Redefining PSC Care

Redefining care for Primary Sclerosing Cholangitis (PSC) requires a comprehensive, patient-centered approach that integrates modern strategies for symptom management, disease progression monitoring, and quality-of-life improvements. PSC is a chronic liver disease with significant unmet needs, including severe symptoms, high cancer risks, and limited therapeutic options. Below is a detailed breakdown of how PSC care is being redefined:

### 1. **Symptom Management: Addressing Quality-of-Life Concerns**

• **Pruritus (Itching):** Pruritus is one of the most common and debilitating symptoms of PSC, affecting about 50% of patients, with 30% experiencing moderate-to-severe itching. Despite the widespread use of treatments like bile acid sequestrants (36%), hydroxyzine (23%), rifampicin (17%), and naltrexone (14%), many of these therapies have limited efficacy.
• **Call for Better Therapies:** There is an urgent need for safe, effective, and long-term antipruritic medications. The FITCH trial demonstrated promising results with bezafibrate, which improved pruritus by at least 50% in 41% of patients compared to 11% in the placebo group.
• **Patient Priorities:** Symptom relief, particularly pruritus, is a top motivator for patients joining drug trials, highlighting the importance of addressing quality-of-life symptoms in care strategies.

### 2. **Structured Surveillance and Monitoring**

• **Scheduled ERCP Follow-Up:** Regularly scheduled ERCP (endoscopic retrograde cholangiopancreatography) interventions have been shown to improve long-term transplant-free survival and reduce infections compared to on-demand procedures. The low complication rate (4%) ensures safety when the procedure is performed in a structured, protocolized manner.
• **Routine MRCP Surveillance:** Magnetic resonance cholangiopancreatography (MRCP) allows earlier detection of dominant strictures and cholangiocarcinoma, which leads to better survival outcomes. Routine MRCP reduces the risk of death by 73.8% compared to symptom-triggered imaging (HR 0.9, p < 0.001). This proactive approach identifies disease progression earlier and enables timely interventions.
• **Stricture-Driven Management:** The benefits of MRCP surveillance come from proactive management of biliary strictures rather than relying solely on late detection of hepatic malignancies.

### 3. **Patient Involvement in Research**

• **Engagement Gap:** While 61% of patients are willing to participate in clinical trials, only 26% have been asked, highlighting a significant gap in patient engagement and recruitment.
• **Patient Motivation:** Pruritus relief is the top motivator for PSC patients joining drug trials, emphasizing the need for trials focused on quality-of-life improvements and symptom control.
• **Future Directions:** Greater inclusion of patient-reported outcome measures in research and therapeutic development is essential for personalized care.

### 4. **Cancer Screening and Risk Management**

• **High Cancer Risk:** PSC remains a progressive disease with a high risk for hepatobiliary and colorectal cancers. Surveillance strategies like MRCP and ERCP are critical for early detection of cholangiocarcinoma and dominant strictures.
• **Earlier Detection Advantage:** Routine imaging allows for timely interventions that improve survival outcomes.

### 5. **Modern Therapeutic Development**

• **Personalized Care:** Future PSC care will emphasize personalized, high-quality ambulatory hepatology care tailored to individual patient needs.
• **ABCDE Model:** A stepwise PSC care strategy includes:
• **A**wareness: Educating patients about PSC and its risks.
• **B**ile ducts: Monitoring and managing strictures and infections.
• **C**ancer: Screening for hepatobiliary and colorectal cancers.
• **D**isability: Addressing quality-of-life symptoms like pruritus and fatigue.
• **E**xplore trials: Encouraging participation in clinical trials to advance treatment options.

### 6. **Improved Disease Management**

• **Long-Term ERCP Follow-Up:** Regular ERCP interventions help identify disease progression earlier and reduce recurrent cholangitis episodes, improving transplant-free survival.
• **State-of-the-Art Review Findings:** Modern care strategies focus on halting disease progression and improving life quality through symptom control, structured surveillance, and personalized treatment approaches.

### 7. **Conclusion: Redefining PSC Care**

Redefining PSC care involves combining early symptom-focused interventions, structured surveillance (MRCP/ERCP), and personalized treatment approaches. This integrated strategy targets both halting disease progression and improving patient quality of life. The urgent need for effective antipruritic therapies, better patient engagement in research, and proactive cancer screening further underscores the importance of modernizing PSC care. By addressing unmet needs and leveraging advancements in monitoring and therapeutic development, PSC care can significantly improve long-term outcomes and provide patients with a better quality of life.