Which statement is incorrect regarding hepatic encephalopathy: Neomycin (neomycin) reducing ammonia, lactulose reducing ammonia, increasing protein diet, or hypokalemia being common?

From the Guidelines

The incorrect statement regarding hepatic encephalopathy is C: Protein diet should increase in management. In fact, protein restriction was traditionally recommended for hepatic encephalopathy management, though current guidelines suggest maintaining adequate protein intake rather than severe restriction. Increasing protein intake would actually worsen encephalopathy by increasing ammonia production. Ammonia is a neurotoxin that accumulates when the liver cannot properly metabolize it, leading to neurological symptoms. The other statements are correct: Neomycin is an antibiotic that reduces ammonia-producing gut bacteria; lactulose works as a laxative and acidifies the gut to trap and eliminate ammonia; and hypokalaemia (low potassium) is indeed a common electrolyte imbalance in these patients, often due to diuretic therapy, malnutrition, or secondary hyperaldosteronism. Management typically includes addressing precipitating factors, reducing ammonia production through medications like lactulose and rifaximin, maintaining electrolyte balance, and providing adequate but not excessive protein intake (typically 1.0-1.5 g/kg/day) to prevent muscle wasting while avoiding ammonia excess, as suggested by recent studies 1.

Some key points to consider in the management of hepatic encephalopathy include:

• Maintaining adequate protein intake without excessive restriction, as severe restriction can lead to muscle wasting and worsening of the condition 1
• Using non-absorbable disaccharides like lactulose as first-line treatment for reducing ammonia production and improving cognitive function 1
• Considering the use of rifaximin in combination with lactulose for patients who do not respond to lactulose alone 1
• Monitoring and managing electrolyte imbalances, particularly hypokalaemia, which can exacerbate hepatic encephalopathy 1
• Avoiding excessive protein intake, which can increase ammonia production and worsen encephalopathy, as supported by the most recent and highest quality study 1

From the FDA Drug Label

For the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma. Controlled studies have shown that lactulose solution therapy reduces the blood ammonia levels by 25 to 50%; The clinical response has been observed in about 75% of patients, which is at least as satisfactory as that resulting from neomycin therapy. An increase in patients’ protein tolerance is also frequently observed with lactulose therapy.

The incorrect statement is: C. Protein diet should increase in management (protein will increase ammonia--> encephalopathy).

• Lactulose therapy actually increases patients’ protein tolerance, which suggests that a protein diet may not necessarily increase ammonia levels and worsen encephalopathy in patients being treated with lactulose 2.
• Hypokalemia is indeed a common electrolyte imbalance that may occur in patients with portal-systemic encephalopathy, and other specific therapy may be required to manage it 2.
• Neomycin and lactulose can both be used to reduce ammonia production, although there may be interactions between the two drugs 2.

From the Research

Hepatic Encephalopathy Management

The following points highlight the incorrect statement regarding hepatic encephalopathy management:

• Ammonia production can be reduced by neomycin, which is a correct statement as neomycin is used to reduce bacterial production of ammonia 3, 4, 5.
• Lactulose is useful for ammonia reduction, which is also correct as lactulose is considered the first-line therapeutic agent for treating hepatic encephalopathy by inhibiting production of ammonia by coliform bacteria 3, 4, 5, 6.
• Protein diet should increase in management, which is incorrect as a low-protein diet was previously recommended, but recent studies suggest that protein restriction should be avoided in patients with hepatic encephalopathy, and a normal-protein diet is safe and does not exacerbate the condition 7.
• Hypokalaemia is common imbalance, which is correct as electrolyte disturbances, including hypokalaemia, are predisposing factors for hepatic encephalopathy 4, 5.