Cirrhosis in over 16s: assessment and management (NG50)

What this platform has drawn from it — 23 claims

• NICE advises against routinely offering antibiotics to prevent spontaneous bacterial peritonitis in people with cirrhosis and ascites. Recommendation 1.8.1 [2023]
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• NICE states that antibiotic prophylaxis against spontaneous bacterial peritonitis should be considered only where the person is at high risk because of severe liver disease, or where the consequences of infection could seriously affect their care. Recommendation 1.8.2 [2023]
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• Where antibiotic prophylaxis against spontaneous bacterial peritonitis is given, NICE advises following local microbiological advice and continuing treatment until the ascites has resolved. Recommendation 1.8.3 [2023]
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• NICE recommends considering a transjugular intrahepatic portosystemic shunt procedure for people with cirrhosis who have refractory ascites. Recommendation 1.10.1 [2016]
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• NICE advises that carvedilol should be avoided in people with severe hepatic impairment, giving large-volume or refractory ascites as examples of that state. Recommendation 1.5.1 [2023]
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• NICE NG50 recommends calculating a Model for End-Stage Liver Disease (MELD) score every 6 months for people with compensated cirrhosis. This recommendation last had an evidence review in 2016. Recommendation 1.2.2 [2016]
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• NICE NG50 advises considering a MELD score of 12 or more as an indicator that a person with compensated cirrhosis is at high risk of complications of cirrhosis. This recommendation last had an evidence review in 2016. Recommendation 1.2.3 [2016]
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• NICE advises awareness of an increased risk of cirrhosis in people with hepatitis B virus infection, hepatitis C virus infection, alcohol misuse, obesity with a body mass index of 30 kg/m2 or higher, or type 2 diabetes. Recommendation 1.1.1 [2016]
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• NICE recommends offering transient elastography to diagnose cirrhosis in people with hepatitis C virus infection, in men and people registered male at birth drinking over 50 units of alcohol per week for several months, in women and people registered female at birth drinking over 35 units per week for several months, and in people diagnosed with alcohol-related liver disease. Recommendation 1.1.3 [2016]
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• NICE advises against using routine laboratory liver blood tests to rule out cirrhosis. Recommendation 1.1.8 [2016]
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• NICE recommends considering liver biopsy to diagnose cirrhosis in people for whom transient elastography is not suitable. Recommendation 1.1.5 [2016]
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• NICE recommends referring people diagnosed with cirrhosis to a specialist in hepatology, and discussing the accuracy, limitations and risks of the different diagnostic tests with the person. Recommendations 1.1.9 and 1.1.2 [2016]
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• NICE recommends retesting for cirrhosis every 2 years in people diagnosed with alcohol-related liver disease, people with hepatitis C virus infection who have not achieved a sustained virological response to antiviral therapy, and people with MASLD and advanced liver fibrosis. Recommendation 1.1.10 [2016]
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• NICE recommends referring people who have, or are at high risk of, complications of cirrhosis to a specialist hepatology centre. Recommendation 1.2.1 [2016]
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• NICE recommends calculating the Model for End-Stage Liver Disease score every 6 months for people with compensated cirrhosis, and suggests considering a MELD score of 12 or more as an indicator that the person is at high risk of complications of cirrhosis. Recommendations 1.2.2 and 1.2.3 [2016]
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• NICE recommends offering ultrasound, with or without measurement of serum alpha-fetoprotein, every 6 months as surveillance for hepatocellular carcinoma in people with cirrhosis who do not have hepatitis B virus infection. Recommendation 1.3.1 [2016]
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• NICE advises against offering surveillance for hepatocellular carcinoma to people who are receiving end of life care. Recommendation 1.3.2 [2016]
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• NICE recommends offering upper gastrointestinal endoscopy after a diagnosis of cirrhosis to detect oesophageal varices, unless the person is planning to take carvedilol or propranolol to prevent decompensation. Recommendation 1.4.1 [2016, amended 2023]
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• NICE recommends offering surveillance by upper gastrointestinal endoscopy every 3 years to people who have already had an endoscopy in which no oesophageal varices were found and who are not taking carvedilol or propranolol. Recommendation 1.4.2 [2016, amended 2023]
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• NICE NG50 advises considering simultaneous endoscopic variceal band ligation if medium or large varices are detected during upper gastrointestinal endoscopy. This recommendation is new at the 2023 update. Recommendation 1.4.3 [2023]
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• For people with medium or large oesophageal varices, NICE NG50 recommends offering either carvedilol or propranolol, or endoscopic variceal band ligation where a beta blocker is not tolerated or contraindicated or the person cannot take tablets regularly. NICE records that in September 2023 carvedilol for preventing variceal bleeding, and carvedilol and propranolol for primary prevention of decompensation, were off-label uses. Recommendation 1.7.2 [2023] · Off-label note attached to section 1.7
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• When starting carvedilol or propranolol in a person with cirrhosis, NICE NG50 recommends using a low dosage - for example 6.25 mg a day for carvedilol or 40 mg twice a day for propranolol - and increasing or decreasing the dose depending on the results of heart rate and blood pressure monitoring. Recommendation 1.5.2, first bullet [2023] · Recommendation 1.5.2, second bullet [2023]
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• NICE NG50 recommends offering prophylactic intravenous antibiotics to people with cirrhosis who have upper gastrointestinal bleeding. This recommendation last had an evidence review in 2016. Recommendation 1.9.1 [2016]
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