From the Guidelines
The treatment for asterixis in liver cirrhosis focuses primarily on addressing the underlying hepatic encephalopathy, with lactulose and rifaximin being key medications, alongside ammonia-lowering strategies and management of precipitating factors. The management of asterixis, a condition characterized by a flapping tremor due to loss of postural tone, is intricately linked with the management of hepatic encephalopathy, a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction [ 1 ].
Key Components of Treatment
- Lactulose: Typically started at 25-30 mL orally two to three times daily, with the dose adjusted to achieve 2-3 soft bowel movements per day, as it helps in reducing ammonia production in the gut [ 1 ].
- Rifaximin: 550 mg twice daily, often added as an adjunct therapy for those who don't respond adequately to lactulose alone, due to its ability to modulate the gut microbiota and reduce ammonia production [ 1 ].
- Ammonia-lowering strategies: Essential since asterixis results from neurotoxic substances accumulating in the brain due to impaired liver function.
- Protein intake: Patients should maintain adequate nutrition with 1.2-1.5 g/kg/day of protein, as protein restriction is no longer routinely recommended [ 1 ].
- Precipitating factors: Infections, gastrointestinal bleeding, electrolyte disturbances, and certain medications should be identified and corrected.
- Substance avoidance: Patients should avoid sedatives, alcohol, and other substances that can worsen encephalopathy.
Monitoring and Definitive Treatment
Regular monitoring of mental status, asterixis, and ammonia levels helps guide therapy adjustments. In severe cases that don't respond to medical therapy, liver transplantation may be considered as definitive treatment [ 1 ]. The goal is to improve morbidity, mortality, and quality of life for patients with liver cirrhosis and asterixis, emphasizing the importance of a comprehensive approach to managing hepatic encephalopathy and its complications.
From the FDA Drug Label
The primary endpoint was the time to first breakthrough overt HE episode. A breakthrough overt HE episode was defined as a marked deterioration in neurological function and an increase of Conn score to Grade ≥2. In patients with a baseline Conn score of 0, a breakthrough overt HE episode was defined as an increase in Conn score of 1 and asterixis grade of 1 Breakthrough overt HE episodes were experienced by 31 of 140 subjects (22%) in the XIFAXAN group and by 73 of 159 subjects (46%) in the placebo group during the 6-month treatment period.
The treatment for asterixis in liver cirrhosis is rifaximin (XIFAXAN), which has been shown to reduce the risk of hepatic encephalopathy (HE) breakthrough by 58% during a 6-month treatment period 2.
- Rifaximin significantly reduced the risk of HE breakthrough and HE-related hospitalizations by 50% during the 6-month treatment period.
- The treatment effect of rifaximin was consistent across different demographic and baseline characteristics, including sex, baseline Conn score, duration of current remission, and diabetes.
From the Research
Treatment for Asterixis in Liver Cirrhosis
Asterixis, also known as flapping tremor, is a complication of liver cirrhosis that is often associated with hepatic encephalopathy. The treatment for asterixis in liver cirrhosis is primarily focused on managing the underlying hepatic encephalopathy.
- The therapeutic management involves reducing ammonia production and increasing its elimination from the blood and the brain 3.
- Various anti-ammonia therapies with synergistic and complementary actions have been attempted for overt hepatic encephalopathy and for prophylaxis of the first and recurrent episodes of hepatic encephalopathy 3.
- Branched-chain amino acids (BCAAs) supplementation may enhance detoxification of ammonia in skeletal muscle and may be a possible therapeutic strategy for hepatic encephalopathy 4.
- The most widely empirical pharmacological approach consists of non-absorbable antibiotics (rifaximin) and non-absorbable disaccharides (lactulose, lactitol per os and per enemas) 5.
- Lactulose is associated with reduced mortality relative to placebo and reduced risk of recurrent overt hepatic encephalopathy 6.
Management of Hepatic Encephalopathy
The management of hepatic encephalopathy includes:
- Lifestyle and nutritional modifications
- Lactulose and rifaximin as needed 7
- Prevention of hepatic encephalopathy in patients at high risk of first and recurrent episodes is important for prolonging survival 3.
Key Considerations
- Hepatic encephalopathy is a severe metabolic disorder with neurologic manifestations such as flapping tremors and coma in patients with liver cirrhosis 4.
- The diagnosis of hepatic encephalopathy is essential for the resolution of symptoms, and every effort to identify and correct the precipitating cause is necessary 5.