From the Guidelines
Rifaximin should be started in patients with decompensated liver failure who have experienced at least one episode of hepatic encephalopathy (HE) or are at high risk for recurrent HE, as an add-on to lactulose when lactulose alone fails to prevent recurrent overt HE, as recommended by the French guidelines 1. The standard dosage is 550 mg taken orally twice daily, and it is typically prescribed as a long-term maintenance therapy.
- Rifaximin is particularly beneficial for secondary prevention of HE after the first episode, often used alongside lactulose (usual dose 25-30 mL every 6-12 hours, titrated to 2-3 soft bowel movements daily) 1.
- For patients hospitalized with acute HE, rifaximin can be initiated during hospitalization once the patient can take oral medications, but lactulose is the first-line agent during acute episodes.
- Rifaximin works by reducing ammonia-producing gut bacteria without significant systemic absorption, making it well-tolerated even in patients with advanced liver disease, as shown in a double-blind, placebo-controlled RCT including 299 cirrhotic patients 1.
- The medication has minimal drug interactions and few side effects, with the most common being nausea, bloating, and abdominal discomfort.
- Insurance coverage may be challenging, so verifying coverage and exploring patient assistance programs is advisable before prescribing.
- A therapeutic education program should be offered to the patient and caregiver to improve quality of life and limit hospitalizations, as suggested by the experts 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Timing of Rifaximin Initiation in Decompensated Liver Failure
- The optimal timing for starting rifaximin in patients with decompensated liver failure is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, the studies suggest that rifaximin can be beneficial in preventing complications and improving survival in patients with decompensated liver cirrhosis 2, 6.
- Rifaximin has been shown to be effective in reducing the incidence of hepatic encephalopathy, spontaneous bacterial peritonitis, and other complications in patients with decompensated liver cirrhosis 2, 3, 4, 5.
- The studies do not provide a specific guideline for when to start rifaximin in patients with decompensated liver failure, but they suggest that it can be started as part of the treatment regimen for patients with decompensated liver cirrhosis 2, 6.
- The dosage of rifaximin used in the studies varied, with some studies using a low dose of 400-550 mg twice daily 2, 6 and others using a higher dose of 1200 mg/day 3, 4, 5.
Patient Selection and Monitoring
- Patients with decompensated liver cirrhosis, including those with hepatic encephalopathy, spontaneous bacterial peritonitis, and other complications, may benefit from rifaximin therapy 2, 3, 4, 5, 6.
- The decision to start rifaximin should be based on individual patient needs and medical history, and patients should be monitored closely for adverse events and treatment response 2, 3, 4, 5, 6.
- The studies suggest that rifaximin can be used in combination with other treatments, such as lactulose and midodrine, to improve outcomes in patients with decompensated liver cirrhosis 4, 5, 6.