What is the recommended treatment for hepatic encephalopathy using Rifaxmin (Rifaximin)?

From the Guidelines

Rifaximin is recommended for the treatment of hepatic encephalopathy at a dose of 550 mg taken orally twice daily, as an add-on to lactulose, for prevention of recurrent episodes of HE after the second episode. This medication should be used as a long-term maintenance therapy to prevent recurrent episodes of hepatic encephalopathy in patients with liver cirrhosis. Rifaximin works by reducing ammonia-producing bacteria in the intestines, thereby decreasing the production and absorption of ammonia, which is a key factor in the development of hepatic encephalopathy. According to a recent study 1, rifaximin reduced the risk of recurrent HE by 58% compared to placebo, and also reduced the risk of readmissions and improved quality of life.

Key Points

• Rifaximin is typically used in conjunction with lactulose (a first-line treatment), though some patients may be managed on rifaximin alone if they cannot tolerate lactulose or have inadequate response to it.
• Rifaximin has a favorable safety profile with minimal systemic absorption and few drug interactions, making it suitable for long-term use in patients with advanced liver disease.
• Patients should be monitored for clinical improvement in mental status, asterixis (hand flapping), and other neurological symptoms.
• Treatment is generally continued indefinitely in patients with recurrent hepatic encephalopathy unless they undergo liver transplantation or their liver function significantly improves, as recommended by recent guidelines 1.

Dosage and Administration

• The recommended dose of rifaximin is 550 mg taken orally twice daily.
• The medication should be taken with food to minimize gastrointestinal side effects.
• Patients with severe hepatic encephalopathy may require dose adjustments or alternative treatments, as recommended by recent studies 1.

Monitoring and Follow-up

• Patients should be monitored regularly for signs of hepatic encephalopathy, such as mental status changes, asterixis, and other neurological symptoms.
• Laboratory tests, such as ammonia levels and liver function tests, should be performed regularly to assess the effectiveness of treatment and potential side effects, as recommended by recent guidelines 1.

From the FDA Drug Label

XIFAXAN is a rifamycin antibacterial indicated for: • Reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults (1.2)

Condition Recommended Dosage Regimen HE (2.2) One 550 mg tablet 2 times a day

The recommended treatment for hepatic encephalopathy using Rifaxmin (Rifaximin) is one 550 mg tablet 2 times a day.

• The dosage regimen for HE is specified as 550 mg twice daily.
• This treatment is intended for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults 2.

From the Research

Rifaxmin Hepatic Encephalopathy Treatment

• Rifaximin is a semisynthetic, nonsystemic antibiotic approved by the United States Food and Drug Administration for the treatment of overt hepatic encephalopathy 3.
• The drug decreases intestinal production and absorption of ammonia by altering gastrointestinal flora and is almost completely excreted unchanged in the feces 3.
• Rifaximin has been effective in improving behavioral, laboratory, mental, and intellectual abnormalities in patients with hepatic encephalopathy 3.

Dosage and Efficacy

• Most medical centers use a dosage of rifaximin 400 mg 3 times/day for hepatic encephalopathy, although recent clinical trials have used 550 mg twice/day to improve patient compliance 3.
• Rifaximin was compared with lactulose in well-designed clinical studies in patients with hepatic encephalopathy and was generally found to be equal or superior to lactulose in these studies 3.
• A randomized, double-blind, controlled trial found that rifaximin plus lactulose was more effective than lactulose alone in the treatment of overt hepatic encephalopathy, with a significant decrease in mortality and hospital stay 4.
• Another study found that rifaximin significantly reduced the risk of an episode of hepatic encephalopathy, as compared with placebo, over a 6-month period 5.

Combination Therapy

• The combination of rifaximin and lactulose has been shown to be effective in the treatment of hepatic encephalopathy, with some studies suggesting that it is more effective than lactulose alone 6, 4.
• However, one study found that rifaximin plus lactulose combination was not superior to lactulose alone in the treatment of refractory hepatic encephalopathy, although the combination was still effective 6.
• The efficacy of rifaximin once a day dose in the prevention of hepatic encephalopathy was found to be similar to twice daily dose of rifaximin in a randomized control trial 7.