From the Guidelines
For this 60-year-old female with a seizure likely due to hepatic encephalopathy, lactulose should be administered as the primary treatment, as recommended by the most recent and highest quality study 1. The recommended initial dose is 20-30g (30-45mL) orally every 1-2 hours until bowel movements occur, then adjusted to maintain 2-3 soft bowel movements daily (typically 15-30mL two to three times daily) 1. If the patient cannot take oral medication, lactulose can be given as a retention enema (300mL lactulose mixed with 700mL water) 1. Rifaximin 550mg twice daily may be added as an adjunctive therapy, as suggested by recent guidelines 1. The patient's elevated ammonia level of 180 in the setting of cirrhosis strongly suggests hepatic encephalopathy as the cause of her seizure. Lactulose works by acidifying the colon, converting ammonia to ammonium which cannot be absorbed, thereby reducing blood ammonia levels. Additionally, supportive care should include:
- Monitoring for additional seizures
- Maintaining airway protection
- Addressing any electrolyte abnormalities Antiepileptic medications are generally not the first-line treatment when seizures are secondary to hepatic encephalopathy, as treating the underlying cause is more effective 1.
Some key points to consider in the management of this patient include:
- Recognizing and managing precipitating factors of hepatic encephalopathy, such as gastrointestinal bleeding, infection, and constipation 1
- Using non-absorbable disaccharides, such as lactulose or lactitol, as the primary treatment for hepatic encephalopathy 1
- Considering the addition of rifaximin to prevent recurrence of hepatic encephalopathy in cases of failed prevention with a non-absorbable disaccharide 1
- Offering a therapeutic education program to the patient and caregiver to improve quality of life and limit hospitalizations 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%; this is generally paralleled by the improvement in the patients’ mental state and by an improvement in EEG patterns.
The patient has cirrhosis of the liver and an ammonia level of 180, which suggests portal-systemic encephalopathy.
- Lactulose is indicated for the prevention and treatment of portal-systemic encephalopathy.
- It reduces blood ammonia levels and improves the patient's mental state. Given the patient's condition, lactulose would be given to this patient 2.
From the Research
Treatment Options for Hepatic Encephalopathy
The patient in question has cirrhosis of the liver and an elevated ammonia level, which suggests hepatic encephalopathy. The treatment options for this condition include:
- Lactulose, a non-absorbable disaccharide that helps reduce plasma ammonia concentrations 3
- Rifaximin, an anti-microbiological agent that has shown promise in treating hepatic encephalopathy 4, 5, 6
Efficacy of Lactulose and Rifaximin
Studies have shown that lactulose is effective in reducing ammonia levels and improving mental status in patients with hepatic encephalopathy 3, 4. Rifaximin, when used in combination with lactulose, has been shown to be more effective than lactulose alone in treating overt hepatic encephalopathy 5, 6. A systematic review and meta-analysis found that the combination of rifaximin and lactulose was associated with an increased incidence of effective rate and reduced risk of mortality compared to lactulose alone 6.
Long-term Management
For long-term management of hepatic encephalopathy, lactulose and/or rifaximin can be used. Studies have shown that lactulose is effective in preventing overt HE recurrence over the long term, and the addition of rifaximin to lactulose significantly reduces the risk of overt HE recurrence and HE-related hospitalization 7.
Recommended Treatment
Based on the evidence, the recommended treatment for this patient would be lactulose, possibly in combination with rifaximin, to help reduce ammonia levels and improve mental status. However, the specific treatment should be determined by the patient's healthcare provider, taking into account their individual needs and medical history.