From the Guidelines
Rifaximin is a crucial component in the management of decompensated liver cirrhosis, particularly in preventing and treating hepatic encephalopathy (HE), and should be used as an adjunct to lactulose in patients with a history of recurrent HE. The standard dosage of rifaximin is 550 mg taken orally twice daily, typically as a long-term maintenance therapy. According to a recent study 1, rifaximin reduced the risk of recurrent HE by 58% compared to placebo, and also reduced the risk of readmissions and improved quality of life.
Key Points
- Rifaximin is particularly valuable as secondary prophylaxis after a first episode of HE, reducing the risk of recurrence by approximately 58% 1.
- It is recommended to use rifaximin as an adjunct to lactulose in patients with a history of recurrent HE, as it has been shown to decrease the risk of recurrence of overt HE in patients with cirrhosis and more than 2 episodes of overt HE within the previous 6 months 1.
- Rifaximin has minimal systemic absorption, resulting in fewer side effects and reduced risk of bacterial resistance, making it suitable for long-term use.
- Common side effects are mild and may include nausea, bloating, and abdominal discomfort.
- The use of rifaximin in combination with lactulose is supported by the evidence, with a recent study showing that rifaximin decreased the risk of hospitalization and improved quality of life in patients with cirrhosis and HE 1.
Clinical Considerations
- Rifaximin should be considered an essential component of therapy for cirrhotic patients with a history of HE or those at high risk for developing this serious complication.
- The decision to use rifaximin should be based on the individual patient's risk factors and medical history, as well as the presence of any contraindications or potential drug interactions.
- Patients should be monitored regularly for signs of HE and other complications of cirrhosis, and the dosage of rifaximin should be adjusted as needed to achieve optimal therapeutic effects.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Role of Rifaximin in Decompensated Liver Cirrhosis
- Rifaximin has been recommended as a prophylactic drug for hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) in patients with decompensated liver cirrhosis 2.
- A study found that low-dose rifaximin significantly decreases the occurrence of overall complications, leading to prolonged survival in patients with advanced stages of cirrhosis 2.
- Rifaximin has been shown to have beneficial effects on the course of cirrhosis by modulating the gut microbiome and affecting the gut-liver axis, which can interfere with major events of the pathophysiological cascade underlying decompensated cirrhosis 3.
Clinical Effects of Rifaximin
- Rifaximin is currently used worldwide in patients with cirrhosis for preventing recurrent HE because its efficacy and safety have been proven by large randomized clinical trials 3.
- A real-world study found that rifaximin add-on to lactulose for more than 6 months is superior to lactulose alone in the maintenance of HE remission in patients with cirrhosis complicated with recurrent HE 4.
- However, the use of rifaximin for prevention or treatment of other complications, including spontaneous bacterial peritonitis or other bacterial infections, is not accepted because evidence by clinical trials is still very weak 3.
Comparison of Rifaximin Doses
- A study compared the efficacy of high vs low dose rifaximin for primary prophylaxis of portosystemic encephalopathy (PSE) in decompensated liver cirrhosis and found no significant difference between the two groups 5.
- Another study found that long-term administration of rifaximin improves the prognosis of patients with decompensated alcoholic cirrhosis, with a significant lower risk of developing variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome 6.
Overall Complications and Survival
- Rifaximin has been shown to reduce the episodes of ascites exacerbation, HE, and gastric variceal bleeding in patients with decompensated liver cirrhosis 2.
- A study found that rifaximin markedly prolonged liver transplantation-free survival in patients with Child-Pugh score ≥ 9 2.
- Long-term rifaximin administration is associated with reduced risk of developing complications of portal hypertension and improved survival in patients with alcohol-related decompensated cirrhosis 6.