L-Ornithine-L-Aspartate (LOLA) Dosing for Hepatic Encephalopathy
For hepatic encephalopathy, L-Ornithine-L-Aspartate (LOLA) should be administered intravenously at 30 g/day as an adjunct to lactulose therapy to lower plasma ammonia concentrations and improve hepatic encephalopathy grade. 1
Primary Dosing Recommendation
- LOLA is dosed at 30 g/day intravenously when used as adjunctive therapy in patients with hepatic encephalopathy 1, 2
- This medication works by lowering plasma ammonia concentrations and has demonstrated improvement in hepatic encephalopathy grade when combined with lactulose 1
Role in Treatment Algorithm
LOLA should be considered as adjunctive therapy rather than first-line treatment:
- First-line therapy remains lactulose at 30-45 mL (20-30 g) every 1-2 hours until achieving 2-3 soft bowel movements daily, then maintenance dosing of 30-45 mL 3-4 times daily 1, 3
- LOLA is added when first-line lactulose therapy is inadequate to control hepatic encephalopathy symptoms 2
- The combination of LOLA with lactulose has been shown to improve hepatic encephalopathy grade beyond lactulose alone 1
Alternative and Complementary Therapies
When hepatic encephalopathy control remains inadequate despite optimized lactulose:
- Rifaximin at 400 mg three times daily or 550 mg twice daily (maximum 1200 mg/day) shows superior recovery rates of 76% vs 44% when combined with lactulose 1, 2
- Branched-Chain Amino Acids (BCAAs) at 0.25 g/kg/day orally can inhibit proteolysis and decrease toxic material influx across the blood-brain barrier 1, 2
- Albumin at 1.5 g/kg/day intravenously until clinical improvement or maximum 10 days can improve recovery rates when combined with lactulose 1, 2
Clinical Context
The evidence supporting LOLA comes from guideline recommendations based on its mechanism of lowering plasma ammonia and improving clinical outcomes when used adjunctively 1. However, rifaximin has stronger evidence with randomized controlled trial data demonstrating significant improvement in recovery rates and reduced hospitalizations when added to lactulose 2.