Obeticholic Acid

How it works

As a potent agonist of the nuclear farnesoid X receptor, it modulates bile acid synthesis, transport and secretion, reducing the hepatic accumulation of toxic bile acids that drives cholestatic liver injury.

Prescribing in practice

• It is contraindicated in decompensated cirrhosis and complete biliary obstruction, and the MHRA has warned of serious liver injury and the need for careful dosing and monitoring in those with hepatic impairment.
• Dose-related pruritus is the most common adverse effect and can limit tolerability, sometimes requiring dose adjustment or symptomatic treatment.
• It can reduce HDL cholesterol and may require less frequent dosing in moderate to severe hepatic impairment.

Monitoring

Monitor liver biochemistry regularly to assess response and detect hepatotoxicity, and review for worsening cholestatic itch and signs of hepatic decompensation.

Counselling the patient

• Report any worsening itching, which is common and can often be managed.
• Seek prompt advice if you notice jaundice, dark urine, abdominal swelling or confusion.
• Attend your blood tests so your liver function can be checked.

Evidence & guidelines

Obeticholic acid is recommended by NICE as an option for primary biliary cholangitis inadequately controlled by, or intolerant of, ursodeoxycholic acid, with MHRA safety advice on hepatic monitoring.