High-dose ursodeoxycholic acid increases risk of adverse outcomes in patients with early stage primary sclerosing cholangitis

BACKGROUND

Ursodeoxycholic acid (UDCA) in a dose of 28-30 mg/kg/day increases the likelihood of clinical deterioration of primary sclerosing cholangitis (PSC) patients.

AIM

To compare the risk of adverse clinical endpoints in patients with varying disease status.

METHODS

We reviewed records from patients previously enrolled in a study evaluating the effects of high dose (28-30 mg/kg/day) UDCA in PSC. Patients were grouped according to treatment (UDCA vs. placebo) and baseline disease status (histological stage of PSC, total serum bilirubin). Development of clinical endpoints including death, liver transplantation, cirrhosis, oesophageal varices and cholangiocarcinoma was sought.

RESULTS

A total of 150 patients were included of whom 49 patients developed endpoints. There was an increased development of endpoints among patients using UDCA vs. placebo (14 vs. 4, P=0.0151) with early histological disease (stage 1-2, n=88) but not with late stage (stage 3-4, n=62) disease (17 vs. 14, P=0.2031). Occurrence of clinical endpoints was also higher in patients receiving UDCA vs. placebo (16 vs. 2, P=0.0008) with normal bilirubin levels (total bilirubin ≤1.0 mg/dL) but not in patients with elevated bilirubin levels (15 vs. 16, P=0.6018). Among patients not reaching endpoints 31.7% had normalisation of their alkaline phosphatase levels when compared to 14.3% in patients who reached endpoints (P=0.073).

CONCLUSION

The increased risk of adverse events with UDCA treatment when compared with placebo is only apparent in patients with early histological stage disease or normal total bilirubin.

The predictors of the presence of varices in patients with primary sclerosing cholangitis

The predictors for developing varices in patients with primary sclerosing cholangitis (PSC) have not been well studied prospectively. We sought to define the predictors for the presence of varices at baseline and for newly developing varices in patients with PSC. We used prospectively collected data from a multicenter randomized trial of high dose ursodeoxycholic acid for PSC. All 150 patients enrolled were reviewed for predictors of varices and we excluded 26 patients who had esophageal varices at baseline so that predictors of newly developing varices could be determined. Clinical examination, blood tests, and upper endoscopy were done before randomization, at 2 years and after 5 years. Liver biopsy was performed at entry and at 5 years. The median age (interquartile range) of patients was 45.9 years (35.8, 54.9). In a multivariable logistic regression, a higher Mayo risk score (> or =0.87) or a higher aspartate/alanine aminotransferase (AST/ALT) ratio (> or =1.12) were significantly associated with the presence of varices at initial endoscopy (odds ratio = 1.9 and 3.9). By the end of the study, 25 patients had new varices (20.2%). In a Cox model, after adjustment for baseline variables lower platelet count and higher total bilirubin at 2 years were significantly associated with the presence of new varices. The platelet count of 205 (x 10(9)/L) and the total bilirubin level of 1.7 mg/dL were the best cutoff values for the detection of new varices.

CONCLUSION

A higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of varices at initial endoscopy. Lower platelet count and higher total bilirubin at 2 years were significantly associated with an increased risk of developing new varices in patients with PSC.

High-dose ursodeoxycholic acid for the treatment of primary sclerosing cholangitis

Previous controlled trials are inconclusive regarding the efficacy of ursodeoxycholic acid (UDCA) for treating primary sclerosing cholangitis (PSC). One hundred fifty adult patients with PSC were enrolled in a long-term, randomized, double-blind controlled trial of high-dose UDCA (28-30 mg/kg/day) versus placebo. Liver biopsy and cholangiography were performed before randomization and after 5 years. The primary outcome measures were development of cirrhosis, varices, cholangiocarcinoma, liver transplantation, or death. The study was terminated after 6 years due to futility. At enrollment, the UDCA (n = 76) and placebo (n = 74) groups were similar with respect to sex, age, duration of disease, serum aspartate aminotransferase and alkaline phosphatase levels, liver histology, and Mayo risk score. During therapy, aspartate aminotransferase and alkaline phosphatase levels decreased more in the UDCA group than the placebo group (P < 0.01), but improvements in liver tests were not associated with decreased endpoints. By the end of the study, 30 patients in the UDCA group (39%) versus 19 patients in the placebo group (26%) had reached one of the pre-established clinical endpoints. After adjustment for baseline stratification characteristics, the risk of a primary endpoint was 2.3 times greater for patients on UDCA than for those on placebo (P < 0.01) and 2.1 times greater for death, transplantation, or minimal listing criteria (P = 0.038). Serious adverse events were more common in the UDCA group than the placebo group (63% versus 37% [P < 0.01]).

CONCLUSION

Long-term, high-dose UDCA therapy is associated with improvement in serum liver tests in PSC but does not improve survival and was associated with higher rates of serious adverse events.

The diagnostic value of anti-mitochondrial antibodies, especially in primary biliary cirrhosis

Anti-mitochondrial antibodies (AMA) are present in sera of approximately 90-95% of patients with primary biliary cirrhosis (PBC) and, thus, constitute one of the most important diagnostic criteria for this disease. The major mitochondrial autoantigens have been identified, cloned, and sequenced and the immunological features of AMA, including their antigen specificities and epitopes, have been well characterized. In clinical laboratories, indirect immunofluorescence (IIF) microscopy is routinely employed for the detection of AMA mainly because of technical simplicity and cost effectiveness. However, IIF lacks both specificity and sensitivity, and in up to 10% of patients diagnosed with PBC based on standard diagnostic criteria, AMA cannot be detected by IIF. In some of these patients, AMA aredetectable by more sensitive techniques, such as enzyme-linked immunosorbent assays (ELISAs) or SDS-PAGE followed by immunoblotting. Nonetheless, there are patients whose sea are negative for AMA by any of these methods despite clinical, biochemical, and histological findings that are diagnostic for PBC. Some have argued that AMA-positive and AMA-negative PBC represent two distinct entities, but recent evidence supports the view that they are clinically and biochemically quite similar. The situation is further complicated by the fact that AMA, even those recognizing the major PBC autoantigens, are also present in a variety of other liver diseases. In addition, patients exhibiting the clinical, histological, and biochemical features of both PBC and autoimmune hepatitis, the so-called 'overlap syndrome,' are not uncommon. In conclusion, AMA status, though invaluable in establishing and confirming the diagnosis of PBC in > or =90% of PBC patients, is not sufficient by itself to allow the differential diagnosis of liver diseases. The choice of therapeutic regimen should, therefore, be based on a combination of serological, biochemical and histological findings, rather than AMA status alone.