Nancy S. Reau, MD Rush Medical Group
QUESTION
1
Is there some guidance you can provide to support the timely diagnosis and referral of PBC patients to GI specialty care?
ANSWER “The most important thing is recognizing patient risk. If the alkaline phosphatase (ALP) is elevated on the chemistry panel in a woman, especially over the age of 40, you should be asking about itching, fatigue as well as ordering an anti-mitochondrial antibody (AMA). Linking your patient to an individual who can provide treatment is also very important and will be more successful if the referring provider can help the patient understand that they have a chronic immune disease that can be treated.” QUESTION
2
What is your current threshold for PBC treatment escalation?
ANSWER “Biochemical goals are normal ALP and total bilirubin (TB) <0.6 x ULN. Treatment also works quickly. You should see an improvement in the first month of therapy; but I do like to see the ALP plateau before I add another agent. If there is no change in the ALP by 3 months, I’m going to change my approach. Certainly, if we have not achieved biochemical response by 6 months, we need to add another agent.” QUESTION
3
How do you treat pruritus?
ANSWER “First, I have the patient try lifestyle modifications and topical options. If the itching is very severe, I may have them start cholestyramine, though it’s a difficult agent to use. After that, I will pick pharmacotherapy based on their other symptoms and liver enzymes. If second-line therapy for their PBC is warranted, then I am going to start a PPAR agonist. If their liver enzymes are perfect, then I may try naltrexone or an SSRI, and then consider rifampin.”