Finding the right treatment

As soon as you are diagnosed with primary biliary cholangitis (PBC), your specialist will prescribe treatment. The aim of your treatment is to:

• slow down the development of your PBC
• prevent complications or delay them for as long as possible
• manage any symptoms you have and improve your quality of life

Your doctor will measure your ALP levels to see how well the treatment is working. They are checking to see whether they are back within the normal range.

Treatment is life long, but try not to be alarmed by this. PBC is generally very slow to develop and the treatment should slow it down further. Rather than feeling negative about having to take a daily medicine, try to think of your treatment as a benefit that is keeping you as well as possible.

If the first treatment you take doesn’t help, there are alternatives your doctor will suggest. They may discuss the best treatment for you at a multi-disciplinary team meeting (MDT). This is a group of all the health professionals involved in caring for patients with PBC. It will include your consultant and your specialist nurse.

There is information on all current treatments on this page. There are also new treatments in the pipeline. There is information about these on the page about the future of PBC treatment.

If your PBC can’t be controlled with medicine, then a liver transplant is also an option. There is more about this in our page on treating advanced PBC.

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Ursodeoxycholic acid (UDCA)

This is most likely to be the first treatment your doctor suggests. It’s pronounced er-so-dee-ox-ee-kol-ik acid. So it’s usually called ‘Urso’ for short! It is a bile acid and works by replacing more damaging bile acids. This helps to protect your liver and bile ducts from damage.

Urso comes as a capsule that you swallow. You may start on a low dose and gradually increase this to the full dose. The total dose you should take is based on your weight, so your doctor will monitor this. Any significant changes in weight may mean that your doctor will need to change your dose.

At the start, your doctor may ask you to take it spread over 3 doses a day, while they monitor your response to the treatment. Once your doctor is happy with your dose, you may switch to the same total amount but once a day, at bedtime. Some people continue to take Urso in 2 or 3 doses a day. As this can vary, it’s best to always follow the advice of your doctor.

Urso occurs naturally in the body, so it has few side effects. The commonest side effect is diarrhoea. You may also notice that your poo looks pale. If you notice other changes or possible side effects, discuss them with your doctor or specialist nurse.

Your doctor will use regular blood tests to check how well Urso is working. Around 6 out of every 10 people find that Urso controls their PBC. It is less likely to work well in people diagnosed before the age of 50.

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Obeticholic acid (OCA)

If blood tests show that Urso isn’t working well enough for you, your doctor may suggest adding another medicine called obeticholic acid (sometimes called OCA). This medicine works by reducing high levels of bile salts within the liver. If you aren’t getting on with Urso, your doctor may suggest reducing your dose of Urso and taking OCA as well. Less commonly, you may take OCA on its own to control your PBC.

OCA is a tablet you take once a day. You start treatment at the lowest suggested dose.  Your doctor will check your liver blood tests regularly. If your ALP and bilirubin levels haven’t gone down far enough after 6 months of treatment, they will increase your dose.

After a year, if there’s been no significant improvement in your liver test results your doctor may decide it isn’t helping and stop giving it to you.

OCA has more side effects than Urso. Even so, the majority of patients take it without having any major problems. If you do have side effects, the commonest are itching and tiredness. Less often, it can also cause:

• dizziness
• palpitations
• mouth pain
• constipation
• joint pain
• abdominal pain

There are some issues around the use of OCA in Europe. These do not currently affect how the medicine is used in the UK. You can find the latest information on this here.

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Elafibranor

Elafibranor was approved by NICE for patients in England and Wales in November 2024 and by the SMC for patients in Scotland in April 2025. Like OCA it is a second-line option for people where urso either doesn’t work well enough or is causing too many side effects. You may be given elafibranor as well as urso, or more rarely as a standalone medicine.

You take one tablet once a day. It’s important to swallow the tablet whole. Do not chew, crush or split it.

Elafibranor does not make itching any worse, which is important in PBC. Any side effects are usually mild or moderate. The most common ones are tummy upsets, headaches, gallstones and muscle pain.

You shouldn’t take elafibranor if you are pregnant, trying to get pregnant, or breastfeeding. Speak to your medical team, they can help you manage your PBC in the best way for you and your baby.

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Bezafibrate

This medicine is not yet specifically licensed for treating PBC, but doctors do commonly give it to patients. If Urso hasn’t controlled your PBC as well as your doctor would like, adding bezafibrate can often help. Or your doctor may suggest you take it on its own.

Bezafibrate doesn’t usually cause too many side effects. You may have a drop in appetite and it can cause stomach upsets. You will have regular blood tests while you are taking bezafibrate, especially when you first start taking it.  This is to make sure your kidneys are working well and not being affected by the drug, which is an uncommon side effect.

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Treatment for PBC symptoms

PBC can cause itching and extreme tiredness (fatigue). These can also be side effects of the treatment.

Itching

If you have itching, your doctor will suggest a medicine called colestyramine. This helps to get rid of the bile acids that are causing the itching.

Colestyramine comes as a powder that you mix with water. It can taste bitter and if you’re finding it difficult to take, you can mix it with fruit juice instead of water.

If you’re taking colestyramine, it’s very important that you take it separately from any other medicines. It can stop them from being absorbed properly. You should take it at least 4 hours before or after any other medicines.

If you can’t take colestyramine or it isn’t helping, your doctor may suggest other medicines for itching, such as

• colesevalam – this is related to colestyramine but comes as a tablet
• rifampicin – a type of antibiotic
• naltrexone – a type of drug called an opioid antagonist
• Sertraline a medicine usually used for depression that can also help with itching
• Bezafibrate – as well as helping treat the underlying PBC, bezafibrate can also treat itching

Adding an antihistamine may also help, although they don’t usually do much when taken on their own for PBC itching. If itching is still a problem despite treatment, your doctor may suggest trying other medicines, such as gabapentin.

Dry skin tends to be itchy, so using a body moisturising cream may help too.  Some patients find creams containing menthol helpful (1% menthol in aqeuous cream). This can be soothing and relieve itching short term. It can also help to wear loose fitting clothing. Avoid anything that could be scratchy or irritating such as wool. Taking cool showers may help too.

Fatigue

Unfortunately, there are no medicines your doctor can suggest that can help with fatigue. But they can check for other conditions that may be making fatigue worse, such as anaemia, underactive thyroid or type 2 diabetes. If you have any of these conditions, treating them will help.

You may find that altering your usual routine helps you manage your tiredness. Fatigue usually gets worse later in the day. So if you can, it may help to prioritise your most important tasks earlier.

Trying to improve the quality of your sleep may help. You could try

• making sure your bedroom is as peaceful, dark and quiet as possible
• going to bed and getting up at a regular time
• avoiding caffeine, nicotine and alcohol later in the evenings
• getting some exercise daily, but not within 2 hours of going to bed

Fatigue related to medical conditions isn’t like ordinary tiredness. You need to pace yourself. If you feel wiped out, you need to rest. Don’t try and push through it. At first, your family and friends may not understand that, so it may help to show them this information.

Read more about living with fatigue.

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