Treatment of Hepatic Encephalopathy
Introduction to Hepatic Encephalopathy Management
- The American Association for the Study of Liver Diseases recommends lactulose as the first-line treatment for hepatic encephalopathy, with rifaximin as an effective add-on therapy for prevention of recurrence 1, 2
Four-Pronged Approach to Management
- Initiation of care for patients with altered consciousness, including intensive care monitoring for those with higher grades of HE who cannot protect their airway, is recommended 1, 3
- Identifying and treating alternative causes of altered mental status, such as ruling out other causes of encephalopathy that may coexist with HE, is crucial 1, 3
- Identifying and correcting precipitating factors, which can treat nearly 90% of patients, is of paramount importance 1, 4
- Common precipitating factors include infections, GI bleeding, electrolyte disturbances, and medication non-compliance 3
Pharmacological Management
- The European Association for the Study of the Liver recommends commencing empirical HE treatment, including lactulose, with initial dosing of 25 mL of lactulose syrup every 12 hours, titrated to achieve 2-3 soft bowel movements per day 1, 2
- Oral Branched-Chain Amino Acids (BCAAs) can be used as an alternative or additional agent for patients not responding to conventional therapy, with meta-analyses showing improvement in manifestations of episodic HE 2, 4, 5
- IV L-Ornithine L-Aspartate (LOLA) is an alternative for patients not responding to conventional therapy, improving psychometric testing and reducing postprandial venous ammonia levels 2, 5
- Antibiotics, such as neomycin and metronidazole, are alternative choices for treatment of overt HE, but long-term use is limited by ototoxicity, nephrotoxicity, and neurotoxicity 5
Prevention of Recurrence
- Secondary prophylaxis after an episode of overt HE is strongly recommended, with lactulose and rifaximin added to lactulose being the best-documented regimen for maintaining remission 4, 5
- Primary prophylaxis is not required except in patients with cirrhosis at high risk for developing HE 4
Special Considerations
- Neither rifaximin nor lactulose has been shown to prevent post-TIPS HE better than placebo, and shunt diameter reduction may be necessary if severe HE occurs after TIPS 5
- Recurrent intractable overt HE, together with liver failure, is an indication for liver transplantation, and for patients with preserved liver function, consider evaluating for large spontaneous portosystemic shunts 1, 4, 5
Monitoring and Follow-up
- Regularly assess for medication side effects, particularly with long-term use of antibiotics 5