosis
  • Liver Cirrhosis, Biliary* / drug therapy
  • Liver Cirrhosis, Biliary* / metabolism
  • Middle Aged
  • Positron-Emission Tomography / methods*
  • Receptors, Cytoplasmic and Nuclear / agonists*
  • Treatment Outcome
  • Ursodeoxycholic Acid / administration & dosage
  • Ursodeoxycholic Acid / pharmacokinetics


  • Bile Acids and Salts
  • Gastrointestinal Agents
  • Receptors, Cytoplasmic and Nuclear
  • obeticholic acid
  • farnesoid X-activated receptor
  • Chenodeoxycholic Acid
  • Ursodeoxycholic Acid
  • Alkaline Phosphatase

Associated data

  • ClinicalTrials.gov/NCT03253276