Ivermectin for fatty liver disease is not supported by clinical evidence or UK guidance. Ivermectin is an antiparasitic medication licensed in the UK only for specific parasitic infections, not for treating hepatic steatosis or non-alcoholic fatty liver disease (NAFLD). Despite interest in repurposing this drug, no high-quality trials demonstrate benefit for liver conditions, and NICE guidance does not recommend it. Evidence-based treatment for fatty liver disease focuses on lifestyle modification—particularly weight loss through diet and exercise—alongside management of metabolic risk factors such as diabetes and dyslipidaemia. Patients should avoid unproven therapies and consult their GP or hepatologist for appropriate, safe management.

What Is Fatty Liver Disease and How Is It Treated?

Fatty liver disease, medically termed hepatic steatosis, occurs when excess fat accumulates in liver cells. This condition exists in two main forms: non-alcoholic fatty liver disease (NAFLD), which affects people who drink little or no alcohol, and alcohol-related liver disease (ARLD), caused by excessive alcohol consumption. NAFLD is increasingly common in the UK, affecting approximately one in three adults, often associated with obesity, type 2 diabetes, and metabolic syndrome. (Note: NAFLD is increasingly referred to as metabolic dysfunction-associated steatotic liver disease [MASLD] in newer literature, though NICE guidance currently uses NAFLD terminology.)

The condition typically progresses through stages. Simple steatosis involves fat accumulation without significant inflammation. However, in some individuals, this can advance to non-alcoholic steatohepatitis (NASH), characterised by inflammation and liver cell damage. Without intervention, NASH may progress to fibrosis, cirrhosis, or even hepatocellular carcinoma. Many people with fatty liver disease experience no symptoms initially, though some report fatigue, discomfort in the upper right abdomen, or general malaise. Importantly, liver function tests may be normal even in the presence of significant liver disease.

Current evidence-based treatment focuses primarily on lifestyle modification rather than pharmacological intervention. NICE guidance (NG49) emphasises weight loss through dietary changes and increased physical activity as the cornerstone of management. A weight reduction of 7–10% can significantly reduce liver fat and inflammation. Additional measures include:

• Managing underlying conditions such as diabetes, hypertension, and dyslipidaemia

• Complete abstinence from alcohol, particularly in advanced disease

• Regular assessment of fibrosis risk using non-invasive scores (FIB-4 or NAFLD Fibrosis Score), followed by Enhanced Liver Fibrosis (ELF) test or elastography where indicated

• In advanced fibrosis or cirrhosis, surveillance for hepatocellular carcinoma with ultrasound (± alpha-fetoprotein) every 6 months, and consideration of variceal screening

Whilst several medications are under investigation for NASH, no drug therapy is currently licensed specifically for fatty liver disease in the UK. Treatment remains focused on addressing metabolic risk factors and preventing disease progression through sustainable lifestyle changes.

Ivermectin: Uses and Mechanism of Action

Ivermectin is an antiparasitic medication that has been used in clinical practice for over four decades. It belongs to the avermectin class of drugs and was originally derived from soil bacteria. In the UK, oral ivermectin is licensed only for treating onchocerciasis (river blindness) and strongyloidiasis. It is sometimes used off-label under specialist guidance for scabies and other parasitic conditions when first-line treatments have failed. Topical ivermectin 1% cream (Soolantra) is licensed in the UK for the treatment of rosacea, not for head lice or scabies.

The mechanism of action involves binding to glutamate-gated chloride channels found in invertebrate nerve and muscle cells. This binding increases cell membrane permeability to chloride ions, causing hyperpolarisation and subsequent paralysis and death of the parasite. Importantly, these specific chloride channels are not present in mammals, which contributes to ivermectin's favourable safety profile when used at therapeutic doses for approved indications.

Ivermectin oral tablets (typically 3 mg) are absorbed from the gastrointestinal tract and widely distributed throughout body tissues, with metabolism occurring primarily in the liver via cytochrome P450 3A4 enzymes. The drug has a relatively long half-life of approximately 18 hours, allowing for convenient dosing schedules.

Common adverse effects when used for parasitic infections include dizziness, nausea, diarrhoea, and mild skin reactions. Serious adverse effects are rare but may include severe skin reactions, neurological effects (particularly in patients with high parasite burdens or co-infection with Loa loa), and hepatic enzyme elevations in exceptional cases. The MHRA emphasises that ivermectin should only be used for licensed indications under appropriate medical supervision. Patients should not self-source ivermectin online or use it off-label without specialist advice, as such use may carry unforeseen risks. Suspected adverse reactions should be reported via the MHRA Yellow Card Scheme (https://yellowcard.mhra.gov.uk).

Evidence and Research on Ivermectin for Liver Conditions

Despite interest in repurposing ivermectin for various conditions, there is no official link or established evidence supporting its use for fatty liver disease. The drug is not licensed for this indication in the UK, and neither NICE (NG49) nor the British Association for the Study of the Liver (BASL) recommend ivermectin as a treatment for NAFLD, MASLD, or any form of hepatic steatosis.

Some preclinical laboratory studies have explored ivermectin's potential anti-inflammatory and metabolic effects in cellular and animal models. These investigations have examined whether the drug might influence pathways involved in lipid metabolism, inflammation, or fibrosis. However, these experimental findings have not translated into clinical evidence demonstrating benefit in human patients with fatty liver disease. The biological mechanisms studied in laboratory settings often do not replicate in complex human physiology, and extrapolating from animal models to clinical practice requires rigorous human trials.

No high-quality randomised controlled trials have been published evaluating ivermectin specifically for fatty liver disease treatment. The absence of such evidence means that efficacy, appropriate dosing, duration of treatment, and safety profile for this indication remain unknown. Furthermore, using medications outside their licensed indications carries potential risks, including unexpected adverse effects and drug interactions.

It is important to note that ivermectin itself can, in rare circumstances, cause liver enzyme elevations or hepatotoxicity, as documented in the UK Summary of Product Characteristics. Administering a medication with potential hepatic effects to patients with existing liver disease without established benefit would be clinically inappropriate. Patients with fatty liver disease should focus on evidence-based interventions that have demonstrated efficacy in improving liver health, rather than unproven treatments that may offer false hope or potential harm. Any consideration of off-label therapies should be discussed with a GP or hepatologist.

Recommended Treatments for Fatty Liver Disease in the UK

NICE guidance (NG49) provides clear, evidence-based recommendations for managing fatty liver disease, with lifestyle modification forming the foundation of treatment. Weight loss remains the most effective intervention for reducing hepatic steatosis and inflammation. Studies demonstrate that losing 7–10% of body weight can significantly improve liver histology, reduce fat content, and decrease inflammation in patients with NASH. Even modest weight loss of 3–5% can reduce liver fat, though greater reductions are needed to improve inflammation and fibrosis.

Dietary interventions should focus on reducing overall calorie intake whilst maintaining nutritional adequacy. The Mediterranean diet pattern, rich in vegetables, fruits, whole grains, legumes, nuts, and olive oil, has shown particular promise in improving liver health. Patients should limit consumption of:

• Refined carbohydrates and added sugars, particularly fructose-containing beverages

• Saturated and trans fats

• Processed foods high in salt and additives

• Alcohol (complete abstinence is advisable, especially in advanced disease)

Physical activity provides benefits independent of weight loss. The UK Chief Medical Officers' Physical Activity Guidelines recommend at least 150 minutes of moderate-intensity aerobic exercise weekly, combined with resistance training on two or more days. Both aerobic exercise and resistance training can reduce liver fat content and improve insulin sensitivity.

Pharmacological management focuses on treating associated metabolic conditions. This includes optimising glycaemic control in diabetes with appropriate agents such as metformin. Whilst emerging evidence suggests SGLT2 inhibitors may offer hepatic benefits, they are not currently recommended solely for the treatment of NAFLD or MASLD. Dyslipidaemia should be managed with statins, which are safe and indicated for cardiovascular risk reduction in fatty liver disease. Hypertension should be controlled according to standard guidance.

Specialist pharmacotherapy may be considered in select cases. NICE recommends that pioglitazone may be considered in adults with biopsy-proven NASH, initiated by a specialist after discussion of risks and benefits (this is an off-label use). Vitamin E supplementation may be considered in select patients with biopsy-proven NASH without diabetes, though this also requires specialist input.

Fibrosis risk assessment should follow a staged approach: initial calculation of FIB-4 or NAFLD Fibrosis Score in primary care (with age-adjusted thresholds: FIB-4 <1.3 suggests low risk if age <65 years; <2.0 if ≥65 years; >3.25 suggests possible advanced fibrosis), followed by Enhanced Liver Fibrosis (ELF) test or transient elastography (FibroScan) to confirm or stratify risk, as per NICE diagnostic guidance (DG16) and local pathways. Patients with advanced fibrosis or cirrhosis require specialist hepatology follow-up, surveillance for hepatocellular carcinoma with ultrasound (± alpha-fetoprotein) every 6 months, and consideration of variceal screening according to local protocols.

When to Seek Medical Advice About Fatty Liver

Many individuals with fatty liver disease remain asymptomatic, with the condition often detected incidentally through abnormal liver function tests or imaging performed for other reasons. However, certain circumstances warrant prompt medical evaluation. Patients should contact their GP if they experience persistent fatigue, unexplained weight loss, abdominal pain or discomfort in the upper right quadrant, jaundice (yellowing of skin or eyes), or signs of fluid retention such as abdominal swelling or ankle oedema.

Urgent or emergency symptoms require immediate action. Patients should seek same-day urgent assessment or call 999 if they experience confusion or drowsiness (possible hepatic encephalopathy), vomiting blood or passing black tarry stools, severe abdominal pain, or fever with jaundice. For urgent advice, contact NHS 111.

Initial assessment by a GP typically includes a comprehensive history focusing on alcohol consumption, medications, family history of liver disease, and metabolic risk factors. Physical examination may reveal hepatomegaly (enlarged liver), signs of insulin resistance, or features of advanced liver disease. Blood tests assess liver enzymes (ALT, AST, GGT), liver synthetic function (albumin, prothrombin time), and screen for alternative causes of liver disease including viral hepatitis, autoimmune conditions, and hereditary disorders. It is important to note that normal liver function tests do not exclude fatty liver disease or significant fibrosis.

Risk stratification is essential to identify patients requiring specialist referral. The NHS recommends using non-invasive fibrosis scores such as the FIB-4 index or NAFLD Fibrosis Score to assess the likelihood of advanced fibrosis. Age-adjusted thresholds should be applied: for FIB-4, values <1.3 (if age <65 years) or <2.0 (if age ≥65 years) suggest low risk, whilst values >3.25 suggest possible advanced fibrosis and warrant further assessment with ELF testing or elastography. Patients with:

• Elevated fibrosis scores suggesting advanced disease

• Persistently abnormal liver function tests despite lifestyle modification (typically >3–6 months)

• Clinical features of cirrhosis or portal hypertension

• Concurrent liver conditions requiring specialist management

should be referred to hepatology services for further evaluation, which may include specialist imaging (FibroScan or MRI) or liver biopsy if uncertainty persists.

Patients considering any treatment, including medications not licensed for fatty liver disease such as ivermectin, should discuss this with their GP or hepatologist. Self-medication with unproven therapies may delay appropriate treatment, cause harm, or interact with existing medications. Evidence-based management under medical supervision offers the best outcomes for liver health and overall wellbeing.

Frequently Asked Questions