What is the recommended dose and treatment duration of Rifaximin (rifamycin derivative) for preventing recurrence of hepatic encephalopathy in patients with cirrhosis?

From the Guidelines

The recommended dose of rifaximin for preventing recurrence of hepatic encephalopathy in patients with cirrhosis is 550 mg taken orally twice daily for long-term maintenance therapy. This treatment is typically continued indefinitely as long as the patient continues to benefit and tolerate the medication, as hepatic encephalopathy is a chronic, recurrent condition in cirrhotic patients. Rifaximin works by reducing ammonia-producing gut bacteria without being significantly absorbed systemically, which minimizes side effects compared to other antibiotics. It is usually prescribed following an episode of hepatic encephalopathy and is often used in conjunction with lactulose therapy, as supported by the French recommendations for the diagnosis and management of hepatic encephalopathy 1.

Some key points to consider when prescribing rifaximin for hepatic encephalopathy include:

• The medication should be taken with or without food
• Patients should be advised to continue their other liver-directed therapies and follow dietary protein recommendations as directed by their healthcare provider
• Rifaximin has demonstrated effectiveness in reducing hospitalizations related to hepatic encephalopathy and improving quality of life for cirrhotic patients, as shown in a study published in Liver International 1
• Patients should be monitored for potential side effects, which are generally mild and may include nausea, bloating, or diarrhea

It is also important to note that rifaximin is typically used as an add-on to lactulose therapy, as recommended by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases 1. However, the most recent and highest quality study, published in 2023, suggests that rifaximin can be used alone in cases where lactulose is poorly tolerated 1.

From the Research

Rifaximin for Hepatic Encephalopathy

• Rifaximin is a rifamycin derivative used to prevent the recurrence of hepatic encephalopathy in patients with cirrhosis.
• The recommended dose of Rifaximin for preventing recurrence of hepatic encephalopathy is 550 mg twice daily 2, 3.
• However, a study suggests that once a day dosage of Rifaximin may be as effective as twice a day dosage in preventing recurrence of hepatic encephalopathy 4.
• The treatment duration of Rifaximin for preventing recurrence of hepatic encephalopathy is typically 6 months 5, 2, 4, but it can be continued for up to 2.5 years with no new safety signals arising during this period 3.

Efficacy of Rifaximin

• Rifaximin has been shown to significantly reduce the risk of an episode of hepatic encephalopathy, as compared with placebo, over a 6-month period 2.
• Rifaximin also significantly reduces the risk of hospitalization involving hepatic encephalopathy 2, 3.
• However, a study found that Rifaximin failed to maintain remission from hepatic encephalopathy more effectively than placebo in the studied group 5.

Combination Therapy

• Rifaximin is often used in combination with lactulose to prevent recurrence of hepatic encephalopathy 2, 3.
• A study is being conducted to compare the efficacy of Rifaximin alone versus Rifaximin in combination with lactulose in the treatment of minimal hepatic encephalopathy 6.