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National Guideline Centre (UK). Cirrhosis in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence (NICE); 2016 Jul. (NICE Guideline, No. 50.)
O.1. Risk factors and risk assessment tools
None.
O.2. Diagnostic tests
See Table 63 in Appendix N.
O.3. Severity risk tools
Table 91Unit costs of severity risk tools
| Risk tool | Unit cost | Comments |
|---|---|---|
| Child-Pugh | £7.42(a) | Includes bilirubin, albumin, INR, ascites events, hepatic encephalopathy events |
| MELD | £10.42(a) | Includes creatinine, bilirubin, INR |
| Transient elastography | £68.00 | Imaging technique |
Sources: Donnan 2009, NHS hospital trust (GDG source)
- a
MELD and Child-Pugh are inflated to 2013–14 prices
O.4. Surveillance for the early detection of hepatocellular carcinoma (HCC)
See Table 64 in Appendix N.
O.5. Surveillance for the detection of varices
See Table 64 in Appendix N.
O.6. Prophylaxis of variceal haemorrhage
Table 92Unit costs of variceal haemorrhage prophylaxis – band ligation
| Treatment | Unit cost | Details |
|---|---|---|
| Band ligation | £1,326 | £530 per procedure; assuming 2.5 procedures |
Source: NHS Hospital trust; GDG assumption
Table 93Unit costs of variceal haemorrhage prophylaxis – beta blockers
| Treatment | Daily dose | Cost per day | Cost per year |
|---|---|---|---|
| Propranolol(a) | 60–120 mg | £0.08–0.16 | £28.37–56.74 |
| Carvedilol(b) | 6.25–12.5 mg | £0.05, £0.04 | £17.86, £16.42 |
Sources: NHS Drug Tariff July 2015
- a
Starting dose 20 mg three times per day, adjusted up to 40 mg three times per day, according to drug response
- b
Starting dose 6.25 mg, adjusted up to 12.5 mg according to drug response; note that 12.5 mg tablets are cheaper than 6.25 mg tablets
O.7. Primary prevention of bacterial infections in cirrhosis and gastrointestinal bleeding
Table 94Unit costs of antibiotics to treat bacterial infections
| Antibiotic | Daily dose | Cost per day | Cost of 5-day course |
|---|---|---|---|
| Ceftriaxone (IV) | 1 g | £9.58 | £47.90 |
| Ceftriaxone (IV) | 2 g | £19.18 | £95.90 |
| Ciprofloxacin (oral) | 500 mg ×2 | £0.21 | £1.05 |
| Norfloxacin (oral)(a) | 400 mg ×2(b) | £1.71 | £8.57 |
| Norfloxacin (oral)(a) + ceftriaxone (IV) | 400 mg ×2 + 2 g | £20.89 | £104.47 |
| Ofloxacin (oral) | 400 mg ×2 | £4.36 | £21.8 |
Sources: NHS Drug Tariff July 2015, BNF August 2014
- a
Norfloxacin is currently unavailable in the UK
- b
Note that the Spanish group study used 1x 400 mg dosage
O.8. Transjugular intrahepatic portosystemic shunt (TIPS) versus large-volume paracentesis (LVP) for ascites
Table 95Unit costs of TIPS and LVP procedures
| Procedures | Unit cost | Details |
|---|---|---|
| TIPS | £2,904 | Average procedure costs of 28 patients |
| LVP | £672 | Cost per single procedure, includes 1 elective day case admission, 100 ml of 20% albumin, catheter system use |
Sources: TIPS: Parker 2013; LVP: NHS reference costs 2013–14, Parker 2013, GDG
O.9. Primary prevention of spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites
Table 96Unit costs of antibiotics used for the primary prevention of SBP
| Antibiotic | Daily dose | Cost per day | Cost per year |
|---|---|---|---|
| Ciprofloxacin (oral) | 500 mg | £0.11 | £40 |
| Ciprofloxacin (oral) | 750 mg | £0.80(a) | £292(a) |
| Norfloxacin (oral)(b) | 400 mg | £0.86 | £313 |
Sources: NHS Drug Tariff 2015, BNF August 2014
- a
Or £0.11 per day (£40 per year) if one and a half 500 mg tablets are used instead
- b
Norfloxacin is not currently available in the UK
Table 97Unit costs of managing SBP related complications
| Cost type | Unit cost | Details |
|---|---|---|
| 7 day hospital stay | £1,561 | GB03D (excess days), Intermediate, Endoscopic or Percutaneous, Hepatobiliary or Pancreatic Procedures, with CC Score 5-7 |
| Tazocin | £237.30 | Piperacillin 4 g/tazobactam 500 mg IV every 8 hours for 5 days |
| Paracentecis | £78 | |
| Ultrasound | £49 |
Sources: NHS reference costs 2013–14, NHS Drug Tariff July 2015, Parker 2013, GDG
O.10. Volume replacers in hepatorenal syndrome
Table 98Unit costs of IV volume replacers
| IV fluid type | Unit cost for 100 ml bag | Unit cost for 250 ml bag | Unit cost for 500 ml bag | Unit cost for 1000 ml bag |
|---|---|---|---|---|
| IV albumin | ||||
| Albumin (4.5%) | – | £17.03 | – | – |
| Albumin (5%) | – | – | £30.52 | – |
| Albumin (20%) | £35–50 | – | – | – |
| IV crystalloids | ||||
| Ringer's lactate solution | – | – | £1.25 | – |
| 0.9% sodium chloride (saline) | – | – | £0.63 | £0.70 |
| Hartmann's solution | – | – | £0.70 | £0.85 |
| Dextrose (5%) | – | – | £0.63 | £0.70 |
| IV polygels, plasma, colloids | ||||
| Plasmalyte 148ph 7.4 | – | – | – | £0.92 |
| Haemocel | – | – | – | – |
| Gelofusion/gelofusine | – | – | – | £4.80 |
| Dextran 70 (RescueFlow) | – | £28.50 | – | – |
| Mannitol (10%) | – | – | £3.20 | – |
| Mannitol (20%) | – | £3.78 | £5.80 | – |
| Voluven | – | – | £7.50–12.50 | – |
| Volulyte | – | – | £7.65–18.00 | – |
Sources: BNF July 2015, NICE CG174 Intravenous fluid therapy in adults in hospital, personal communication with NHS hospitals
O.11. Management of an episode of acute hepatic encephalopathy
Table 99Unit costs of drugs used to manage acute hepatic encephalopathy
| Drug | Cost per day(a) | Dosage |
|---|---|---|
| BCAA | – | No cost information |
| Flumazenil (IV) | £81.00 | One 5 ml ampule, 6x per day |
| Lactulose (oral solution) | £0.32 | 10–30 ml, 2–3x per day (average 50 ml) |
| Lactitol | Not prescribable | |
| LOLA | £34.4 | 10 ml ampoules, 4× per day |
| Metronidazole | £0.22 | One 400 mg tablet, 3× per day |
| MARS | – | No cost information |
| Neomycin sulphate | £0.50 | One 500 mg tablet, 2× per day |
| Rifaximin | £9.26 | One 550 mg tablet, 2× per day |
Sources: NHS Drug Tariff July 2015, BNF July 2015, NHS hospital trust (GDG source)
- a
Costs would apply for the duration of acute care (up to 5 days)
- Risk factors and risk assessment tools
- Diagnostic tests
- Severity risk tools
- Surveillance for the early detection of hepatocellular carcinoma (HCC)
- Surveillance for the detection of varices
- Prophylaxis of variceal haemorrhage
- Primary prevention of bacterial infections in cirrhosis and gastrointestinal bleeding
- Transjugular intrahepatic portosystemic shunt (TIPS) versus large-volume paracentesis (LVP) for ascites
- Primary prevention of spontaneous bacterial peritonitis (SBP) in people with cirrhosis and ascites
- Volume replacers in hepatorenal syndrome
- Management of an episode of acute hepatic encephalopathy
- Unit costs - Cirrhosis in Over 16sUnit costs - Cirrhosis in Over 16s
- Mus musculus guanylate nucleotide binding protein 3 (Gbp3), mRNAMus musculus guanylate nucleotide binding protein 3 (Gbp3), mRNAgi|9055221|ref|NM_018734.1|Nucleotide
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