From the Guidelines
The first line treatment for encephalopathy after Transjugular Intrahepatic Portosystemic Shunt (TIPS) is medical management with lactulose and rifaximin, as recommended by current guidelines. This approach is based on the most recent and highest quality study available, which suggests that lactulose and rifaximin are effective in treating overt hepatic encephalopathy (HE) after TIPS 1. The initial dose of lactulose is typically 25-30 mL orally every 1-2 hours until bowel movements occur, followed by maintenance dosing of 15-30 mL 2-3 times daily, titrated to achieve 2-3 soft bowel movements per day. For patients unable to take oral medications, lactulose can be administered as a retention enema at 300 mL in 700 mL of water. Rifaximin 550 mg twice daily is often added as an adjunctive therapy for patients with severe or recurrent episodes. Some key points to consider in the management of post-TIPS encephalopathy include:
- Monitoring for clinical improvement in mental status, with dosing adjusted accordingly
- Reducing ammonia levels by trapping ammonia in the gut and altering gut flora
- Dietary protein restriction (limiting to 0.8-1.0 g/kg/day)
- Addressing precipitating factors such as dehydration, infection, or gastrointestinal bleeding In severe cases that don't respond to medical therapy, TIPS reduction or occlusion may be necessary, as noted in earlier studies 1. However, the most recent guidelines prioritize medical management with lactulose and rifaximin as the first line treatment 1.
From the FDA Drug Label
The usual adult, oral dosage is 2 to 3 tablespoonfuls (30 mL to 45 mL, containing 20 grams to 30 grams of lactulose) three or four times daily. Hourly doses of 30 mL to 45 mL of lactulose solution may be used to induce the rapid laxation indicated in the initial phase of the therapy of portal-systemic encephalopathy. Continuous long-term therapy is indicated to lessen the severity and prevent the recurrence of portal-systemic encephalopathy.
The first line treatment for encephalopathy after Transjugular Intrahepatic Portosystemic Shunt (TIPS) is lactulose. The recommended initial daily oral dose is 2 to 3 tablespoonfuls (30 mL to 45 mL) three or four times daily, which may be adjusted to produce 2 or 3 soft stools daily 2.
- The goal of treatment is to reverse the coma stage and prevent recurrence of portal-systemic encephalopathy.
- Lactulose has been shown to reduce blood ammonia levels and improve mental state and EEG patterns in about 75% of patients 2.
From the Research
Encephalopathy after TIPS
- Encephalopathy is a common complication after Transjugular Intrahepatic Portosystemic Shunt (TIPS) implantation, with 35-50% of patients developing overt hepatic encephalopathy (HE) after TIPS 3.
First Line Treatment
- The first line treatment for encephalopathy after TIPS is not well established, but combination therapy with lactulose and rifaximin may be effective in preventing HE recurrence 4, 5, 6.
- Lactulose monotherapy has no prophylactic effect on HE recurrence after TIPS 4.
- Rifaximin alone may not significantly reduce the development of post-TIPS HE, but the combination of rifaximin and lactulose shows a promising trend towards preventing post-TIPS HE 3, 5.
Treatment Options
- Other treatment options, such as lactitol, L-Ornithine-L-aspartate (LOLA), and albumin, have not been shown to be effective in preventing post-TIPS HE when used alone 5.
- The addition of LOLA to lactulose and rifaximin combination therapy has no additional benefit in preventing HE recurrence 4, 5.
Long-term Management
- Long-term management of HE with lactulose and/or rifaximin is effective and safe, with lactulose reducing the risk of overt HE recurrence and rifaximin reducing the risk of overt HE recurrence and HE-related hospitalization when added to lactulose therapy 6.