From the Guidelines
Lactulose and Rifaximin are the primary medications used to manage hyperammonemia.
Medication Options
- Lactulose: 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, then titrated to maintain two to three bowel movements per day 1.
- Rifaximin: 400 mg three times/day or 550 mg twice/day, is recommended as an add-on to lactulose for prevention of recurrent episodes of HE after the second episode 1.
Additional Therapies
- Oral BCAA: 0.25 g/kg/day, can be used additionally to manage HE 1.
- Intravenous LOLA: 30 g/day, can be used additionally to manage HE 1.
- Albumin: 1.5 g/kg/day until clinical improvement or for 10 days, maximum, can be used additionally to manage HE 1.
Important Considerations
- Non-absorbable disaccharides (e.g., lactulose, lactitol) are recommended to manage acute episodic overt HE, with enema recommended in severe HE or a clinical situation in which oral intake is inappropriate 1.
- Rifaximin might be combined with non-absorbable disaccharides to treat patients with HE 1.
- Liver transplantation is indicated in patients with severe HE who do not respond to medical treatments 1.
From the Research
Medications Used to Manage Hyperammonemia
- Lactulose is a commonly used medication to manage hyperammonemia, as it helps decrease the intestinal production of ammonia and its absorption into the body 2, 3, 4.
- Rifaximin is also used to treat hyperammonemia, and is often used in combination with lactulose for secondary prophylaxis 2, 3.
- Other medications and therapies, such as molecular adsorbent recirculating system, may also be used to treat hyperammonemia, although their mechanisms of action may be independent of ammonia levels 3.
- The use of probiotics has also been explored as a potential treatment for hyperammonemia, as modifications to the gut microbiota may help reduce ammonia production and absorption 5.
Treatment Approaches
- The treatment of hyperammonemia typically involves reducing ammonia production, absorption, or elimination 2.
- In acute settings, management strategies may include identifying and addressing precipitating factors, reducing protein intake, reversing catabolism, and using pharmacologic treatments to remove ammonia 6.
- In severe cases, extracorporeal therapies may be used to remove ammonia, and transcranial Doppler ultrasound may be used to monitor cerebral blood flow and titrate therapies 6.