What is the treatment for an onset of hepatic encephalopathy episode?

Treatment of Hepatic Encephalopathy Episodes

The first-line treatment for an acute episode of hepatic encephalopathy is lactulose, which should be initiated immediately while simultaneously identifying and treating precipitating factors. 1, 2

Four-Pronged Approach to Management

1. Initiate appropriate care based on consciousness level

   • Patients with higher grades of HE who cannot protect their airway require intensive care monitoring 1, 2
   • For patients unable to take oral medications, administer lactulose via nasogastric tube 3

2. Identify and rule out alternative causes of altered mental status

   • Other causes of encephalopathy may coexist with HE and require separate treatment 1, 2

3. Identify and correct precipitating factors

   • Nearly 90% of patients can be treated with just correction of precipitating factors 1, 2
   • Common precipitating factors include infections, GI bleeding, electrolyte disturbances, and medication non-compliance 2

4. Commence empirical HE treatment

   • Start treatment without waiting for complete diagnostic workup 1, 2

Pharmacological Management

First-Line Treatment: Lactulose

• Start with 25 mL of lactulose syrup orally every 12 hours 1, 4
• Titrate dose to achieve 2-3 soft bowel movements per day 1
• Lactulose reduces blood ammonia levels by 25-50%, which generally parallels improvement in mental state 4
• Clinical response is observed in approximately 75% of patients 4, 5

Second-Line and Add-On Treatments

• Rifaximin: Add 550 mg twice daily when lactulose alone is insufficient 1, 6

  • Rifaximin decreases intestinal production and absorption of ammonia by altering gastrointestinal flora 6, 5
  • More than 90% of patients in clinical trials received concomitant lactulose therapy 6, 7

• Alternative options for non-responders to conventional therapy:

  • Oral Branched-Chain Amino Acids (BCAAs) 1, 2
  • IV L-Ornithine L-Aspartate (LOLA) 1, 2
  • Neomycin (limited by ototoxicity and nephrotoxicity with long-term use) 1, 2
  • Metronidazole (limited by neurotoxicity with long-term use) 1

Prevention of Recurrence

• Secondary prophylaxis after an episode of overt HE is strongly recommended 1, 3
• Lactulose is recommended for prevention of recurrent episodes 1, 3
• For patients with recurrent HE despite lactulose therapy, add rifaximin 550 mg twice daily 1, 8
• Rifaximin reduces the risk of HE recurrence by 58% when added to lactulose 6, 7

Special Considerations

• Post-TIPS HE: Neither rifaximin nor lactulose prevents post-TIPS HE better than placebo; shunt diameter reduction may be necessary if severe HE occurs 1, 2
• Recurrent intractable HE: Consider liver transplantation in patients with recurrent intractable HE and liver failure 1, 3
• Preserved liver function with recurrent HE: Evaluate for large spontaneous portosystemic shunts that may be amenable to embolization 1, 3

Common Pitfalls to Avoid

• Overuse of lactulose can paradoxically precipitate HE and cause complications such as aspiration, dehydration, hypernatremia, and perianal skin irritation 1, 3
• Failure to identify precipitating factors is a common reason for poor treatment response 1, 2
• Delaying empirical treatment while awaiting diagnostic confirmation can worsen outcomes 2
• Protein restriction can worsen malnutrition and sarcopenia, which are risk factors for HE 3