From the Guidelines
Alternative to Xifaxan (Rifaximin) in Cirrhosis
Lactulose is a recommended alternative to Xifaxan (Rifaximin) for patients with cirrhosis, as it is effective in preventing recurrent hepatic encephalopathy (HE) 1. A typical dose of Lactulose is 30-50 mL (or 1-2 tablespoons) orally three times a day, adjusted to produce 2-3 soft stools per day.
- Key Considerations:
- Lactulose is often preferred over Neomycin due to its better efficacy and safety profile 1.
- The use of Lactulose as secondary prophylaxis following a first episode of overt HE is strongly recommended, with a high level of evidence (LoE 1) 1.
- Rifaximin is recommended as an adjunct to Lactulose for secondary prophylaxis following more than one additional episode of overt HE within 6 months of the first one, with a moderate level of evidence (LoE 2) 1.
- Important Notes:
- Patients with cirrhosis require careful management and monitoring, and any new medication should be started under the guidance of a healthcare provider.
- The French recommendations suggest that Rifaximin can be used as an add-on to Lactulose when Lactulose alone fails to prevent recurrent overt HE, but it is difficult to recommend Rifaximin alone for prevention 1.
From the Research
Alternative to Xifaxan (Rifaximin) in Patients with Cirrhosis
- Lactulose is considered an alternative to Xifaxan (Rifaximin) in patients with cirrhosis, as it has been shown to be effective in reducing the recurrence of overt hepatic encephalopathy and hospitalizations 2, 3.
- Studies have compared the efficacy of rifaximin and lactulose in patients with hepatic encephalopathy, with results showing that both treatments are effective, but rifaximin may be superior in reducing the risk of HE-related hospitalization 2, 3.
- A prospective, randomized, open-label, non-inferiority trial found that rifaximin and lactulose were equally effective in reversing minimal hepatic encephalopathy (MHE) in cirrhotic patients, but non-inferiority of rifaximin over lactulose could not be established 4.
- Real-world experience has shown that rifaximin add-on to lactulose is superior to lactulose alone in maintaining HE remission and reducing HE-related hospitalizations in patients with cirrhosis complicated with recurrent hepatic encephalopathy 5.
- A pooled post hoc subgroup analysis found that rifaximin plus lactulose was more efficacious than lactulose alone in reducing the risk of overt HE recurrence and HE-related hospitalization in adults with cirrhosis, regardless of baseline disease characteristics 6.
Key Findings
- Lactulose is a viable alternative to Xifaxan (Rifaximin) in patients with cirrhosis.
- Rifaximin and lactulose have been shown to be effective in reducing the recurrence of overt hepatic encephalopathy and hospitalizations.
- The combination of rifaximin and lactulose may be more efficacious than lactulose alone in maintaining HE remission and reducing HE-related hospitalizations.