Serum total bilirubin and cholestatic enzymes (ALP, GGT) are important

for assessing the activity and progression of PBC. Liver biochemical tests should be done every 3–6 months. In addition, thyroid hormone (every year) and bone mineral density (every 2–4 years) tests are recommended because PBC is likely to be complicated with other autoimmune diseases, such as Sjögren’s syndrome, chronic thyroiditis, and rheumatoid arthritis. Regular upper gastrointestinal endoscopy, depending on stage (1 or 2 times per year), is required because esophageal/gastric varices may develop even in patients without jaundice. Abdominal Daporinad manufacturer ultrasound (US) and serum AFP testing every 6–12 months are necessary in patients with definite or suspected liver cirrhosis. Liver cirrhosis, older age, and male sex are high risk factors for developing hepatocellular carcinoma (HCC). Therefore, testing for tumor markers and imaging studies [US and computed tomography (CT)] are required for early detection of HCC in patients with advanced PBC. Management

for other complicating autoimmune diseases should be done depending on each symptom. Finally, special attention should be paid to pregnancy in PBC and patients who have a desire to bear children. The chance for pregnancy could be the same in the early stage of aPBC as in the normal population; there is no evidence to recommend Midostaurin supplier avoidance of pregnancy in patients with aPBC. In sPBC, however, if worsening of icterus second or varices is reported, then avoidance of pregnancy could be justified. The impact of pregnancy on PBC is unclear because both exacerbation and improvement of cholestasis have been reported. Estrogen could potentially worsen cholestasis; pruritus may become severe in pregnancy and could be prolonged even after delivery. Conversely, it should be noted that cholestasis could be symptomatic after pregnancy. After a patient has become pregnant, monitoring for varices is necessary as in other

cirrhotic patients, especially after the second trimester, due to increase in circulating blood volume. The use of β blockers is considered to be safe. It is also advisable to shorten the second trimester of pregnancy, if possible. Recommendations: The blood and other clinical tests should be undertaken regularly to investigate complicating comorbidities, prevent complications, and detect portal hypertension and liver cancer as early as possible. (Table 13) (LE 3, GR B) It is advisable to consult with hepatologists when the diagnosis of PBC is made, or when patients with PBC become symptomatic. In patients with atypical forms of PBC such as PBC–AIH overlapping syndrome, earlier referral is recommended. (Table 14) (LE 6, GR A-B) For patients in the symptomatic stage, there is a likelihood of worsening of pruritus or icterus in the pregnancy, as well as an increased possibility of variceal rupture.