When is Rifaximin (Rifaximin) prescribed in patients with cirrhosis (liver cirrhosis)?

From the Guidelines

Rifaximin is prescribed in cirrhosis primarily for the prevention of hepatic encephalopathy recurrence, particularly in patients who have experienced previous episodes of hepatic encephalopathy and have failed lactulose therapy, as evidenced by a recent study published in 2023 1. The typical dose of rifaximin for this indication is 550 mg twice daily for long-term maintenance therapy.

• Rifaximin is particularly useful in patients who have had recurrent episodes despite standard therapy with lactulose.
• It can be used either as an add-on to lactulose or as monotherapy in patients who cannot tolerate lactulose.
• Rifaximin works by reducing ammonia-producing bacteria in the gut without being significantly absorbed into the bloodstream, which makes it well-tolerated with minimal systemic side effects.
• This medication is also sometimes used in the management of small intestinal bacterial overgrowth (SIBO) that can occur in cirrhotic patients.
• Common side effects include nausea, bloating, and abdominal discomfort, but these are generally mild.
• Rifaximin should be used with caution in patients with severe hepatic impairment (Child-Pugh C) as dosage adjustments may be necessary, although the most recent evidence does not specifically address this population 1. The use of rifaximin in cirrhosis is supported by recent guidelines, including the French recommendations for the diagnosis and management of hepatic encephalopathy, which suggest that rifaximin can reduce the risk of recurrent HE by 58% compared to placebo 1.
• The guidelines recommend a rifaximin add-on when lactulose alone fails in the prevention of recurrent overt HE.
• However, it is difficult to recommend the use of rifaximin alone in the prevention of hepatic encephalopathy recurrence, as the evidence is not as strong for this indication 1.
• Previous studies, such as the 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases, also support the use of rifaximin in combination with lactulose for the prevention of hepatic encephalopathy recurrence 1.

From the FDA Drug Label

The pharmacokinetics of rifaximin in patients with a history of HE was evaluated after administration of XIFAXAN 550 mg twice a day. Mean rifaximin exposure (AUCτ) in patients with a history of HE was approximately 12-fold higher than that observed in healthy subjects Among patients with a history of HE, the mean AUC in patients with Child-Pugh Class C hepatic impairment was 2-fold higher than in patients with Child-Pugh Class A hepatic impairment

Rifaximin is prescribed in cirrhosis for the treatment of Hepatic Encephalopathy (HE). It is used to reduce the risk of overt HE recurrence in patients with a history of HE.

From the Research

Rifaximin Prescription in Cirrhosis

Rifaximin is prescribed in cirrhosis for the prevention of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) 2, 3, 4, 5. The following are some key points to consider:

• Rifaximin has been shown to prevent complications and improve survival in patients with decompensated liver cirrhosis 2.
• The drug is effective in reducing the incidence of overall complications, including ascites exacerbation, HE, and gastric variceal bleeding 2.
• Rifaximin may reduce the incidence of cirrhosis-related complications, including SBP, variceal bleeding, and acute kidney injury/hepatorenal syndrome 3.
• The use of rifaximin for prevention or treatment of other complications, including spontaneous bacterial peritonitis or other bacterial infections, is not widely accepted due to limited evidence 4.

Dosage and Administration

The dosage and administration of rifaximin in cirrhosis vary:

• A study compared once a day rifaximin to twice a day dosage in the prevention of recurrence of HE in patients with chronic liver disease, and found no significant difference between the two dosages 6.
• Another study used low-dose rifaximin (400 mg twice daily) for 6 months and found it to be effective in preventing overall complications and improving survival in patients with decompensated cirrhosis 2.
• Rifaximin is typically administered in combination with lactulose for the treatment of HE 5.

Patient Selection

Rifaximin is typically prescribed for patients with:

• Decompensated liver cirrhosis 2.
• Hepatic encephalopathy (HE) 3, 4, 5.
• Spontaneous bacterial peritonitis (SBP) 2, 3.
• Advanced stages of cirrhosis, as defined by a Child-Pugh score ≥ 9 2.