Approval of ursodeoxycholic acid (UDCA) in 1997 significantly reduced liver transplant and death risks for primary biliary cholangitis (PBC), but up to 40% of patients do not sufficiently respond. Off-label use of fibrates and the 2016 approval of obeticholic acid (Ocaliva) as a second-line treatment provided additional options, though Ocaliva has downsides like increased pruritus. New PPAR agonists, seladelpar and elafibranor, have been approved for PBC, showing potential benefits but with unknown long-term risks.