From the Guidelines
The recommended duration of treatment with rifaximin for hepatic encephalopathy is typically long-term or indefinite for patients with recurrent episodes, as continuation of open-label treatment with rifaximin for more than 24 months prevented recurrence of HE with a good rifaximin safety profile 1. The standard dosage is 550 mg taken orally twice daily. Rifaximin is usually prescribed as a maintenance therapy to prevent recurrence of hepatic encephalopathy in patients who have experienced previous episodes, particularly those who have had at least one episode while on lactulose therapy. It is often used in conjunction with lactulose rather than as monotherapy. Some key points to consider when treating with rifaximin include:
- Rifaximin works by reducing ammonia-producing bacteria in the gut without significant systemic absorption, which helps prevent the neurotoxic effects of ammonia on the brain that cause encephalopathy symptoms.
- The medication is generally well-tolerated with minimal side effects due to its limited systemic absorption, making it suitable for long-term use in patients with liver disease.
- Regular follow-up with healthcare providers is important to monitor treatment effectiveness and adjust therapy as needed.
- A post hoc analysis assessed the repeatability of these results by switching their treatment to rifaximin for 6 months, and rifaximin effectively reduced the number of HE recurrences 1.
- Rifaximin as an adjunct to lactulose is recommended as secondary prophylaxis following >1 additional episodes of overt HE within 6 months of the first one 1. It's also worth noting that:
- No solid data support the use of rifaximin alone 1.
- Rifaximin has been used for the therapy of HE in a number of trials comparing it with placebo, other antibiotics, nonabsorbable disaccharides, and in dose-ranging studies, showing effect of rifaximin that was equivalent or superior to the compared agents with good tolerability 1.
From the Research
Recommended Duration of Treatment with Rifaximin
The recommended duration of treatment with rifaximin for hepatic encephalopathy is not strictly defined, but several studies provide insight into the efficacy of rifaximin over various treatment periods.
- A 6-month randomized, double-blind, placebo-controlled trial 2 demonstrated that rifaximin significantly reduced the risk of an episode of hepatic encephalopathy and hospitalization involving hepatic encephalopathy compared to placebo.
- A review of long-term management of hepatic encephalopathy with lactulose and/or rifaximin 3 suggests that lactulose is effective for the prevention of 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.
- A study comparing once a day rifaximin to twice a day dosage in the prevention of recurrence of hepatic encephalopathy 4 found no significant difference in rifaximin once a day or twice daily dose in preventing HE over a 6-month period.
- A review of rifaximin's use in reducing recurrence of overt hepatic encephalopathy episodes 5 states that the efficacy of rifaximin with or without lactulose in reducing the recurrence of overt HE episodes was maintained after up to 2.5 years of treatment.
Treatment Duration and Efficacy
The efficacy of rifaximin in preventing hepatic encephalopathy recurrence and reducing hospitalization rates has been demonstrated over treatment periods ranging from 6 months to 2.5 years 2, 3, 5.
- However, one study 6 found that patients treated with lactulose only had better outcomes than those treated with lactulose and rifaximin, suggesting that lactulose may be sufficient as a first-line therapy in overt hepatic encephalopathy.
- The optimal duration of treatment with rifaximin may depend on individual patient factors, such as the severity of hepatic encephalopathy and the presence of other underlying medical conditions.