A first drug guideline for PBC, who keeps diabetes in remission, and what a calcium score at 40 predicts
Five documents published October 19-25, 2026 translate a first medication guideline for primary biliary cholangitis, two decades of data on what now causes drug-induced liver injury, who keeps type 2 diabetes in remission, a 30-year look at calcium scores in adults under 45, and a large safety comparison of two diabetes drug classes into questions for your next appointment.
Five documents published between October 19 and October 25, 2026 touch the three conditions this brief follows. The American Association for the Study of Liver Diseases and the American Gastroenterological Association issued their first joint guideline that weighs specific medicines for primary biliary cholangitis. A 20-year national registry showed which drugs and supplements are now causing liver injury in the United States. A 14-year randomized study reported who keeps type 2 diabetes in remission after surgery. A 30-year follow-up looked at what a coronary calcium score means in someone under 45. And a large national database compared the safety of two common second-line diabetes drug classes.
The summaries below are background for your next appointment. Your clinician knows your history, your test results, and your current prescriptions, and treatment decisions belong in that conversation.
Quick view
| Update | What changed | Who may care | Action window | Appointment question |
|---|---|---|---|---|
| A first medication guideline for primary biliary cholangitis | AASLD and AGA published six recommendations on October 22, covering antibody testing when the standard test is negative, ursodeoxycholic acid as first-line treatment, liver stiffness measurement, newer add-on drugs, a drug for severe itching, and treatment after transplant. 12 | Adults with PBC, and anyone whose liver tests stay abnormal without a clear cause | Before your next hepatology or gastroenterology visit | "How will we know at 12 months whether my ursodeoxycholic acid is working, and if it isn't, which second-line option fits me now?" |
| Who stays in diabetes remission after surgery | In a 14-year randomized study of 262 adults, 58 percent of those assigned to metabolic-bariatric surgery reached remission, against 3 percent assigned to intensive medical and lifestyle therapy. Shorter diabetes duration, no insulin use, and weight loss in the first year predicted remission. 3 | Adults with type 2 diabetes considering surgery, and adults deciding how aggressively to treat early | If surgery is on your list of options | "Given how long I've had diabetes and that I do or don't take insulin, what would remission look like for me — and what would you expect five years out?" |
| Supplements keep climbing as a cause of liver injury | The DILIN registry followed 1,983 high-causality cases from 2004 to 2024. Antibiotics remain the largest single drug class, but their share fell while herbal and dietary supplements and cancer drugs rose. People with existing liver disease died more often. 4 | Anyone taking herbal, botanical, or bodybuilding supplements, especially with existing liver disease | This week — write the list down | "Should we go through everything I take, including supplements you wouldn't call medicine?" |
| A calcium score under 45 and the next 30 years | Among 12,847 adults aged 30 to 45 who had a calcium scan, a score above the 90th percentile carried a 3.7-fold higher risk of dying of coronary heart disease over a median 22.6 years, compared with a score of zero. 5 | Adults under 45 with a family history of early heart attack, diabetes, high LDL cholesterol, or smoking history | At your next visit, if that list describes you | "I'm under 45 with these risk factors — would a calcium score change what we do, or would you treat me the same either way?" |
| Two diabetes drug classes, compared on real-world harms | In a Taiwanese national database, new users of SGLT2 inhibitors had lower rates of urinary infection, acute kidney injury, falls and fractures, and death than new users of DPP-4 inhibitors, but more genital infections. 6 | Adults with type 2 diabetes taking, or about to start, a second glucose-lowering drug | At your next medication review | "SGLT2 inhibitors and DPP-4 inhibitors both lower my sugar — which one fits my kidneys and my infection history better?" |
1. A first medication guideline for a liver disease most people have never heard of
On October 22 the American Association for the Study of Liver Diseases and the American Gastroenterological Association published a joint guideline on primary biliary cholangitis. 2 It appears in Hepatology and in Gastroenterology. 1
Primary biliary cholangitis, usually shortened to PBC, is a lifelong autoimmune disease. The immune system attacks the small bile ducts inside the liver, and bile backs up. 7
Over years that damage can scar the liver and, in some people, lead to cirrhosis or a transplant. PBC is not caused by alcohol, and it is not contagious. 7
The guideline answers six specific questions rather than describing every corner of care. 1
First, when someone is suspected of having PBC but the usual antimitochondrial antibody test is negative, two other antibodies, SP100 and GP210, should be checked. 2 Those results can spare some people a liver biopsy. 7
Second, ursodeoxycholic acid is the first-line treatment, started as soon as the diagnosis is made. 2 It is a tablet most people tolerate; diarrhea, nausea, or weight gain are the usual complaints. 7
Third, liver stiffness should be measured to estimate how much scarring is present and how fast things may move. 2 That is the painless vibration test, often called elastography or by the brand name FibroScan. 7
Fourth, for people who respond poorly to ursodeoxycholic acid, or cannot tolerate it, the guideline suggests adding a PPAR agonist. 2 The two drugs named for patients are seladelpar and elafibranor. 7
Fifth, linerixibat is an option for moderate-to-severe itching, which is the symptom that most erodes daily life in PBC. 2 The guideline asks for a shared decision, because diarrhea, abdominal pain, more frequent bowel movements, and cost all weigh against relief. 7
Sixth, ursodeoxycholic acid should continue after a liver transplant, because PBC can return in the new liver. 2
Timing is why this guideline landed now. Obeticholic acid, the second-line drug many patients were taking, was withdrawn from the United States market late in 2025. 2
On response, the practical marker is a blood test. Teams generally judge whether ursodeoxycholic acid is working at six to twelve months, using alkaline phosphatase, bilirubin, and symptoms. 7
Two limits belong here. The certainty behind these recommendations ranges from moderate to very low. 2 And the panel said plainly that it does not yet know how often to repeat elastography or what to do when a second-line drug also falls short. 2
PBC is uncommon enough that many people are managed by a general gastroenterologist rather than a liver specialist, which is who this guideline was written for. 2
Ask at your next visit: "How will we know at 12 months whether my ursodeoxycholic acid is working, and if it isn't, which second-line option fits me now that obeticholic acid is gone?"
2. Who actually stays in diabetes remission after surgery
On October 20, Diabetes Care published an analysis of who reached remission in the ARMMS-T2D study. 3
The study followed 262 adults with type 2 diabetes for a median of 11 years, and up to 14. 3 Participants had been assigned at random to metabolic-bariatric surgery, 166 of them, or to intensive medical and lifestyle therapy, 96. 3
Remission here has a strict definition: an A1c below 6.5 percent with no glucose-lowering medication at all. 3
By that standard, 58 percent of the surgery group reached remission at some point, against 3 percent of the medical group. 3
The more useful finding is which people got there. Shorter diabetes duration, no insulin use, and fewer glucose-lowering medication classes all predicted remission. 3
Higher fasting C-peptide and insulin levels predicted it too, as did greater body weight at the start and weight loss during the first year. 3 C-peptide is a marker of how much insulin a person's own pancreas still makes. 3
Relapse followed the same logic in reverse. Among people who first reached remission, a longer history of diabetes and more medication classes at the start predicted the disease coming back. 3
Read that as a portrait of a group, not a verdict on one person. A long duration or insulin use lowers the odds; it does not close the door. 3
The limits are size and design. This is 262 people across three different operations, analyzed for patterns rather than tested as a new treatment. 3
What it changes for a reader is the shape of the conversation. If surgery is on your list, the questions worth asking are about duration, insulin, and what your weight did in the first year — not about averages. 3
Ask at your next visit: "Given how long I've had diabetes and that I do or don't take insulin, what would remission look like for me — and what would you expect five years out?"
3. Supplements keep climbing the list of what injures the liver
On October 23, Hepatology published two decades of the DILIN registry, the United States study of drug-induced liver injury. 4
The analysis covers 1,983 cases judged highly likely to be caused by a drug, seen at multiple centers from 2004 through 2024 and followed for six months. 4
The typical patient was 52 years old, 59 percent were women, and just over half had a pattern of injury that starts in liver cells rather than in the bile ducts. 4
Antibiotics were the single largest drug class across the whole period, at 41 percent of cases. 4
The trend is what changed. The share attributed to antibiotics fell, including isoniazid and nitrofurantoin, and the share attributed to nervous-system drugs fell too. 4
Meanwhile two categories rose significantly: herbal and dietary supplements, and cancer drugs including checkpoint inhibitors. 4
Severity eased overall. Peak bilirubin, clotting time, and severity scores all declined across the 20 years. 4
Who got hurt worst is the part to keep. People who already had chronic liver disease died more often than those who did not. 4
Adults over 65 had higher overall and liver-related mortality than younger adults. 4 Cancer patients on treatment had a 6-month death rate of 30 percent, though most of those deaths were not from the liver. 4
The plain-language lesson is boring and useful. A supplement bottle is a set of active chemicals, and the liver processes all of them. 4
Two limits belong with it. This registry counts suspected cases referred to study centers, so it describes proportions among recognized injuries rather than the risk of any one product. 4
And idiosyncratic means unpredictable. These reactions are not simple overdoses, which is why they cannot be avoided by staying under a dose. 4
What a reader can do this week is small and concrete: put every bottle on the table, photograph the labels, and hand the list to the clinician who manages your liver. 4
Ask at your next visit: "Should we go through everything I take, including supplements you wouldn't call medicine?"
4. A calcium score under 45 says something about the next thirty years
On October 23, JAMA Cardiology published a long follow-up of coronary artery calcium scores in younger adults. 5
A calcium score comes from a CT scan of the heart. It measures hardened plaque in the coronary arteries, and a score of zero means none was detected. 5
The study pooled 12,847 adults aged 30 to 45 who had a scan for a clinical reason at four institutions. They were followed for a median of 22.6 years. 5
Two groups were compared: a score above the 90th percentile for age and sex, and a score of exactly zero. 5
The high-score group had 1.87 times the risk of dying from any cause, 2.60 times the risk of dying of cardiovascular disease, and 3.71 times the risk of dying of coronary heart disease. 5
Modeled over 30 years, all-cause mortality was 12.9 percent against 7.5 percent. Cardiovascular death was 4.5 percent against 1.5 percent, and coronary death 3.0 percent against 0.6 percent. 5
Those absolute numbers are the honest headline. In your thirties and forties, most people with a high score still do not die of heart disease within 30 years. 5
But the gap between the two groups is wide, and it opens early. That matters because standard risk calculators are weakest in younger adults, where age alone keeps the computed risk low. 5
Three limits belong here. These were people referred for a scan, not a random sample, so they may have had symptoms or risk factors that prompted it. 5
Seventy-seven percent were men, so the estimates for women are thinner. 5
And this is observational. A score reveals risk; the study does not show that acting on it in your forties saves lives, though that is the reasonable hope behind testing. 5
The practical question is whether a scan would change a decision. If you are under 45 with a family history of early heart attack, diabetes, high LDL cholesterol, or a smoking history, that is a fair thing to ask. 5
Ask at your next visit: "I'm under 45 with these risk factors — would a calcium score change what we do, or would you treat me the same either way?"
5. Two diabetes drug classes, compared on the harms that make people stop
On October 19, Diabetic Medicine published a comparison of two second-line drug classes for type 2 diabetes. 6
This is not a trial but the next best thing when a trial is impractical: a target trial emulation. 6 The researchers used Taiwan's national insurance database and compared people who started one class or the other, matched statistically on their baseline characteristics. 6
The comparison covered 224,510 new SGLT2 inhibitor users and 698,012 new DPP-4 inhibitor users, each on treatment for at least 30 days. 6
SGLT2 inhibitors came out ahead on most of the harms measured. 6
Urinary tract infections were lower, with a hazard ratio of 0.86. Falls and fractures were lower, at 0.93. 6
Acute kidney injury was about half as common, at 0.55. A rare skin reaction called bullous pemphigoid was also less frequent, at 0.35. 6
Death from any cause was lower in the SGLT2 inhibitor group, with a hazard ratio of 0.66, or 13.05 against 19.72 per 1,000 person-years. 6
One harm went the other way. Genital infections were more common with SGLT2 inhibitors, a hazard ratio of 1.44, or 2.96 against 2.05 per 1,000 person-years. 6
That risk is real but manageable, and it is the reason these drugs come with hygiene advice and a warning to report genital pain or swelling. 6
The results held in the people who worry clinicians most: older adults and people with frailty or kidney disease. 6
Three limits matter. Insurance records show prescriptions and diagnoses, not lab values, so some events are surely missed. 6
The population was Taiwanese, and results can shift across populations with different body composition and prescribing habits. 6
And a mortality difference this size in observational data deserves caution, since people who receive one drug may differ from those who receive the other in ways no adjustment captures. 6
What it gives a reader is a better question at the pharmacy counter. Both classes lower glucose; they differ in what else they do to kidneys, infections, and falls. 6
Ask at your next visit: "SGLT2 inhibitors and DPP-4 inhibitors both lower my sugar — which one fits my kidneys and my infection history better?"
Questions to take to your appointment
- "How will we know at 12 months whether my ursodeoxycholic acid is working, and if it isn't, which second-line option fits me now that obeticholic acid is gone?"
- "Given how long I've had diabetes and that I do or don't take insulin, what would remission look like for me — and what would you expect five years out?"
- "Should we go through everything I take, including supplements you wouldn't call medicine?"
- "I'm under 45 with these risk factors — would a calcium score change what we do, or would you treat me the same either way?"
- "SGLT2 inhibitors and DPP-4 inhibitors both lower my sugar — which one fits my kidneys and my infection history better?"
References
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