Medications to Avoid in Hepatic Encephalopathy

Primary Medications to Avoid

The American Association for the Study of Liver Diseases and the European Association for the Study of the Liver recommend that benzodiazepines are contraindicated due to their deleterious effects on encephalopathy and delayed clearance by the failing liver 1, 3
A meta-analysis of 8 RCTs (736 patients) demonstrated that flumazenil lowered encephalopathy scores, providing evidence that benzodiazepines cause harm in this population 4
The American College of Gastroenterology recommends that if benzodiazepines must be used for seizure control, only minimal doses should be administered given their prolonged half-life in hepatic failure 3, 4
The European Association for the Study of the Liver recommends that metoclopramide and other psychotropic drugs should be avoided as they can precipitate or worsen encephalopathy 1, 2
Non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated due to nephrotoxicity risk, which can precipitate or worsen hepatic encephalopathy, according to the American Association for the Study of Liver Diseases 1, 2

The American Association for the Study of Liver Diseases recommends that in acute liver failure specifically, lactulose and rifaximin should NOT be used to lower ammonia levels 1, 2
The European Association for the Study of the Liver recommends that dexmedetomidine should be used with extreme caution as its metabolism is exclusively hepatic 4

The American Heart Association recommends that most calcium channel blockers should be avoided (except amlodipine which is safe) due to adverse effects on clinical status 7
The American College of Cardiology recommends that most antiarrhythmic drugs are potentially harmful and should be withdrawn when possible 7
The American Association for the Study of Liver Diseases recommends that thiazolidinediones should be avoided in patients with hepatic encephalopathy 7
The American College of Gastroenterology recommends that long-term infused positive inotropic drugs are potentially harmful except for palliation in end-stage disease 7

The American Association for the Study of Liver Diseases recommends that do not use sedatives to manage agitation without first addressing precipitating factors of encephalopathy 1
The European Association for the Study of the Liver recommends that do not confuse acute liver failure guidelines with chronic liver disease management: lactulose/rifaximin are avoided in acute liver failure but are standard therapy in cirrhosis 1
The American College of Gastroenterology recommends that phenytoin is the preferred agent, not benzodiazepines, for seizures in hepatic encephalopathy 3
The American Association for the Study of Liver Diseases recommends that propofol is the preferred sedative in acute liver failure due to its short duration of action and minimal impact on encephalopathy 4