|Trade names||Actigall, Urso, others|
|CompTox Dashboard (EPA)|
|Chemical and physical data|
|Molar mass||392.580 g·mol−1|
|3D model (JSmol)|
|Melting point||203 °C (397 °F)|
Ursodeoxycholic acid (UDCA), also known as ursodiol, is a secondary bile acid, produced in humans and most other species from metabolism by intestinal bacteria. It is synthesized in the liver in some species, and was first identified in bile of bears of genus Ursus, from which its name derived. In purified form, it has been used to treat or prevent several diseases of the liver or bile ducts.
UDCA has been used as medical therapy in gallstone disease (cholelithiasis) and for biliary sludge. UDCA helps reduce the cholesterol saturation of bile and leads to gradual dissolution of cholesterol-rich gallstones.
UDCA may be given after bariatric surgery to prevent cholelithiasis, which commonly occurs due to the rapid weight loss producing biliary cholesterol oversaturation and also biliary dyskinesia secondary hormonal changes.
Primary biliary cholangitis
UDCA is used as therapy in primary biliary cholangitis (PBC; previously known as primary biliary cirrhosis) where it can produce an improvement in biomarkers. Meta-analyses have borne out conflicting results on the mortality benefit. However analyses that exclude trials of short duration (i.e. < 2 years) have demonstrated a survival benefit and are generally considered more clinically relevant. A Cochrane systematic review in 2012 found no significant benefit in reducing mortality, the rate of liver transplantation, pruritus or fatigue. Ursodiol and obeticholic acid are FDA-approved for the treatment of primary biliary cholangitis.
Primary sclerosing cholangitis
UDCA use is associated with improved serum liver tests that do not always correlate with improved liver disease status. WHO Drug Information advises against its use in primary sclerosing cholangitis in unapproved doses beyond 13–15 mg/kg/day.
UDCA in a dose of 28-30mg/kg/day increases risk of death and need for liver transplant by 2.3 folds among those with primary sclerosing cholangitis, despite decrease in liver enzymes.
Intrahepatic cholestasis of pregnancy
UDCA has been used for intrahepatic cholestasis of pregnancy. UDCA lessens itching in the mother and may reduce the number of preterm births. Effects on fetal distress and other adverse outcomes are unlikely to be great.
UDCA use is not licensed in children, as its safety and effectiveness have not been established. Evidence is accumulating that ursodeoxycholic acid is ineffective, unsafe and its use is associated with significant risk of morbidity and mortality in neonatal hepatitis and neonatal cholestasis.
In cystic fibrosis there is insufficient evidence to justify routine use of UDCA, especially as there is a lack of available data for long-term outcomes such as death or need for liver transplantation.
UDCA has also been in effective in non-alcoholic fatty liver disease, in liver bile duct-paucity syndromes. It is contraindicated in obstruction of biliary tracts such as biliary atresia. It's not effective in liver allograft rejection, and in Graft-versus-host disease involving the liver.
Diarrhea was the most frequent adverse event seen in trial of UDCA in gallstone dissolution, occurring in 2 to 9%, which is less frequent than with chenodeoxycholic acid therapy. Bacterial conversion of UDCA to chenodeoxycholic acid may be the mechanism for this side effect. Right upper quadrant abdominal pain and exacerbation of pruritus was occasionally reported in trials in patients with PBC. Additional symptoms may include bloating, weight gain, and occasionally, thinning of hair.
Mechanisms of action
Primary bile acids are produced by the liver and stored in the gall bladder. When secreted into the intestine, primary bile acids can be metabolized into secondary bile acids by intestinal bacteria. Primary and secondary bile acids help the body digest fats. Ursodeoxycholic acid helps regulate cholesterol by reducing the rate at which the intestine absorbs cholesterol molecules while breaking up micelles containing cholesterol. The drug reduces cholesterol absorption and is used to dissolve (cholesterol) gallstones in patients who want an alternative to surgery. There are multiple mechanisms involved in cholestatic liver diseases.
Ursodeoxycholic acid has also been shown experimentally to suppress immune response such as immune cell phagocytosis. Prolonged exposure and/or increased quantities of systemic (throughout the body, not just in the digestive system) ursodeoxycholic acid can be toxic.
Ursodeoxycholic acid has been shown to exert anti-inflammatory and protective effects in human epithelial cells of the gastrointestinal tract. It has been linked to regulation of immunoregulatory responses by regulation of cytokines, antimicrobial peptides defensins, and take an active part in increased restitution of wound in the colon. Moreover, UDCA's effects has been shown to have exert actions outside the epithelial cells.
While some bile acids are known to be colon tumor promoters (e.g. deoxycholic acid), others such as ursodeoxycholic acid are thought to be chemopreventive, perhaps by inducing cellular differentiation and/or cellular senescence in colon epithelial cells.
Ursodeoxycholic acid is an epimer of chenodeoxycholic acid, which has similar choleretic effects and a wider species distribution. However, CDCA is not as well-tolerated in humans and it does not show immunomodulating or chemoprotective effects. Both are 7-hydroxyl derivatives of deoxycholic acid, but UDCA has the group in the beta instead of the alpha orientation.
Other vertebrates produce UDCA in much smaller amounts by gut bacteria. CDCA is oxidized into 7-oxo-CDCA then reduced into UDCA.
Society and culture
Ursodeoxycholic acid can be chemically synthesized and is marketed under multiple trade names, including Ursetor, Udikast, Actibile, Actigall, Biliver, Deursil, Egyurso, Udcasid, Udiliv, Udinorm, Udoxyl, Urso, Urso Forte, Ursocol, Ursoliv, Ursofalk, Ursosan, Ursoserinox, Udimarin, Ursonova, and Stener.
Bear bile, a natural source of UDCA, is used in traditional Chinese medicine since the seventh century. Japanese scientists successfully synthesized UDCA chemically in 1955. The earliest reference to UDCA in PubMed dates to 1957 under an alternative spelling "ursodesoxycholic acid", in a small-scale clinical trial.
- "Ursodiol Use During Pregnancy". Drugs.com. 4 November 2019. Retrieved 20 February 2020.
- "Ursodeoxycholic acid 300mg Tablets - Summary of Product Characteristics (SmPC)". (emc). 10 July 2019. Retrieved 29 April 2020.
- "Actigall- ursodiol capsule". DailyMed. Retrieved 25 September 2021.
- "Urso 250- ursodiol tablet, film coated Urso Forte- ursodiol tablet, film coated". DailyMed. Retrieved 25 September 2021.
- Hagey LR, Crombie DL, Espinosa E, Carey MC, Igimi H, Hofmann AF (November 1993). "Ursodeoxycholic acid in the Ursidae: biliary bile acids of bears, pandas, and related carnivores". Journal of Lipid Research. 34 (11): 1911–7. PMID 8263415.
- "2020 First Generic Drug Approvals". U.S. Food and Drug Administration (FDA). 23 February 2021. Retrieved 25 September 2021.
- "Ursodiol: FDA-Approved Drugs". U.S. Food and Drug Administration (FDA). Retrieved 25 September 2021.
- Hofmann AF (September 1989). "Medical dissolution of gallstones by oral bile acid therapy". American Journal of Surgery. 158 (3): 198–204. doi:10.1016/0002-9610(89)90252-3. PMID 2672842.
- Jüngst C, Kullak-Ublick GA, Jüngst D (2006). "Gallstone disease: Microlithiasis and sludge". Best Practice & Research. Clinical Gastroenterology. 20 (6): 1053–62. doi:10.1016/j.bpg.2006.03.007. PMID 17127187.
- Magouliotis DE, Tasiopoulou VS, Svokos AA, Svokos KA, Chatedaki C, Sioka E, Zacharoulis D (November 2017). "Ursodeoxycholic Acid in the Prevention of Gallstone Formation After Bariatric Surgery: an Updated Systematic Review and Meta-analysis". Obesity Surgery. 27 (11): 3021–3030. doi:10.1007/s11695-017-2924-y. PMID 28889240. S2CID 4622165.
- Poupon RE, Balkau B, Eschwège E, Poupon R (May 1991). "A multicenter, controlled trial of ursodiol for the treatment of primary biliary cirrhosis. UDCA-PBC Study Group". The New England Journal of Medicine. 324 (22): 1548–54. doi:10.1056/NEJM199105303242204. PMID 1674105.
- Goulis J, Leandro G, Burroughs AK (September 1999). "Randomised controlled trials of ursodeoxycholic-acid therapy for primary biliary cirrhosis: a meta-analysis". Lancet. 354 (9184): 1053–60. doi:10.1016/S0140-6736(98)11293-X. PMID 10509495. S2CID 25562983.
- Shi J, Wu C, Lin Y, Chen YX, Zhu L, Xie WF (July 2006). "Long-term effects of mid-dose ursodeoxycholic acid in primary biliary cirrhosis: a meta-analysis of randomized controlled trials". The American Journal of Gastroenterology. 101 (7): 1529–38. doi:10.1111/j.1572-0241.2006.00634.x. PMID 16863557. S2CID 32076958.
- Rudic JS, Poropat G, Krstic MN, Bjelakovic G, Gluud C (December 2012). "Ursodeoxycholic acid for primary biliary cirrhosis". The Cochrane Database of Systematic Reviews. 12: CD000551. doi:10.1002/14651858.CD000551.pub3. PMC 7045744. PMID 23235576.
- Bowlus CL, Kenney JT, Rice G, Navarro R (October 2016). "Primary Biliary Cholangitis: Medical and Specialty Pharmacy Management Update". Journal of Managed Care & Specialty Pharmacy. 22 (10-a-s Suppl): S3–S15. doi:10.18553/jmcp.2016.22.10-a-s.s3. PMID 27700211.
- Poropat G, Giljaca V, Stimac D, Gluud C (January 2011). "Bile acids for primary sclerosing cholangitis". The Cochrane Database of Systematic Reviews (1): CD003626. doi:10.1002/14651858.CD003626.pub2. PMC 7163275. PMID 21249655.
- "Ursodeoxycholic acid: serious hepatic events" (PDF). WHO Drug Information. 26 (1). 2012.
- Lindor KD, Kowdley KV, Luketic VA, Harrison ME, McCashland T, Befeler AS, et al. (September 2009). "High-dose ursodeoxycholic acid for the treatment of primary sclerosing cholangitis". Hepatology. 50 (3): 808–14. doi:10.1002/hep.23082. PMC 2758780. PMID 19585548.
- Walker KF, Chappell LC, Hague WM, Middleton P, Thornton JG (July 2020). "Pharmacological interventions for treating intrahepatic cholestasis of pregnancy". The Cochrane Database of Systematic Reviews. 2020 (7): CD000493. doi:10.1002/14651858.CD000493.pub3. PMC 7389072. PMID 32716060.
- Chappell LC, Bell JL, Smith A, Linsell L, Juszczak E, Dixon PH, et al. (September 2019). "Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial". Lancet. 394 (10201): 849–860. doi:10.1016/S0140-6736(19)31270-X. PMC 6739598. PMID 31378395.
- Kotb MA (July 2008). "Review of historical cohort: ursodeoxycholic acid in extrahepatic biliary atresia". Journal of Pediatric Surgery. 43 (7): 1321–7. doi:10.1016/j.jpedsurg.2007.11.043. PMID 18639689.
- Paediatric Formulary Committee (2008). British National Formulary for Children 2008. London: Pharmaceutical Press. p. 91. ISBN 978-0-85369-780-0.
- "Urso package insert" (PDF). Birmingham, AL: Axcan Pharma U.S. January 2000.
- Kotb MA, Mosallam D, Basanti CW, El Sorogy ST, Badr AM, Abd El Baky HE, Draz IH (February 2020). "Ursodeoxycholic acid use is associated with significant risk of morbidity and mortality in infants with cholestasis: A strobe compliant study". Medicine. 99 (7): e18730. doi:10.1097/MD.0000000000018730. PMC 7035015. PMID 32049781.
- McCabe ME, Dilly CK (September 2018). "New Causes for the Old Problem of Bile Reflux Gastritis". Clinical Gastroenterology and Hepatology. 16 (9): 1389–1392. doi:10.1016/j.cgh.2018.02.034. hdl:1805/15771. PMID 29505908. S2CID 3748071.
- Cheng K, Ashby D, Smyth RL (September 2017). Cochrane Cystic Fibrosis and Genetic Disorders Group (ed.). "Ursodeoxycholic acid for cystic fibrosis-related liver disease". The Cochrane Database of Systematic Reviews. 9 (4): CD000222. doi:10.1002/14651858.CD000222.pub4. PMC 6483662. PMID 28891588.
- Hempfling W, Dilger K, Beuers U (November 2003). "Systematic review: ursodeoxycholic acid--adverse effects and drug interactions". Alimentary Pharmacology & Therapeutics. 18 (10): 963–72. doi:10.1046/j.1365-2036.2003.01792.x. PMID 14616161. S2CID 25738560.
- Lleo A, Wang GQ, Gershwin ME, Hirschfield GM (December 2020). "Primary biliary cholangitis". Lancet. 396 (10266): 1915–1926. doi:10.1016/S0140-6736(20)31607-X. PMID 33308474. S2CID 228086916.
- Tint GS, Salen G, Shefer S (October 1986). "Effect of ursodeoxycholic acid and chenodeoxycholic acid on cholesterol and bile acid metabolism". Gastroenterology. 91 (4): 1007–18. doi:10.1016/0016-5085(86)90708-0. PMID 3527851.
- Paumgartner G, Beuers U (September 2002). "Ursodeoxycholic acid in cholestatic liver disease: mechanisms of action and therapeutic use revisited". Hepatology. 36 (3): 525–31. doi:10.1053/jhep.2002.36088. PMID 12198643. S2CID 28282761.
- Material Safety Data Sheet on Ursodiol MSDS. https://fscimage.fishersci.com/msds/70916.htm
- Ward JB, Lajczak NK, Kelly OB, O'Dwyer AM, Giddam AK, Ní Gabhann J, et al. (June 2017). "Ursodeoxycholic acid and lithocholic acid exert anti-inflammatory actions in the colon". American Journal of Physiology. Gastrointestinal and Liver Physiology. 312 (6): G550–G558. doi:10.1152/ajpgi.00256.2016. PMID 28360029.
- Lajczak NK, Saint-Criq V, O'Dwyer AM, Perino A, Adorini L, Schoonjans K, Keely SJ (September 2017). "Bile acids deoxycholic acid and ursodeoxycholic acid differentially regulate human β-defensin-1 and -2 secretion by colonic epithelial cells". FASEB Journal. 31 (9): 3848–3857. doi:10.1096/fj.201601365R. PMID 28487283.
- Mroz MS, Lajczak NK, Goggins BJ, Keely S, Keely SJ (March 2018). "The bile acids, deoxycholic acid and ursodeoxycholic acid, regulate colonic epithelial wound healing". American Journal of Physiology. Gastrointestinal and Liver Physiology. 314 (3): G378–G387. doi:10.1152/ajpgi.00435.2016. PMID 29351391.
- O'Dwyer AM, Lajczak NK, Keyes JA, Ward JB, Greene CM, Keely SJ (August 2016). "Ursodeoxycholic acid inhibits TNFα-induced IL-8 release from monocytes". American Journal of Physiology. Gastrointestinal and Liver Physiology. 311 (2): G334-41. doi:10.1152/ajpgi.00406.2015. PMID 27340129.
- Akare S, Jean-Louis S, Chen W, Wood DJ, Powell AA, Martinez JD (December 2006). "Ursodeoxycholic acid modulates histone acetylation and induces differentiation and senescence". International Journal of Cancer. 119 (12): 2958–69. doi:10.1002/ijc.22231. PMID 17019713. S2CID 21187798.
- Feng Y, Siu K, Wang N, Ng KM, Tsao SW, Nagamatsu T, Tong Y (2009). "Bear bile: dilemma of traditional medicinal use and animal protection". Journal of Ethnobiology and Ethnomedicine. 5 (1): 2. doi:10.1186/1746-4269-5-2. PMC 2630947. PMID 19138420.
- Devlin, AS; Fischbach, MA (September 2015). "A biosynthetic pathway for a prominent class of microbiota-derived bile acids". Nature Chemical Biology. 11 (9): 685–90. doi:10.1038/nchembio.1864. PMC 4543561. PMID 26192599.
- Tonin, F; Arends, IWCE (2018). "Latest development in the synthesis of ursodeoxycholic acid (UDCA): a critical review". Beilstein Journal of Organic Chemistry. 14: 470–483. doi:10.3762/bjoc.14.33. PMC 5827811. PMID 29520309.
- ARAKAWA, T; KAGAYA, A; INABA, Y (10 September 1957). "Ursodesoxycholic acid as in accelerator for riboflavin phosphorylation in children with nutritional dystrophy". The Journal of Vitaminology. 3 (3): 165–7. doi:10.5925/jnsv1954.3.165. PMID 13476545.
- "Actigall: FDA-Approved Drugs". U.S. Food and Drug Administration (FDA). Retrieved 29 April 2020.
- "Actigall Orphan Drug Designation and Approval". U.S. Food and Drug Administration (FDA). Retrieved 29 April 2020.