Non-Lactulose Medication Therapies for the Management of Hepatic Encephalopathy: A Literature Review

Abstract

Objective: The most appropriate medication regimen to mitigate the consequences hepatic encephalopathy remains inconclusive. This review seeks to serve as a reference for clinicians to help guide therapy decisions with regard to hepatic encephalopathy. Methods: A comprehensive literature review between August 2018 and April 2019 was accomplished with the assistance of a medical librarian. Sources of literature review include PubMed, MEDLINE, SCOPUS, ProQuest Central, CINAHL, and ProQuest Dissertations. The authors selected randomized clinical and double-blind cross-over trials evaluating probiotics, zinc, polyethylene glycol, rifaximin, and flumazenil. Sixteen clinical trials are discussed in this review. Pertinent safety, efficacy, and statistical and clinical outcomes are summarized by the authors. Conclusions: The most appropriate regimen to mitigate the consequences of hepatic encephalopathy remains elusive; however, the agents discussed within this review offer alternative options for patients unresponsive to or intolerant of traditional lactulose therapy. This review seeks to serve as a repository for relevant clinical trials, and as a reference for clinicians to help guide therapy decisions.

Comparison of current and emerging strategies for treating hepatic encephalopathy.

“…In one study, rifaximin was found effective in 22.1% cases of hepatic encephalopathy. 12 While according to another study 13 , metronidazole is effective in 78% patients.…”

“…14 The adjustment of disaccharide dose in order to get two to three bowel movements per day often leads to side effects like nausea, vomiting, flatulence and poor drug compliance. 13 Oral antibiotics such as neomycin, vancomycin or paromomycin are more useful than disaccharides and have less side effects, but have a risk of toxicity. 13,16 Due to this risk of toxicity, these agents are not commonly used in clinical practice now a days.…”

“…13 Oral antibiotics such as neomycin, vancomycin or paromomycin are more useful than disaccharides and have less side effects, but have a risk of toxicity. 13,16 Due to this risk of toxicity, these agents are not commonly used in clinical practice now a days. 19 Our hypothesis that rifaximin is better than metronidazole with respect to efficacy in treatment of hepatic encephalopathy was rejected as our study results came out in favor of metronidazole with significant p value.…”

Multi-omic data integration study of immune system alterations in the development of minimal hepatic encephalopathy in patients with liver cirrhosis

“…Rifaximin is a systematically studied antibiotic for the treatment of HE which has minimal systemic absorption, a subtle adverse effect profile, and a low risk for bacterial resistance due its gut-selective nature. The efficacy and safety of this medication makes rifaximin an important therapeutic tool for the management of HE because it alleviates endotoxemia and improves cognition 57 .…”