What are the recommended first-line treatments for managing symptoms in patients diagnosed with PBC?

First-line treatment for managing symptoms in patients with primary biliary cholangitis (PBC) is ursodeoxycholic acid (UDCA), which improves liver biochemistry and delays disease progression. This is the established standard of care recommended by UK clinical guidelines, reflecting its efficacy in symptom control and slowing cholestasis ¹. UDCA is typically initiated at a dose of 13-15 mg/kg/day. For patients who do not respond adequately to UDCA or have persistent symptoms, recent literature highlights the emerging role of obeticholic acid as an adjunct or alternative therapy, though it is generally considered second-line after UDCA failure or intolerance (Levy et al., 2023; Cho, 2025).

Symptomatic management of pruritus, a common and distressing symptom in PBC, involves cholestyramine as first-line therapy, followed by rifampicin or naltrexone if pruritus persists. This approach aligns with UK guidelines and is supported by recent reviews emphasizing the importance of addressing symptom burden to improve quality of life ¹ (Floreani et al., 2025).

Fatigue management remains challenging, with no specific pharmacological treatment recommended; supportive care and addressing contributing factors are advised. This is consistent across guidelines and recent literature (Levy et al., 2023).