This article was written in January 2026 and reflects information available at the time of publication. Information is subject to change as new details emerge.
While primary sclerosing cholangitis (PSC) currently has no treatment that is both approved for PSC and proven effective at curing or slowing PSC progression, there are treatments and medical interventions that may help with symptoms or complications related to PSC. Health care providers also refer to clinical guidelines when treating people with PSC.
What are the treatment options for PSC?
Medications
Ursodeoxycholic acid (UDCA)
Ursodeoxycholic acid (Urso) has received much attention as a potential PSC treatment and may improve liver function tests; however, there is no consensus that the published evidence shows that Urso slows down the progression of PSC. There is a subgroup of patients, Urso-responders, who respond to Urso with improved liver tests and reported improvement of symptoms. Several studies suggest that Urso-responders have an improved prognosis.
Urso provides several functions that might prevent inflammation and improve bile acid flow through the liver and bile ducts. High doses can be harmful, so be sure to follow your doctor’s prescribed dosage.1
Antibiotics
Bacterial or acute cholangitis (infection in the bile ducts), a complication of PSC, is typically treated with antibiotics (common first-line agents include ciprofloxacin orco-amoxiclav); sometimes, in order to prevent recurring cholangitis, patients are treated with rotating antibiotics.
Antibiotics are also sometimes prescribed as a treatment for PSC to potentially modify gut microbiome and lower inflammation. Oral Vancomycin (OV) is one antibiotic actively being studied, yet at this time there is no consensus recommendation for OV to treat PSC.2 Experience and emerging data with OV in PSC have shown encouraging signals, though results have been mixed. Uncertainties remain across multiple aspects of its use. There is more published evidence of the use of OV in paediatric patients than in adults.3 A 2024 study demonstrated that for paediatric patients with PSC-related IBD, use of OV is associated with better IBD outcomes in retrospective data.4
The use of OV for PSC has generated debate in the medical community. The rationale for OV use is biologically plausible, and research—particularly from case reports and small studies—has shown encouraging signals. However, definitive confirmation of clinically meaningful benefit from large randomized controlled trials is not available. Potential concerns regarding antimicrobial resistance have been raised, though the magnitude and clinical significance of this risk are not yet well defined nor does the published literature report cases. While current clinical guidelines do not formally recommend routine use of OV, the AASLD notes that while there is insufficient evidence to make a definitive recommendation, this uncertainty should not be used to restrict access when a treating physician believes the therapy is appropriate. Patient-reported evidence on OV in PSC has intensified the need for larger studies.
The 2022 webinar, The Future of PSC: Disease Pathogenesis, Oral Vancomycin, and Cancer Prevention and Surveillance, provides a 20-minute patient-facing summary of OV in PSC.
Other medications
- Cholestyramine – a bile acid sequestrant, which means it basically grabs onto bile acids in your gut and helps remove them from your body (“sequesters them”). This can be especially effective for treating itchiness, a common symptom of PSC. While the medication does not treat the disease itself, it can make you feel much less itchy and more comfortable.
- Rifampicin (antibiotic) and naltrexone (opioid antagonist), and antihistamines – also used to treat itching if bile acid sequestrants don’t work.
- Bezafibrate – belongs to a class of medications known as fibrates (approved for use in cholesterol management) and the European PSC guidelines propose bezafibrate as the first-line treatment for moderate to severe itching in PSC. (Available for prescription in Canada and Europe)
- Vitamin supplements (i.e. Vitamin D and calcium) – used to treat fat-soluble vitamin (A, D, E, K) deficiencies and weak bones as a result of PSC.
Researchers are continually developing and testing new drugs for PSC in clinical trials. Be sure to visit the PSC Clinical Trials page to see which studies may be currently recruiting in Canada.
Read and download the PSC Alert Sheet for Acute Cholangitis for a useful reference to help understand cholangitis symptoms and make treatment decisions with your medical team if acute cholangitis (also called bacterial cholangitis) is suspected.
Endoscopic procedures
Endoscopic retrograde cholangiopancreatography (ERCP): A procedure where doctors insert a thin, flexible tube with a camera through the mouth and down through the esophagus and stomach to the top of the small intestine (duodenum) to look at the bile ducts. If a duct is blocked or very narrow, they can open it with a balloon or place a small tube (stent) to keep it open. An ERCP may help improve bile flow and can relieve symptoms like jaundice and itching.
Percutaneous transhepatic cholangiography
Another way to open blocked bile ducts, but instead of using a tube through the mouth, doctors go through the skin with a needle. This is usually done if ERCP is not possible. It is more invasive and may cause some discomfort or more serious side effects..
Surgery
Non-transplant surgery
Sometimes, surgery is done to remove or bypass blocked parts of the bile ducts. This can help improve bile flow and reduce symptoms, but it is less common because it can make a future liver transplant more difficult.
Liver transplantation
- A liver transplant is currently the only proven long-term treatment for PSC. A transplant is generally considered in the following instances: (transplant listing criteria and priority on the transplant waitlist vary by country and transplant centre within Canada)
- Decompensated cirrhosis of the liver: liver failure when the liver can no longer work properly. Symptoms of decompensated cirrhosis include jaundice, ascites (swollen belly), edema (swollen legs/ankles), confusion (hepatic encephalopathy), severe fatigue, easy bleeding/bruising, itching, and gastrointestinal bleeding (vomiting blood/dark stools).
- Recurring episodes of bacterial cholangitis: frequent infections in the bile ducts
- Portal hypertension: high blood pressure in the liver’s blood vessels causing swelling or bleeding
- Cancer risk or occurrence: increased risk of bile duct or liver cancer or early, treatable bile duct cancer
- Severe symptoms like unbearable itching or pain that cannot be controlled with other treatments
Many go on to live active, healthy lives after transplant. However, there are some people (around 25-30%) that may have their PSC come back later on, called recurrent PSC or rPSC. Doctors and researchers are always working on better ways to prevent and treat rPSC, and most people experience a great improvement in their quality of life after transplant.
What are the treatment options for PSC symptoms?
There are many common symptoms seen in PSC. Treatments used to help manage these symptoms include:
Itching: Cholestyramine is usually the first medicine doctors try. If it doesn’t work, other medicines like bezafibrate, rifampicin,naltrexone, or sertraline may be tried..
Pain: Pain can be managed by treating infections with antibiotics, opening blocked ducts with ERCP, and using pain medicines if needed. Strong painkillers are used carefully because of risks of causing more damage to the liver. Always consult your doctor before taking any over-the-counter or other pain medication.
Fatigue: There is no specific medicine for fatigue. Doctors look for and treat other causes like anemia or thyroid problems. Exercise and good sleep habits may help some people.
Jaundice: yellow skin or eyes) is usually treated by opening blocked bile ducts with ERCP or surgery. If jaundice is caused by severe liver damage, a transplant may be needed.
Depression: Depression is common in people with chronic illnesses like PSC. Counseling, support groups, and sometimes medications can help manage depression. PSC Partners offers in-person and virtual (Zoom Room) support group events to help people impacted by PSC.
Chills and Fever: Can be signs of a bile duct infection (cholangitis). Antibiotics such as vancomycin or metronidazole are needed right away, and sometimes a blocked duct needs to be opened. The PSC Alert Information for Acute Cholangitis page provides helpful information about what to do if you are experiencing a cholangitis attack.
Weak Bones (Vitamin Deficiencies): Bile is needed to help the body absorb nutrients, especially fats and fat-soluble vitamins (A, D, E, K). When the bile ducts are scarred or blocked due to PSC, absorption of these essential nutrients may be limited, which can lead to bone problems (osteopenia and osteoporosis). Taking supplements such as Vitamin D and calcium can help manage this symptom.
Once again, it is important to remember that one treatment that may be effective for one individual may not be effective for another. It is important to discuss your symptoms and treatment options with your hepatologist or health care provider.
Footnotes:
- From AASLD guidance (2022): ursodeoxycholic acid (13–23 mg/kg/day) can be considered and continued if well tolerated with a meaningful improvement in alkaline phosphatase (GGT in children) and/or symptoms with 12 months of treatment.
From EASL guidelines (2022): Recommendations
– UDCA at doses of 15-20 mg/kg/d can be given since it may improve serum liver tests and surrogate markers of prognosis. Available data does not allow for a firmer recommendation (LoE 1, weak recommendation, 76% consensus).
– UDCA at doses of 28-30 mg/kg/d should not be given (LoE 1, strong recommendation, 100% consensus). - From AASLD guidance (2022): “Given the potential for antibiotic resistance and lack of adequate randomized clinical trials, at this point, there is insufficient evidence to recommend the use of oral vancomycin for the treatment of PSC. “ but AASLD also notes in a supporting statement regarding the guidance that “Although there is not sufficient evidence to make a formal recommendation regarding the use of vancomycin for PSC, it should not be used as justification to restrict coverage of this treatment if a physician feels it is the right course of action.”From EASL guidelines (2022): “Long-term use of antibiotics is not recommended for treatment of PSC in the absence of recurrent bacterial cholangitis (LoE 3, strong recommendation, 100% consensus).”
- Listing of publications related to oral vancomycin in PSC can be found on the PSC Partners Patient Registry site HERE: https://www.pscpartnersregistry.org/clinical-trials/publications/mayo-clinic%3A-oral-vancomycin-for-psc
- Ricciuto A, et al., Oral vancomycin is associated with improved inflammatory bowel disease clinical outcomes in primary sclerosing cholangitis-associated inflammatory bowel disease (PSC-IBD): A matched analysis from the Paediatric PSC Consortium. Aliment Pharmacol Ther. 2024 May; https://pubmed.ncbi.nlm.nih.gov/38462727/
References:
PSC Clinical Guidance (2023) from the American Association for the Study of Liver Disease: https://journals.lww.com/hep/fulltext/2023/02000/aasld_practice_guidance_on_primary_sclerosing.29.aspx
AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma., Bowlus, Christopher L. et al.,Hepatology 77(2):p 659-702, February 2023.
PSC Clinical Guidelines (2023) from the European Association for the Study of the Liver: https://www.journal-of-hepatology.eu/article/S0168-8278(22)00326-9/fulltext EASL Clinical Practice Guidelines on sclerosing cholangitis, Chazouilleres, Olivier et al., Journal of Hepatology, Volume 77, Issue 3, 761 – 806
