Primary Biliary Cholangitis (PBC) is a chronic cholestatic liver disease involving the autoimmune-mediated destruction of biliary epithelial cells. PBC is a progressive disorder, and may ultimately result in hepatic fibrosis, cirrhosis, and decompensated liver disease [
1]. Patients are frequently asymptomatic from the disorder for a period of years or even decades. If symptoms do eventually develop, they are most commonly pruritus and fatigue and less commonly jaundice or abdominal pain [
2]. Ursodeoxycholic acid (UDCA) is the preferred, first-line pharmacologic agent for treatment of PBC and is indicated in all patients with the disorder. UDCA is administered at a dose of 13–15 mg/kg/day, typically divided into 2–4 doses per day. The medication is generally well tolerated and, when used for PBC, the only true contraindication is hypersensitivity. In the absence of UDCA pharmacotherapy, the median survival for patients with PBC ranges from 5 to 8 years from the onset of symptoms [
3‐
6]. Treatment with UDCA has been consistently shown to improve biochemical indices, delay histologic progression, delay development of esophageal varices, and improve transplant-free survival in patients with PBC [
7‐
10].
However, despite the efficacy of UDCA in the treatment of PBC, approximately 40% of people will respond incompletely to the drug as monotherapy [
11]. Recent investigations have demonstrated the efficacy of alternative treatments for PBC. Obeticholic Acid (OCA) received FDA approval in 2016 after the POISE trial showed that 46–47% of patients receiving the medication were able to achieve reduction in alkaline phosphatase to less than 1.67 times the upper limit of normal and normalization of bilirubin compared to 10% of patients in the placebo group [
12]. Pruritus is a common adverse effect that limits the use of OCA in some patients, but the medication is otherwise generally well-tolerated [
13]. Fibrates also have an off-label indication for treatment of PBC given their anticholestatic properties [
14]. At present, alternative therapies are only recommended for patients who cannot tolerate UDCA or who demonstrate an inadequate response to UDCA monotherapy. Furthermore, based on an FDA restriction published in 2021, obeticholic acid (OCA) is contraindicated in any patient with advanced cirrhosis, defined as Child-Pugh class B or C cirrhosis, known portal hypertension, and/or any history of liver decompensation [
15]. In spite of UDCA’s proven efficacy in the treatment of PBC, recent studies have demonstrated that as many as 30% of patients with PBC may never have received appropriate treatment with UDCA and further suggest that these differences vary on the basis of demographic factors like age, sex, and race [
16‐
18]. To the authors’ knowledge, however, no study has yet quantified usage rates of second line therapies for PBC. The aim of this study is to characterize usage rates of UDCA and second line therapies among patients with PBC.