Announcer:
Welcome to GI Insights on ReachMD. On this episode, we’ll hear from Dr. Gideon Hirschfield, who’s the Lily and Terry Horner Chair in Autoimmune Liver Disease Research, and Director of the Autoimmune and Rare Liver Disease Programme at Toronto General Hospital. He’ll be discussing how we can take a personalized approach to primary biliary cholangitis care. Here’s Dr. Hirschfield now.
Dr. Hirschfield:
When you’re looking after people living with PBC, you’ve obviously got to focus on the PBC itself, but when you make treatment decisions, you’ve got to focus on the whole patient. What that means is that you always got to be aware of what might be going on in the liver which is not PBC related. The most common condition that is not PBC related that we encounter for people living with PBC would be consequences of being overweight, so metabolic-associated steatotic liver disease, which is a very long word for fatty liver. And clearly, when we see someone with PBC, if they’ve also got fat in their liver, we don’t want the fat in the liver not to be treated, but equally, we don’t expect the treatments for PBC to treat the fatty liver, so we make a very careful assessment for that individual patient as to what’s going on.
And the two commonest problems we encounter would be fatty liver from being overweight and also sometimes—not very commonly, but sometimes—people may drink a little bit to excess, and maybe there’s some alcohol causing some harm. The rarer condition that can so-called “overlap” with PBC is whether the patient has got a second autoimmune disease in the liver, which we would call autoimmune hepatitis. This has proved to be a lot harder for clinicians and patients to agree on definitions, but sometimes we see patients who have got more information than we expect where we think that some of the disease is more like autoimmune hepatitis. We find this very hard to diagnose confidently. We often need to do a liver biopsy. We frequently need to discuss as a team to decide what is the dominant liver injury. Is it PBC? Is at autoimmune hepatitis? Is it both? Because that then helps us choose the treatment.
My message would be that overlap with autoimmune hepatitis is very rare; in fact, if you treat PBC most effectively with first- and second-line therapies, we won’t see very much overlap. And if you do genuinely believe you see overlap when you’ve fully treated the PBC, then be judicious in the use of drugs such as steroids or other immunosuppression because of their side effects and because we wouldn’t want patients to be on the wrong treatments and accruing the side effects, which in the context for someone living with PBC, if they’re given steroids, then there’s a real risk that we’re going to exacerbate osteoporosis.
I think when you look after someone with PBC, of course you want to make a good diagnosis, of course you want to start first-line therapy, and of course you want to use second-line therapy judiciously and appropriately; but at the same time, because you’re looking after this whole patient for many, many decades, you really want to work with that patient to optimize everything else about their health. So of course, a hepatologist doesn’t do everything, and with primary care you’ll need some involvement, but we do encourage our patients to be within their expected body mass, we do encourage patients not to drink to excess, and we do encourage patients to have a healthy lifestyle and diet. We don’t generally give specific advice about the diet, but we know that we don’t want them to have a diet too high in fats or a diet too high in red meat, for example.
We also know that patients with PBC often have symptoms. Some of those symptoms are very specific to PBC, like itch, where our treatments can make a big difference, and we’ve seen new drugs being developed where in clinical trials the drug clearly improves itch as well as the liver biochemistry, so that’s very exciting. And some of those drugs are now marketed in the US, which is great. But another symptom that our patients get is fatigue, and sometimes their patients complain of brain fog. What we’ve realized and learned from listening to patients is that patients with those kind of symptoms often benefit from exercise, so we do encourage our patients to think of the concept of movement as medicine, and we do encourage them to be active and to exercise because we found from our experience that it can actually reduce the impact of fatigue, for example, on their day-to-day quality of life.
Announcer:
That was Dr. Gideon Hirschfield talking about personalizing care for patients with primary biliary cholangitis. To access this and other episodes in our series, visit GI Insights on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
