From the Guidelines
Neomycin should not be used as a first-line treatment for hepatic encephalopathy due to its potential for nephrotoxicity and ototoxicity, and instead, rifaximin or lactulose should be considered as primary treatment options. The use of neomycin is generally considered a second-line therapy, and its use should be carefully weighed against the potential risks, particularly in patients with renal impairment 1.
Treatment Options
- Rifaximin (550 mg twice daily) is a preferred first-line option for the treatment of hepatic encephalopathy, with a better safety profile compared to neomycin 1.
- Lactulose (15-30 ml orally 2-4 times daily) is also a recommended first-line treatment, with a therapeutic goal of achieving two to three soft stools per day 1.
- Neomycin may be considered in refractory cases or when first-line options are not tolerated, but its use requires regular monitoring of renal function and discontinuation if signs of toxicity develop 1.
Supportive Care
- Patients with hepatic encephalopathy should receive supportive care, including protein restriction, correction of precipitating factors like dehydration or infection, and management of any electrolyte imbalances to optimize treatment outcomes 1.
- A therapeutic education program should be offered to the patient and caregiver to improve quality of life and limit hospitalizations 1.
Recent Guidelines
The most recent guidelines from 2023 recommend the use of a non-absorbable disaccharide (lactulose or lactitol) to prevent the recurrence of hepatic encephalopathy in patients with cirrhosis, with the addition of rifaximin in cases of failed prevention 1.
From the FDA Drug Label
Neomycin sulfate has been shown to be effective adjunctive therapy in hepatic coma by reduction of the ammonia-forming bacteria in the intestinal tract. The subsequent reduction in blood ammonia has resulted in neurologic improvement. For use as an adjunct in the management of hepatic coma, the recommended dose is 4 to 12 grams per day given in the following regimen: If less potentially toxic drugs cannot be used for chronic hepatic insufficiency, neomycin in doses of up to four grams daily (eight tablets per day) may be necessary.
Neomycin for Hepatic Encephalopathy: Neomycin sulfate is indicated as adjunctive therapy for the management of hepatic coma (portal-systemic encephalopathy) by reducing ammonia-forming bacteria in the intestinal tract. The recommended dose is 4 to 12 grams per day for a period of 5 to 6 days. For chronic hepatic insufficiency, doses of up to 4 grams daily may be necessary. Frequent monitoring for drug toxicity is mandatory 2 2.
From the Research
Neonycin for Hepatic Encephalopathy
- There is no direct evidence in the provided studies to support the use of Neomycin for hepatic encephalopathy 3, 4, 5, 6, 7.
- However, systemic antibiotics, primarily neomycin, have been employed to reduce bacterial production of ammonia, but associated adverse events limit their use in patients with hepatic encephalopathy 3.
- The use of neomycin is not mentioned in the other studies, which focus on the use of lactulose and rifaximin for the treatment of hepatic encephalopathy 4, 5, 6, 7.
- Rifaximin, a synthetic antibiotic, has been shown to be effective in the treatment of hepatic encephalopathy, with a high benefit-risk ratio 7.
- Lactulose is considered the first-line therapeutic agent for treating hepatic encephalopathy, and the addition of rifaximin to lactulose therapy may result in substantial reductions in healthcare resource utilization over the long term 3, 6.