A 54-year-old woman presents to her physician with worsening fatigue and generalized pruritus over the past year. She denies chest pain, palpitations, or shortness of breath. Her medical history is significant for autoimmune thyroid disease. Medications include levothyroxine. Temperature is 36.8°C (98.2°F), blood pressure is 122/74 mm Hg, pulse is 76/min, and respiratory rate is 14/min. Physical examination reveals excoriations on the arms and trunk. Laboratory studies show the following:
Testing reveals positive antimitochondrial antibodies. Which of the following is the most appropriate initial treatment?
The correct answer is:
C) Ursodeoxycholic acid
This patient has findings consistent with primary biliary cholangitis (PBC), an autoimmune destruction of small intrahepatic bile ducts that occurs predominantly in middle-aged women. The combination of cholestatic liver enzyme abnormalities, pruritus, autoimmune disease, and positive antimitochondrial antibodies is highly characteristic. Ursodeoxycholic acid is first-line therapy and slows disease progression.
Answer choice A: Azathioprine, is incorrect.
Azathioprine may be used in some autoimmune liver diseases but is not first-line treatment for primary biliary cholangitis.
Answer choice B: Prednisone, is incorrect.
Corticosteroids are more commonly used in autoimmune hepatitis than in PBC.
Answer choice D: Vancomycin, is incorrect.
Antibiotics have no routine role in treating PBC.
Answer choice E: Watchful waiting only, is incorrect.
Early treatment of PBC improves outcomes and should not be delayed.
Key Learning Point
Primary biliary cholangitis presents with cholestatic liver enzyme abnormalities and positive antimitochondrial antibodies and is treated with ursodeoxycholic acid.
