Rifaximin therapy and hepatic encephalopathy: Pros and cons

Abstract

Hepatic encephalopathy (HE) is the second most common major complication in cirrhotics and it significantly impacts quality of life. Therapeutic approaches for HE treatment and prevention mainly continue to rely on ammonia-lowering strategies and non-absorbable disaccharides are currently considered the cornerstone therapy. Non-absorbable antibiotics, such as neomycin and paramomycin, are effective in treatment of acute HE episodes but their prolonged use for recurrence prevention is hampered by possible side-effects. To overcome these limitations, rifaximin use has been proposed. Rifaximin has been shown to be not superior to non-absorbable disaccharides for either HE treatment or prevention, with a similar incidence of side-effects. Cirrhosis significantly increases rifaximin absorption and this could be a cause for concern. Following long-term rifaximin therapy, Clostridium difficile colitis has been observed and Candida albicans has been isolated from 20% of patients. In addition, selection of resistant mutants of both Gram-negative and -positive bacteria in the gastrointestinal tract cannot be definitely ruled out. Electrolyte alterations (sodium and potassium) have been reported during rifaximin therapy, a warning for its long-term use in cirrhotics. Moreover, a potential interference with vitamin K production should be considered which could further impair the already altered clotting status of these patients. The therapeutic cost of rifaximin is markedly higher than non-absorbable disaccharides. While waiting for further safety data, caution should be used to limit the use of rifaximin therapy for a very short-term period in selected HE cirrhotics not responding to non-absorbable disaccharides.

La rifaximine : une nouvelle alternative dans la prévention des infections bactériennes chez le cirrhotique ?

“…Par ailleurs le mécanisme étiopathogénique de l'ILA ne se limite pas à la translocation bactérienne et pourrait être en rapport avec une bactériémie [21]. Finalement, il a été signalé 2 cas de colites à clostridium difficile chez des patients recevant de la rifaximine au long cours [22].…”

A look at the hepatic encephalopathy in cirrhosis

“…Inoltre, è stato dimostrato come rifaximina sia in grado di migliorare la qualità di vita e le capacità di guida dei pazienti con EE minima [96,97]. Rifaximina viene oggi considerata da alcuni come la terapia di prima linea dell'EE, tuttavia le evidenze in merito alla sicurezza dell'uso prolungato sono ancora limitate [98]. L'impiego di altri antibiotici, quali paromomicina e neomicina, è consigliabile esclusivamente nel trattamento di episodi acuti di EE, in quanto, nonostante lo scarso assorbimento sistemico, sono stati riportati effetti collaterali quali ototossicità e nefrotossicità.…”

The efficacy and the immunomodulatory effect of rifaximin in prophylaxis of spontaneous bacterial peritonitis in cirrhotic Egyptian patients

“…During the current study, rifaximin intake (400 mg/twice daily, orally) was based on the fact that Escherichia coli is the most commonly isolated microorganisms from cases of SBP, and it has been shown that uptake of 800 mg rifaximin for 5 days markedly reduces fecal Escherichia coli population (31,32).…”