What is the role of Lactulose in the treatment of hepatic encephalopathy with seizures?

From the Guidelines

Lactulose plays a crucial role in the treatment of hepatic encephalopathy (HE), including cases with seizures, as it helps reduce ammonia levels in the blood by promoting the growth of beneficial gut bacteria and increasing the excretion of ammonia in the stool.

Key Points

• Lactulose is recommended as secondary prophylaxis following a first episode of overt HE, and should be titrated to obtain 2-3 bowel movements per day 1.
• The dosing of lactulose should be initiated with 25 mL of lactulose syrup every 1-2 hours until at least two soft or loose bowel movements per day are produced, and subsequently titrated to maintain two to three bowel movements per day 1.
• Lactulose can be administered orally or via nasogastric tube, and enema with lactulose 200 g and 700 mL water might be performed 3-4 times per day in severe cases 1.
• Rifaximin can be considered as an adjunct to lactulose for secondary prophylaxis following more than one additional episode of overt HE within 6 months of the first one 1.
• It is essential to monitor patients with HE for precipitating factors, such as gastrointestinal bleeding, and manage them promptly to prevent worsening of the condition 1.
• In patients with cirrhosis and previous episodes of overt HE, rifaximin can be considered for prophylaxis of HE prior to non-urgent TIPS placement 1.
• Lactulose is not recommended for use alone in patients with seizures, and other treatments such as benzodiazepines or barbiturates may be necessary to control seizures 1.
• The use of lactulose in patients with HE and seizures should be carefully monitored, as it may worsen the condition in some cases 1.
• The treatment of HE with lactulose should be individualized, and the dose and duration of treatment should be adjusted based on the patient's response and tolerance 1.

From the Research

Role of Lactulose in Hepatic Encephalopathy with Seizures

• Lactulose is a nonabsorbable disaccharide used in the treatment of hepatic encephalopathy, including cases with seizures 2.
• The mechanism of action of lactulose involves metabolism by the enteric flora, which increases bacterial incorporation of nitrogen and reduces the breakdown of nitrogen-containing compounds to ammonia and other potential cerebral toxins 3.
• Lactulose has been shown to be effective in reducing plasma ammonia levels and improving clinical status in patients with hepatic encephalopathy, including those with seizures 2.

Treatment of Hepatic Encephalopathy with Seizures

• Lactulose can be administered orally or rectally, and its use has been reported to resolve status epilepticus in a patient with hepatic encephalopathy 2.
• The administration of lactulose enemas may be considered in patients with hepatic encephalopathy who are unable to take oral lactulose, but its use should be carefully evaluated to avoid potential harm 4.
• Lactulose is considered a first-line treatment for hepatic encephalopathy and is listed as one of the World Health Organization's Essential Medicines 5.

Efficacy and Safety of Lactulose

• Lactulose has been shown to be effective in improving clinical status and psychometric performance in patients with hepatic encephalopathy, with significant improvements occurring in the majority of patients treated with lactulose 6.
• Lactulose is generally well-tolerated, with few serious side effects reported, making it a safe and effective treatment option for hepatic encephalopathy 3.