What is the recommended medical management of primary sclerosing cholangitis, and is there a role for corticosteroids?
Medically reviewed by Hovhannes Karapetyan, MD.
Answer
Medical management of primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by intrahepatic or extrahepatic stricturing, or both, with bile duct fibrosis . The management of PSC is primarily supportive, as no single drug has been proven to improve transplant-free survival- Pruritus management: Pruritus is a common symptom in PSC, and several guidelines recommend different approaches for its management. Initial therapy with bile acid sequestrants is recommended by the AASLD 2022 guidelines . If cholestyramine is ineffective or poorly tolerated, second-line treatments such as rifampin and naltrexone can be considered . For moderate-to-severe pruritus, bezafibrate or rifampin can be offered
- Immunosuppressants: The use of immunosuppressants in PSC is generally not recommended. The EASL 2022 guidelines advise against the routine use of immunosuppressives/biologics in PSC patients . However, in patients with PSC with biochemically and histologically suggestive features of autoimmune hepatitis (AIH), initiating immunosuppressive therapies under close monitoring can be considered
- Vancomycin: The AASLD 2022 guidelines state that there is insufficient evidence to support the use of oral vancomycin for the treatment of PSC