From the Guidelines
Hepamerz (L-ornithine L-aspartate) is a beneficial treatment for hepatic encephalopathy, particularly when used in combination with lactulose, as it has been shown to lower plasma ammonia concentrations and improve symptoms of HE 1.
Mechanism of Action
Hepamerz works by providing substrates for the urea cycle in both the liver and skeletal muscle, enhancing ammonia detoxification. The medication supports the conversion of ammonia to glutamine in skeletal muscle and increases urea synthesis in residual hepatocytes.
Dosage and Administration
The typical dosage of Hepamerz is 5-9 grams administered intravenously over 4-8 hours, or 6-9 grams orally divided into three daily doses. Treatment duration depends on clinical response but often continues for several weeks.
Comprehensive Treatment Approach
Hepamerz should be used as part of a comprehensive treatment approach that includes:
- Addressing precipitating factors
- Dietary protein management
- Possibly other ammonia-lowering agents like lactulose or rifaximin Regular monitoring of ammonia levels and mental status is important to assess treatment effectiveness, as recommended by recent guidelines 1.
Recent Guidelines
Recent guidelines suggest that lactulose is recommended as secondary prophylaxis following a first episode of overt HE, and should be titrated to obtain 2-3 bowel movements per day 1. Rifaximin as an adjunct to lactulose is recommended as secondary prophylaxis following >1 additional episodes of overt HE within 6 months of the first one 1.
Quality of Life and Hospitalizations
To improve quality of life and limit hospitalisations, a therapeutic education program should be offered to the patient and caregiver, as suggested by experts 1.
From the Research
Hepatic Encephalopathy Treatment Options
- Hepatic encephalopathy is a serious complication of liver disease, and its management is crucial to prevent further complications 2, 3, 4.
- The nonabsorbable disaccharide lactulose is considered the first-line therapeutic agent for treating hepatic encephalopathy, as it inhibits the production of ammonia by coliform bacteria in the gastrointestinal tract 2, 4.
- Rifaximin, a semisynthetic antibiotic, has been approved for the treatment of overt hepatic encephalopathy and has been shown to be effective in improving behavioral, laboratory, mental, and intellectual abnormalities in patients with hepatic encephalopathy 2, 3, 4, 5.
- Other treatment options, such as L-ornithine-L-aspartate, zinc, and branched-chain amino acids, can be considered for patients who do not respond to lactulose and rifaximin 6, 4.
Comparison of Treatment Options
- Rifaximin has been compared to lactulose in clinical studies and has been found to be equal or superior to lactulose in some cases 2.
- L-ornithine-L-aspartate has been shown to be effective in reducing ammonia levels and improving hepatic encephalopathy grades, regardless of administration route 6.
- The choice of treatment option depends on the individual patient's needs and the severity of their hepatic encephalopathy 3, 4.
Management of Hepatic Encephalopathy
- Management of hepatic encephalopathy involves a multi-step approach, including stabilization, addressing modifiable precipitating factors, lowering blood ammonia, managing elevated intracranial pressure, and managing complications of liver failure 3.
- Continuous renal replacement therapy and liver transplantation may be considered in severe cases of hepatic encephalopathy 3, 4.
- Patients with hepatic encephalopathy should be closely monitored and managed by a healthcare team to prevent further complications and improve outcomes 2, 3, 4.