A 46-year-old woman comes to the office due to fatigue and generalized itching over the last 6 months. She has no energy to accomplish her daily goals and sometimes feels depressed. The patient takes pregabalin for fibromyalgia and diphenhydramine as needed for itching. She does not use tobacco, alcohol, or illicit drugs. Family history is notable for type 2 diabetes in her father and Graves disease in her mother.
Blood pressure is 100/60 mm Hg, pulse is 74/min, and respirations are 14/min. There are no rashes. The abdomen is nontender with the liver edge palpable 4 fingerbreadths below the right costal margin. There is no splenomegaly.
Laboratory results are as follows:
This patient would benefit most from which of the following?

Question

A 46-year-old woman comes to the office due to fatigue and generalized itching over the last 6 months.  She has no energy to accomplish her daily goals and sometimes feels depressed.  The patient takes pregabalin for fibromyalgia and diphenhydramine as needed for itching.  She does not use tobacco, alcohol, or illicit drugs.  Family history is notable for type 2 diabetes in her father and Graves disease in her mother.
Blood pressure is 100/60 mm Hg, pulse is 74/min, and respirations are 14/min.  There are no rashes.  The abdomen is nontender with the liver edge palpable 4 fingerbreadths below the right costal margin.  There is no splenomegaly.
Laboratory results are as follows:
 This patient would benefit most from which of the following?

Quizplus · Accepted Answer

11ec193a_9810_fb45_853d_a9754c8e492f_MD0002_00 This patient has pruritus and fatigue with hepatomegaly. This cholestatic pattern on hepatic markers (predominant elevation in alkaline phosphatase and bilirubin) is most consistent with primary biliary cholangitis (PBC, previously known as primary biliary cirrhosis). PBC is due to autoimmune destruction of the intralobular bile ducts and predominantly affects women (~95%). Patients may be asymptomatic at the time of diagnosis, but additional manifestations may include right upper quadrant discomfort, severe fatigue, abnormal skin pigmentation, and severe hypercholesterolemia. Disrupted bile secretory mechanisms can lead to malabsorption of fat-soluble vitamins (A, D, E, and K). Antimitochondrial antibodies are very sensitive (~95%) for PBC, and antinuclear antibodies are present in most patients as well. Untreated PBC can lead to cirrhosis, but treatment with ursodeoxycholic acid (UDCA) improves symptoms and biomarkers (eg, alkaline phosphatase, cholesterol), slows development of end-stage liver disease, and increases survival. UDCA is most beneficial in the earlier stages of PBC, but all patients should be treated. Antimitochondrial antibodies titers do not correlate with response to treatment, but hepatic function markers should be monitored every 3-6 months during treatment. (Choices A and D) Colchicine and methotrexate have been used for PBC, but there are conflicting data regarding benefit. These drugs are used primarily as second-line treatment for patients with progressive disease on UDCA. (Choice B) Etanercept is a tumor necrosis factor inhibitor used to treat diseases such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It may have some benefit in patients with concurrent rheumatoid arthritis but has not been adequately studied; it is not first-line therapy for PBC. (Choice C) Prednisone may treat autoimmune hepatitis but has limited to no efficacy in PBC. In addition, it can increase the risk of osteoporosis. Educational objective: Primary biliary cholangitis is characterized by pruritus, fatigue, hepatomegaly, and a cholestatic injury pattern on liver function tests. It predominantly affects women, and antimitochondrial antibodies are a sensitive marker for diagnosis. Treatment with ursodeoxycholic acid slows development of end-stage liver disease and increases survival. __________ References: Recent advances in the diagnosis and treatment of primary biliary cholangitis. (http://www.ncbi.nlm.nih.gov/pubmed/27957241)

A 46-Year-Old Woman Comes to the Office Due to Fatigue