Surveillance decision

Surveillance decision

We will update the NICE guideline on cirrhosis in over 16s: assessment and management. The update will focus on primary prophylaxis of variceal haemorrhage and primary prevention of spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites.

Reasons for the decision

This section provides a summary of the areas that will be updated and the reasons for the decision to update.

Primary prophylaxis of variceal haemorrhage

The guideline recommends oesophageal variceal ligation (EVL) as primary prophylaxis for preventing bleeding from medium/large varices. Evidence identified through the current review shows that non-specific beta-blockers may be as effective as EVL for reducing bleeding or mortality and offer an alternative approach. New published evidence may also change the guideline cost-effectiveness estimates for EVL and this may impact on the recommendations.

Primary prevention of SBP in people with cirrhosis and ascites

Evidence indicates fluoroquinolones may no longer be the antibiotics of first choice for primary prevention of SBP in people with cirrhosis and ascites. New published evidence suggests that rifaximin or co-trimoxazole, when compared with the fluoroquinolone antibiotics, may be at least equivalent for reducing both SBP and mortality. Taken together with a recent MHRA drug safety update on fluoroquinolones and withdrawal of norfloxacin from the UK, there is a potential impact on recommendations.

Other areas of the guideline

No update is suggested for other areas of the guideline relating to: diagnosis; monitoring; primary prevention of bacterial infections in cirrhosis and upper gastrointestinal bleeding; and management of ascites. For these areas of the guideline there was limited new evidence, or new evidence generally supported existing recommendations.

We also re-examined areas that were considered during development of the guideline but where recommendations could not be made. We identified no new evidence for volume replacers in hepatorenal syndrome. New evidence was available on the management of hepatic encephalopathy (HE). While new evidence to support lactulose treatment of overt HE episodes was identified, it was noted that lactulose is standard NHS practice and therefore should not need to be addressed by the guideline.

For further details and a summary of all evidence identified in surveillance, see appendix A.

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