Predictive factors for decompensating events in cirrhotic patients with primary biliary cholangitis under different lines of therapy

Background and Aims: The landscape in primary biliary cholangitis (PBC) has changed with the advent of second-line treatments. However, the use of obeticholic acid (OCA) and fibrates in PBC-related cirrhosis is challenging. We assessed the impact of receiving a second-line therapy as a risk factor for decompensated cirrhosis in a real-world population with cirrhosis and PBC, and identify the predictive factors for decompensated cirrhosis in these patients. Approach and Results: Multicenter study enrolling 388 patients with PBC-cirrhosis from the Spanish ColHai registry. Biopsy (20%), ultrasound (59%), or transient elastography (21%) defined cirrhosis, and the presence of varices and splenomegaly defined clinically significant portal hypertension (CSPH). Paris-II and PBC OCA international study of efficacy criteria determined the response to ursodeoxycholic acid (UDCA), fibrates (n=93), and OCA (n=104). The incidence of decompensated cirrhosis decreased for UDCA versus OCA or fibrates in the real-world population, but they were similar considering the propensity score–matched cohort (UDCA 3.77 vs. second-line therapy 4.5 100 persons-year, respectively), as patients on second-line therapy exhibited advanced liver disease. Consequently, GGT, albumin, platelets, clinically significant portal hypertension, and UDCA response were associated with a decompensating event. OCA response (achieved in 52% of patients) was associated with bilirubin (OR 0.21 [95% CI: 0.06–0.73]) and AST (OR 0.97 [95% CI: 0.95–0.99]), while fibrate response (achieved in 55% of patients) with AST [OR 0.96 (95% CI: 0.95–0.98]). In patients treated with OCA, drug response (sHR 0.23 [95% CI: 0.08–0.64]), diabetes (sHR 5.62 [95% CI: 2.02–15.68]), albumin (sHR 0.34 [95% CI: 0.13–0.89]), and platelets (sHR 0.99 [95% CI: 0.98–1.00]) were related to decompensation. In patients treated with fibrate, drug response (sHR 0.36 (95% CI: 0.14–0.95]), albumin (sHR 0.36 (95% CI: 0.16–0.81]), and clinically significant portal hypertension (sHR 3.70 (95% CI: 1.17–11.70]) were associated with decompensated cirrhosis. Conclusions: Advanced PBC, rather than OCA and fibrates, was found to be associated with decompensating events. Therefore, biochemical and clinical variables should be considered when making decisions about the management of these drugs. Moreover, a positive response to OCA and fibrates reduced the risk of decompensation.