From the Guidelines
Medications for end-stage liver disease should focus on managing complications such as hepatic encephalopathy with lactulose (20-30g orally 3-4 times per day) and rifaximin (400mg three times/day or 550mg twice/day), as these are the most effective treatments according to the most recent guidelines 1.
Managing Hepatic Encephalopathy
- Lactulose should be administered orally until the patient is having at least 2 bowel movements a day, then titrated to achieve two to three soft stools per day 1.
- Rifaximin is an alternative or adjunct treatment for hepatic encephalopathy, with a recommended dose of 400mg three times/day or 550mg twice/day 1.
- Other options for managing hepatic encephalopathy include oral BCAA (0.25g/kg/day), intravenous LOLA (30g/day), and albumin (1.5g/kg/day until clinical improvement or for 10 days, maximum) 1.
Considerations for Treatment
- Medication doses must be carefully adjusted as liver dysfunction affects drug metabolism, increasing the risk of toxicity from standard dosing regimens.
- Patients with end-stage liver disease should be considered for liver transplantation, which remains the definitive treatment for this condition, as it can improve quality of life and extend life expectancy 1.
- The decision to list a patient for liver transplantation should be based on a detailed medical evaluation, taking into account the patient's expected survival and quality of life without transplantation, as well as the potential benefits and risks of the procedure 1.
From the FDA Drug Label
XIFAXAN is indicated for reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults. In the trials of XIFAXAN for HE, 91% of the patients were using lactulose concomitantly. Differences in the treatment effect of those patients not using lactulose concomitantly could not be assessed XIFAXAN has not been studied in patients with MELD (Model for End-Stage Liver Disease) scores >25, and only 8.6% of patients in the controlled trial had MELD scores over 19.
The medication rifaximin (XIFAXAN) is used to reduce the risk of overt hepatic encephalopathy (HE) recurrence in adults. The recommended dose for Hepatic Encephalopathy is one 550 mg tablet taken orally two times a day 2.
- Key points:
- Rifaximin is indicated for reduction in risk of overt HE recurrence in adults.
- Most patients in the trials were using lactulose concomitantly.
- The medication has not been studied in patients with MELD scores >25.
- Increased systemic exposure in patients with more severe hepatic dysfunction.
From the Research
Medications for End-Stage Liver Disease
- Medications for end-stage liver disease (ESLD) focus on managing symptoms and slowing disease progression, as seen in studies 3, 4.
- Lactulose, probiotics, and L-ornithine-L-aspartate are used to treat minimal hepatic encephalopathy (MHE), with rifaximin being slightly more effective than lactulose in maintaining remission 4.
- Beta-blockers are used to prevent ascites and hepatorenal syndrome (HRS), with noradrenaline being as effective as terlipressin for treating type 1 HRS 4.
- Palliative care medications aim to improve quality of life, with a focus on symptom management, psychosocial support, and advance care planning 5, 6, 7.
Palliative Care for End-Stage Liver Disease
- Palliative care is an essential component of ESLD management, focusing on improving quality of life and reducing suffering 3, 5, 7.
- Early integration of palliative care is crucial, with benefits including improved quality of life, decreased anxiety, and improved satisfaction with care 7.
- Components of palliative care for ESLD include an interdisciplinary approach, early palliative care, discussion of goals of care, symptom management, and psychosocial support 6.
- Palliative care has been shown to improve symptoms such as itching, well-being, appetite, anxiety, fatigue, and depression, and decrease length of stay 6.