Reviewing novel findings and advances in diagnoses and treatment of primary biliary cholangitis

Introduction: Primary biliary cholangitis (PBC), a chronic autoimmune liver disease, arises following the progressive destruction of intrahepatic bile ducts. In the last decade a growing incidence of PBC was registered worldwide, compelling for novel effective therapies. This review provides a comprehensive update on the evolving landscape of PBC management, with a focus on the recent advances in diagnosis and treatment. Areas covered: Diagnostic guidelines from major hepatology associations emphasize the importance of antimitochondrial antibodies, PBC-specific antinuclear antibodies, and liver biopsy in select cases, as well as emerging data highlight gamma-glutamyl transferase as a prognostic marker. The first-line treatment remains ursodeoxycholic acid, although at least one third of patients has an inadequate response. In 2024 the authorization for obeticholic acid, a farnesoid X receptor agonist previously approved in 2016, was revoked; thus fibrates, particularly bezafibrate, are considered as second-line treatments that improve biochemical markers and potentially decrease long-term outcomes. Expert opinion: Alternative options are agents targeting peroxisome proliferator-activated receptors, such as elafibranor and seladelpar, that demonstrated efficacy in clinical trials. Novel approaches for managing symptoms like fatigue and pruritus are also at disposal. Despite these advances, challenges remain in optimizing care delivery and developing treatments that definitively alter the disease progression.