From the Guidelines
The pillars of treatment for hepatic encephalopathy include rifaximin, lactulose, branched-chain amino acids, and several other important interventions, with a strong recommendation for lactulose as secondary prophylaxis and rifaximin as an adjunct to lactulose for secondary prophylaxis following multiple episodes of overt HE 1. The treatment of hepatic encephalopathy (HE) requires a comprehensive approach that addresses both the immediate symptoms and underlying causes to prevent recurrence and improve quality of life.
- Key treatments include:
- Lactulose, which 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, which is recommended as an adjunct to lactulose for secondary prophylaxis following multiple episodes of overt HE 1
- Branched-chain amino acids (BCAAs), which may be beneficial in patients with HE, particularly those with cirrhosis 1
- Addressing precipitating factors such as gastrointestinal bleeding, infection, electrolyte disturbances, and medication side effects
- Protein restriction is no longer routinely recommended, as patients actually benefit from adequate protein intake (0.8-1.2 g/kg/day) with emphasis on vegetable and dairy protein sources
- Zinc supplementation may be beneficial as zinc deficiency is common in cirrhotic patients and can worsen HE
- L-ornithine L-aspartate (LOLA) helps reduce ammonia levels by enhancing ammonia metabolism
- Probiotics can help modify gut flora to reduce ammonia production
- In refractory cases, albumin dialysis or liver transplantation may be considered
- Neomycin and metronidazole are alternative antibiotics but are less commonly used due to side effect profiles It is essential to note that the management of HE should be individualized, and the treatment plan should be tailored to the specific needs of each patient, taking into account the severity of the disease, the presence of precipitating factors, and the patient's overall health status 1.
From the FDA Drug Label
For the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma. XIFAXAN is indicated for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults.
The pillars of treatment for Hepatic Encephalopathy include:
- Lactulose: for the prevention and treatment of portal-systemic encephalopathy
- Rifaximin: for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults
- Branched Chain Amino Acids: not mentioned in the provided drug labels Other treatments may include:
- Protein restriction and other supportive measures are not mentioned in the provided drug labels, but may be part of the treatment regimen for Hepatic Encephalopathy 2 3
From the Research
Pillars of Treatment for Hepatic Encephalopathy
The treatment of hepatic encephalopathy (HE) involves several key components, including:
- Lactulose: a non-absorbable disaccharide that has been shown to be effective in reducing HE manifestations 4, 5, 6, 7, 8
- Rifaximin: an antibiotic that has been found to be beneficial in combination with lactulose for the treatment of overt HE 4, 6, 7, 8
- Branched Chain Amino Acids (BCAA): which have been shown to have beneficial effects on HE manifestations compared to control supplements 4, 7
Additional Therapies
Other therapies that have been studied for the treatment of HE include:
- L-ornithine L-aspartate: which has been found to have potentially beneficial effects on HE manifestations 4
- Ornithine phenylacetate: a newer treatment that has shown promise in reducing HE manifestations 4
- Spherical carbon: which has been found to have potentially beneficial effects on HE manifestations 4
- Fecal microbiota transplant: a newer treatment that has shown promise in reducing HE manifestations 4
Combination Therapy
The use of combination therapy, such as lactulose plus rifaximin, has been found to be more effective than lactulose alone in the treatment of overt HE 6. Additionally, the combination of non-absorbable disaccharides, rifaximin, and BCAA may be beneficial for the treatment of HE, although more research is needed to fully evaluate the effect of combining all three interventions 7.