Primary Biliary Cholangitis in the Middle East: A Review of Current Challenges and Treatment Approaches

Primary biliary cholangitis (PBC) is a chronic autoimmune cholestatic liver disease that can progress to fibrosis, cirrhosis, and liver failure. Most evidence guiding diagnosis and management is derived from Western populations, while Middle East-specific data remain limited. This review summarizes global and regional evidence and identifies Gulf-specific challenges affecting PBC recognition and care. A literature search of PubMed and Embase (2014-2025) was conducted to identify studies addressing PBC epidemiology and management in the Middle East. In parallel, expert insights were collected from 11 Gulf-based hepatologists through pre-meeting questionnaires and structured discussions. A separate online physician survey assessed awareness, diagnostic pathways, treatment access, and perceived barriers across the Gulf region. Published regional data were sparse and largely limited to small, single-center cohorts, preventing reliable population-level estimates. Experts perceived PBC as underdiagnosed and inconsistently referred, with variable access to confirmatory autoantibody testing and specialist hepatopathology. Treatment was based on ursodeoxycholic acid (UDCA), while access to second-line therapies remained inconsistent despite the substantial proportion of incomplete UDCA responders reported in international literature and guidelines. Emerging agents have demonstrated meaningful biochemical and symptom benefits in phase 3 studies, highlighting a growing gap between evolving evidence and regional therapeutic availability. Overall, PBC in the Middle East remains under-characterized and likely under-recognized. Establishing regional registries, standardizing referral and diagnostic pathways, and improving access to evidence-based second-line therapies should be prioritized to optimize patient outcomes.