Medicine is a science of uncertainty and an art of probability.”
— William Osler
Ursodiol (UDCA) remains the cornerstone and first-line therapy for primary biliary cholangitis. It works by improving bile flow and reducing bile toxicity in the liver, and it improves long-term outcomes when started early and taken consistently. Even as new drugs enter the field, ursodiol remains the backbone of PBC care, and most newer therapies are used in addition to, not instead of, UDCA for patients with an incomplete response.
Obeticholic acid (OCA) played an important historical role but is no longer a routine option in PBC care. Attention has shifted to new FDA-approved agents that target different disease pathways. Seladelpar (Livdelzi®) and elafibranor (Iqirvo®) work through nuclear receptors (PPAR pathways) to reduce liver inflammation and improve bile acid handling. Another emerging approach involves IBAT inhibition, which reduces the re-absorption of bile acids in the intestine, lowering the bile acid burden on the liver and helping relieve symptoms such as itching. Not every medication is appropriate for every patient, and decisions are individualized based on liver tests, symptoms, and overall health.
The PBC treatment landscape is more active than ever, with ongoing clinical trials exploring these mechanisms further and testing additional targeted therapies. The future of PBC care is likely to involve combination and personalized treatment strategies, pairing ursodiol with agents that act through complementary pathways, such as bile acid transport, inflammation, and metabolism, to achieve better disease control and improved quality of life. For patients living with PBC, this progress means more options, more individualized care, and growing reasons for optimism.