Oral vancomycin for primary sclerosing cholangitis and associated inflammatory bowel disease - paving a path forward.
Document Type
Article
Publication Date
3-2026
Identifier
DOI: 10.1080/17474124.2026.2635420
Abstract
INTRODUCTION: Primary sclerosing cholangitis (PSC) is a fibro-inflammatory cholangiopathy strongly associated with inflammatory bowel disease (PSC-IBD). With no approved PSC therapy, clinicians face uncertainty about oral vancomycin (OV) as a therapeutic option. This review synthesizes clinical effectiveness evidence alongside mechanistic data.
AREAS COVERED: We searched PubMed/Google Scholar for studies of vancomycin in PSC from 1998 through November, 2025. OV shows consistent IBD benefits and variable liver responses. In PSC-IBD, clinical and endoscopic remission occurred in 60% at 6 months and in 71% at 12 months in a pediatric cohort; in an adult single-arm study (n = 15), 80% achieved endoscopic remission at 4 weeks with universal mucosal healing, reductions in fecal calprotectin and Mayo scores, and relapse after withdrawal. For liver disease, a pediatric open-label cohort (n = 45) reported ≥50% declines in gamma-glutamyl transferase in 82%; in an adult pilot randomized controlled trial, alkaline phosphatase fell 46% at 12 weeks. Imaging/histology improved as evidenced by MRCP in 26/34 large-duct PSC and reduced portal/periportal inflammation in 11/12 small-duct PSC. No vancomycin-resistant enterococci development has been reported.
EXPERT OPINION: OV appears effective for colitis control in PSC-IBD. Differences in observed liver outcomes across studies likely reflect variation in treatment duration, dose, and endpoint selection. Liver responses may depend on higher doses. Cross-specialty guidance and pragmatic, integrated trials are needed.
Journal Title
Expert Rev Gastroenterol Hepatol
Volume
20
Issue
3
First Page
233
Last Page
246
MeSH Keywords
Humans; Cholangitis, Sclerosing; Vancomycin; Inflammatory Bowel Diseases; Administration, Oral; Anti-Bacterial Agents; Treatment Outcome
PubMed ID
41718556
Keywords
Clinical trials; inflammatory bowel disease; oral vancomycin; primary sclerosing cholangitis
Recommended Citation
Johnson KM, Grady J, Kellermayer R, et al. Oral vancomycin for primary sclerosing cholangitis and associated inflammatory bowel disease - paving a path forward. Expert Rev Gastroenterol Hepatol. 2026;20(3):233-246. doi:10.1080/17474124.2026.2635420
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