Fresh Frozen Plasma is Not Recommended for Hepatic Encephalopathy Treatment
Fresh frozen plasma (FFP) is not routinely recommended for the treatment of hepatic encephalopathy as there is no evidence supporting its efficacy for this indication. 1
Current Standard Treatment for Hepatic Encephalopathy
- The first-line treatment for hepatic encephalopathy is non-absorbable disaccharides such as lactulose, which works by acidifying the gastrointestinal tract and inhibiting ammonia production by coliform bacteria 2, 3
- Rifaximin, a non-systemic antibiotic, is approved by the FDA for the treatment of overt hepatic encephalopathy and is often used as an add-on therapy or alternative to lactulose 2, 4
- Treatment should focus on identifying and addressing precipitating factors of hepatic encephalopathy 3, 4
Evidence Regarding FFP in Liver Disease
- According to the AASLD position paper on the management of acute liver failure, FFP should not be routinely administered to correct clotting abnormalities in the absence of bleeding 1
- FFP is only recommended in acute liver failure when an invasive procedure is planned or in cases of profound coagulopathy (e.g., INR >7) 1
- Using FFP for coagulopathy correction can limit the value of coagulation parameters as a means of monitoring disease progression and may lead to volume overload, which can exacerbate intracranial hypertension 1
Emerging Therapies for Hepatic Encephalopathy
- Fecal microbiota transplantation (FMT) has shown promise in early trials for patients with recurrent/persistent hepatic encephalopathy, though it is not yet routinely recommended 1
- In small studies, both enema and oral capsulized FMT from healthy donors were well-tolerated and associated with improvement in cognitive function (EncephalApp scores) 1
- Ammonia-lowering agents such as ornithine phenylacetate are being investigated, with recent studies showing significant reduction in plasma ammonia levels and improvement in hepatic encephalopathy stage 5
Management Considerations in Hepatic Encephalopathy
- For patients with cirrhosis and acute gastrointestinal bleeding (which can precipitate hepatic encephalopathy), prophylactic antibiotics are recommended to reduce the risk of infections and improve survival 1
- Excessive fluid therapy or blood transfusion should be avoided in patients with liver disease as it may increase portal pressure and worsen outcomes 1
- Patients who have had an episode of overt hepatic encephalopathy should be provided with information about driving risks and the need for formal driving assessment 1
Conclusion on FFP Use
- While FFP contains high circulating levels of proteins, there is no evidence supporting its use specifically for hepatic encephalopathy management 1
- FFP is primarily indicated for coagulopathy correction before invasive procedures or in severe bleeding risk, not as a treatment for the neuropsychiatric symptoms of hepatic encephalopathy 1
- In contrast to hereditary angioedema where FFP may provide benefit (though with caution due to potential exacerbation), there is no established role for FFP in the treatment algorithm for hepatic encephalopathy 1