From the Guidelines
The primary treatment for hepatic encephalopathy is lactulose, a non-absorbable disaccharide, which should be administered orally at a dose of 20-30 g, 3-4 times per day, with the goal of achieving 2-3 soft stools per day 1. The treatment of hepatic encephalopathy focuses on addressing the underlying causes, reducing ammonia levels, and managing symptoms.
Treatment Options
- Lactulose is the first-line medication, given at a dose of 20-30 g, 3-4 times per day, with the goal of achieving 2-3 soft stools per day 1.
- Rifaximin, a non-absorbable antibiotic, can be added at 400 mg three times/day or 550 mg twice/day to reduce ammonia-producing gut bacteria 1.
- Oral branched-chain amino acids (BCAA) can be used additionally at a dose of 0.25 g/kg/day 1.
- Intravenous L-ornithine-L-aspartate (LOLA) can be used at 30 g/day to enhance ammonia detoxification 1.
- Albumin can be administered at 1.5 g/kg/day until clinical improvement or for 10 days, maximum 1.
Precipitating Factors
Precipitating factors such as gastrointestinal bleeding, infection, electrolyte disturbances, and medication side effects must be identified and treated 1.
Severe Cases
In severe cases, an enema with lactulose 200 g and 700 mL water might be performed 3-4 times per day 1.
Monitoring
Patients should be monitored for response to therapy with clinical assessment of mental status and, when appropriate, adjustment of medication dosages. The treatment options are based on the most recent and highest quality study, which recommends lactulose as the primary treatment for hepatic encephalopathy, with the addition of rifaximin, BCAA, LOLA, and albumin as needed 1.
From the FDA Drug Label
For the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma. XIFAXAN is indicated for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults.
The treatment options for hepatic (liver) encephalopathy are:
- Lactulose (PO): for the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma 2
- Rifaximin (PO): for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults, often used concomitantly with lactulose 3
From the Research
Treatment Options for Hepatic Encephalopathy
The treatment options for hepatic encephalopathy include:
- Nonabsorbable disaccharides, such as lactulose, which is considered the first-line therapeutic agent for treating hepatic encephalopathy 4, 5, 6
- Systemic antibiotics, primarily neomycin, although their use is limited due to associated adverse events 4
- Semisynthetic, nonsystemic antibiotics, such as rifaximin, which has been shown to be effective in improving behavioral, laboratory, mental, and intellectual abnormalities in patients with hepatic encephalopathy 4, 5
- Branch chain amino acids, which are beneficial in subjects who are protein intolerant 5
- L-ornithine L-aspartate and probiotics, which are also useful in the management of hepatic encephalopathy 5, 6
- Combination therapy of disaccharides with rifaximin, L-ornithine L-aspartate, or probiotics, although further validation is needed in large studies 6
- Newer therapeutic targets under evaluation, including ammonia scavengers and modulation of gut microbiota, such as fecal microbiota transplantation 7
Dosage and Administration
The dosage of rifaximin for hepatic encephalopathy is typically 400 mg 3 times/day, although recent clinical trials have used 550 mg twice/day to improve patient compliance 4 Lactulose is also effective in primary and secondary prophylaxis of hepatic encephalopathy, and its dosage may vary depending on the patient's response 6
Other Therapies
Other therapies that may be beneficial in managing hepatic encephalopathy include:
- Nutritional therapy, although the evidence is limited and more research is required to prove its efficacy 5
- Fecal microbiota transplantation, which is a newer therapy that requires further validation 5, 7
- Large portosystemic shunts embolization and liver transplant, which may be efficacious in certain groups of patients 5