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Liver conditions

About

What is covered

This interactive flowchart covers the guidance NICE has produced on liver conditions.
To find other information about liver conditions, including evidence from NICE accredited sources, visit NICE Evidence search.

Updates

Updates to this interactive flowchart

20 February 2018 Sofosbuvir–velpatasvir–voxilaprevir for treating chronic hepatitis C (NICE technology appraisal guidance 507) added to sofosbuvir–velpatasvir–voxilaprevir.
23 January 2018 Glecaprevir–pibrentasvir for treating chronic hepatitis C (NICE technology appraisal guidance 499) added to glecaprevir–pibrentasvir.
22 December 2017 Boceprevir for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal guidance 253) and telaprevir for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal guidance 252) removed following their withdrawal.
24 January 2017 Sofosbuvir–velpatasvir for treating chronic hepatitis C (NICE technology appraisal guidance 430) added to sofosbuvir–velpatasvir.
25 October 2016 Elbasvir–grazoprevir for treating chronic hepatitis C (NICE technology appraisal guidance 413) added to elbasvir–grazoprevir.
24 November 2015 Added:
  • ledipasvir–sofosbuvir for treating chronic hepatitis C (NICE technology appraisal guidance 363)
  • daclatasvir for treating chronic hepatitis C (NICE technology appraisal guidance 364)
  • ombitasvir–paritaprevir–ritonavir with or without dasabuvir for treating chronic hepatitis C (NICE technology appraisal guidance 365)
  • simeprevir in combination with sofosbuvir for treating genotype 1 or 4 chronic hepatitis C (terminated appraisal) (NICE technology appraisal 361)
  • living-donor liver transplantation (NICE interventional procedures guidance 535).
21 July 2015 Everolimus for preventing organ rejection in liver transplantation (NICE technology appraisal guidance 348) added to liver transplantation.
24 February 2015 Added:
  • simeprevir in combination with peginterferon alfa and ribavirin for treating genotypes 1 and 4 chronic hepatitis C (NICE technology appraisal guidance 331)
  • sofosbuvir for treating chronic hepatitis C (NICE technology appraisal guidance 330).

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on liver conditions in an interactive flowchart

What is covered

This interactive flowchart covers the guidance NICE has produced on liver conditions.
To find other information about liver conditions, including evidence from NICE accredited sources, visit NICE Evidence search.

Updates

Updates to this interactive flowchart

20 February 2018 Sofosbuvir–velpatasvir–voxilaprevir for treating chronic hepatitis C (NICE technology appraisal guidance 507) added to sofosbuvir–velpatasvir–voxilaprevir.
23 January 2018 Glecaprevir–pibrentasvir for treating chronic hepatitis C (NICE technology appraisal guidance 499) added to glecaprevir–pibrentasvir.
22 December 2017 Boceprevir for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal guidance 253) and telaprevir for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal guidance 252) removed following their withdrawal.
24 January 2017 Sofosbuvir–velpatasvir for treating chronic hepatitis C (NICE technology appraisal guidance 430) added to sofosbuvir–velpatasvir.
25 October 2016 Elbasvir–grazoprevir for treating chronic hepatitis C (NICE technology appraisal guidance 413) added to elbasvir–grazoprevir.
24 November 2015 Added:
  • ledipasvir–sofosbuvir for treating chronic hepatitis C (NICE technology appraisal guidance 363)
  • daclatasvir for treating chronic hepatitis C (NICE technology appraisal guidance 364)
  • ombitasvir–paritaprevir–ritonavir with or without dasabuvir for treating chronic hepatitis C (NICE technology appraisal guidance 365)
  • simeprevir in combination with sofosbuvir for treating genotype 1 or 4 chronic hepatitis C (terminated appraisal) (NICE technology appraisal 361)
  • living-donor liver transplantation (NICE interventional procedures guidance 535).
21 July 2015 Everolimus for preventing organ rejection in liver transplantation (NICE technology appraisal guidance 348) added to liver transplantation.
24 February 2015 Added:
  • simeprevir in combination with peginterferon alfa and ribavirin for treating genotypes 1 and 4 chronic hepatitis C (NICE technology appraisal guidance 331)
  • sofosbuvir for treating chronic hepatitis C (NICE technology appraisal guidance 330).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Glecaprevir–pibrentasvir for treating chronic hepatitis C (2018) NICE technology appraisal guidance 499
Sofosbuvir–velpatasvir for treating chronic hepatitis C (2017) NICE technology appraisal guidance 430
Elbasvir–grazoprevir for treating chronic hepatitis C (2016) NICE technology appraisal guidance 413
Daclatasvir for treating chronic hepatitis C (2015) NICE technology appraisal guidance 364
Ledipasvir–sofosbuvir for treating chronic hepatitis C (2015) NICE technology appraisal guidance 363
Everolimus for preventing organ rejection in liver transplantation (2015) NICE technology appraisal guidance 348
Sofusbuvir for treating chronic hepatitis C (2015) NICE technology appraisal guidance 330
Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C (2006 updated 2013) NICE technology appraisal guidance 106
Living-donor liver transplantation (2015) NICE interventional procedures guidance 535

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

HCV genotype, liver disease stage
Treatment
Duration (weeks)
Recommendation according to treatment history
Untreated
Treated
Interferon-ineligible or intolerant
1, without cirrhosis
Daclatasvir with sofosbuvir
12
Recommended only if the person has significant fibrosis
Recommended only if the person has significant fibrosis
Recommended only if the person has significant fibrosis
4, without cirrhosis
Daclatasvir with sofosbuvir
12
Not recommended
Recommended only if the person has significant fibrosis
Recommended only if the person has significant fibrosis
1 or 4, with compensated cirrhosis
Daclatasvir with sofosbuvir (with or without ribavirin)
24
Not recommended
Not recommended
Recommended
3, without cirrhosis
Daclatasvir with sofosbuvir
12
Not recommended
Not recommended
Recommended only if the person has significant fibrosis
3, with compensated cirrhosis
Daclatasvir with sofosbuvir and ribavirin
24
Not recommended
Not recommended
Recommended
4
Daclatasvir with peginterferon alfa and ribavirin
24
Recommended only if the person has significant fibrosis or compensated cirrhosis
Recommended only if the person has significant fibrosis or compensated cirrhosis
Not applicable
HCV, hepatitis C virus.
Significant fibrosis is defined as METAVIR fibrosis stages F3 and F4.
Treated – the person's hepatitis C has not adequately responded to interferon-based treatment.

Glecaprevir–pibrentasvir

Current treatment options for chronic hepatitis C depend on genotype, cirrhosis status and treatment history. Glecaprevir–pibrentasvir is suitable for all genotypes and has a shorter treatment duration than most other direct-acting antiviral treatments.
Clinical trials show that glecaprevir–pibrentasvir is effective for treating chronic hepatitis C across all genotypes. There was only 1 trial directly comparing glecaprevir–pibrentasvir with other direct-acting antiviral regimens, but comparing individual arms of clinical trials of other direct-acting antivirals suggests that glecaprevir–pibrentasvir works as well as most direct-acting antiviral drugs that NICE already recommends for treating hepatitis C.
The analysis shows that cost-effectiveness estimates for glecaprevir–pibrentasvir across all populations are substantially below what NICE usually considers acceptable. It is therefore recommended for treating chronic hepatitis C.
For more information see the committee discussion in the NICE technology appraisal guidance on glecaprevir–pibrentasvir for treating chronic hepatitis C.

Why we made the recommendations on sofosbuvir–velpatasvir–voxilaprevir

Treatment options for chronic hepatitis C depend on the genotype of the virus and the person's cirrhosis status and treatment history. They include direct-acting antivirals (DAA) and interferon-containing treatments. There are currently no treatments with a marketing authorisation available for people who have had unsuccessful treatment with DAA.
Clinical trials show that sofosbuvir–velpatasvir–voxilaprevir is effective for treating all genotypes of chronic hepatitis C, irrespective of the person's cirrhosis status and treatment history.
The company's economic evidence is limited to people who have had DAA (genotypes 1–6) and people with genotype 3 hepatitis C who have not had DAA before. This reflects the groups with the highest unmet clinical need. Cost-effectiveness estimates for sofosbuvir–velpatasvir–voxilaprevir are within what NICE usually considers acceptable. Therefore sofosbuvir–velpatasvir–voxilaprevir can be recommended for these groups for treating chronic hepatitis C, as specified in the table below.
Treatment history
Hepatitis C virus genotype
Liver disease stage
Recommendation
Previous direct-acting antivirals
1–6
With or without compensated cirrhosis
Recommended for 12 weeks
No direct-acting antivirals
3
Recommended for 8 weeks
For more information see the committee discussion in the NICE technology appraisal guidance on sofosbuvir–velpatasvir–voxilaprevir for treating chronic hepatitis C.

Glossary

Paths in this pathway

Pathway created: March 2014 Last updated: February 2018

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