From the Guidelines
Rifaximin has been used in primary sclerosing cholangitis (PSC), but it is not a standard treatment and its effectiveness is controversial, as a 12-week course of rifaximin resulted in no significant effects on the clinical course of PSC 1. When considering the use of rifaximin in PSC, it is essential to weigh the potential benefits against the lack of definitive evidence supporting its efficacy. Some potential benefits of rifaximin in PSC include:
- Reducing intestinal bacteria that produce beta-glucuronidase, an enzyme that deconjugates bile acids in the gut
- Decreasing the production of potentially harmful secondary bile acids and bacterial translocation, which could theoretically slow PSC progression or improve symptoms However, the current evidence does not support the use of rifaximin as a standard treatment for PSC, and its use should be considered on a case-by-case basis. Key points to consider when evaluating the use of rifaximin in PSC include:
- The lack of large randomized controlled trials demonstrating clear benefit
- The potential for off-label use and limited insurance coverage
- The need for careful patient selection and monitoring to ensure that any potential benefits outweigh the risks. In contrast to rifaximin, other antibiotics such as vancomycin and metronidazole have shown some promise in improving liver enzymes and alkaline phosphatase levels in PSC patients when used in combination with ursodeoxycholic acid 1.
From the Research
Rifaximin Use in PSC
- Rifaximin has been investigated as a potential treatment for Primary Sclerosing Cholangitis (PSC) in a clinical trial 2.
- The study found that oral rifaximin, 550 mg twice daily, did not significantly change serum alkaline phosphatase (ALK) or other biochemical markers after 12 weeks of treatment 2.
- The trial also reported no significant changes in fatigue impact scale, chronic liver disease questionnaire, or SF-36 scores, indicating no improvement in quality of life measures 2.
- Three patients withdrew from the study due to adverse effects, and four others reported mild adverse effects but completed the study 2.
Alternative Therapies for PSC
- Other studies have explored the potential of antibiotics and fecal microbiota transplantation in treating PSC, given the possible role of the microbiome in the disease 3.
- Various therapeutic strategies are being developed, including nuclear receptor agonists, antifibrotic agents, and agents targeting gut-homing T cells 3.
- Ursodeoxycholic acid is widely used in PSC, although its effectiveness is still debated, and other therapies such as obeticholic acid and fibrates are being investigated 3, 4, 5.
Rifaximin Mechanism and Clinical Potential
- Rifaximin is a poorly absorbed antibiotic with a broad spectrum of antibacterial activity, primarily targeting the gastrointestinal tract 6.
- Its clinical potential extends to various gastrointestinal diseases, including hepatic encephalopathy, small intestine bacterial overgrowth, and inflammatory bowel disease 6.
- However, its use in PSC is still experimental, and more research is needed to determine its efficacy and safety in this context 2.