From the Guidelines
Metabolic encephalopathy is a brain dysfunction caused by various metabolic disturbances, and its management should focus on identifying and treating the underlying cause, with precipitants including gastrointestinal bleeding, infection, constipation, and electrolyte imbalance, as recognized by the Kasl clinical practice guidelines for liver cirrhosis 1. The main causes of metabolic encephalopathy include:
- Liver failure (hepatic encephalopathy)
- Kidney failure (uremic encephalopathy)
- Electrolyte imbalances (particularly sodium, calcium, and glucose abnormalities)
- Hypoxia
- Endocrine disorders (such as thyroid dysfunction)
- Vitamin deficiencies (especially thiamine)
- Toxin exposure (including medications, alcohol, and heavy metals) Management of metabolic encephalopathy involves:
- Identifying and treating the underlying cause
- Providing supportive care, such as airway protection and seizure management
- Correcting electrolyte imbalances, with hyponatremia correction limited to 8-10 mEq/L in 24 hours to prevent central pontine myelinolysis
- Administering lactulose (20-30 g orally 3-4 times per day) and rifaximin (400 mg three times/day or 550 mg twice/day) for hepatic encephalopathy, as recommended by the Kasl clinical practice guidelines for liver cirrhosis 1
- Using oral BCAA, intravenous LOLA, or albumin as additional treatments for hepatic encephalopathy, as suggested by the Kasl clinical practice guidelines for liver cirrhosis 1 Key considerations in the management of metabolic encephalopathy include:
- Prompt recognition and treatment to prevent progression to coma and death
- Reversibility of the condition with appropriate intervention targeting the underlying metabolic derangement
- Importance of addressing precipitating factors, such as gastrointestinal bleeding and infection, as recognized by the Kasl clinical practice guidelines for liver cirrhosis 1
From the FDA Drug Label
For the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma. The main precipitant of metabolic encephalopathy mentioned is portal-systemic encephalopathy.
- The management of metabolic encephalopathy includes lactulose therapy, which reduces blood ammonia levels and improves the patient's mental state and EEG patterns 2.
- Key benefits of lactulose therapy include:
- Reduction in blood ammonia levels by 25 to 50%
- Improvement in the patient's mental state
- Improvement in EEG patterns
- Increase in patients' protein tolerance
From the Research
Causes of Metabolic Encephalopathy
- Hepatic failure 3, 4, 5, 6
- Renal failure 3, 4, 5
- Sepsis 3, 4, 5, 7
- Electrolyte disarray 3
- Wernicke encephalopathy 3, 5
- Hypoxia 4, 7
- Ischemia 4, 7
- Systemic diseases 7
- Toxic agents 7
- Liver cirrhosis 7
Management of Metabolic Encephalopathy
- Supportive care 3, 4, 6
- Management of the underlying etiology 3, 4, 5, 6
- Directed therapies that target neurochemical and neurotransmitter pathways are not currently available 3
- Treatment of the underlying systemic illness and supportive measures 4
- Drug and metabolic screens, cultures of blood and cerebrospinal fluids, and neuro-imaging studies may be necessary 4
- Electroencephalogram is useful to grade the severity of encephalopathy 4