Pharmacotherapy of hepatic encephalopathy in cirrhosis.
BACKGROUND
Hepatic encephalopathy (HE) is a major complication encountered in nearly half of the patients with liver cirrhosis.


METHODS
A review of the safety and efficacy of current therapies for HE that seek to pre-empt ammonia production and/or to increase its elimination, reducing inflammation, blocking benzodiazepine-like compound production, and supporting systemic hemodynamics.


RESULTS
Insight into some recent advances in the management of HE that could modify our therapeutic approach to end-stage liver disease. Cirrhotic individuals during an overt HE episode require careful management, focusing on precipitant factors as well as metabolic and hemodynamic derangements.


CONCLUSIONS
Intestinal ammoniagenesis requires flora modification by antibiotics, prebiotics and probiotics; glutaminase inhibition as well as antibiotics to pre-empt systemic inflammation. Hemodynamic/fluid support is essential. Nutritional support is crucial and hypoproteinemic diets should be avoided. Blocking benzodiazepine-like compounds by the use of flumazenil could be useful in patients with severe, benzodiazepine-induced HE. Long-term rifaximin is well tolerated, does not promote resistance and could decrease overt HE bouts in patients with previous episodes of overt HE. Lactulose is better than no treatment in improving quality of life in patients with minimal HE; it also acts as secondary prophylaxis following overt HE.
Romero-Gómez
Manuel
M
Unit for Clinical Management of Digestive Diseases and CIBEREHD, Hospital Universitario de Valme, University of Seville, Seville, Spain. mromerogomez@us.es
D000641:Ammonia / Q000378:metabolism; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D005440:Fluid Therapy; D005442:Flumazenil / Q000627:therapeutic use; D006501:Hepatic Encephalopathy / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D006801:Humans; D007413:Intestinal Mucosa / Q000378:metabolism; D007422:Intestines / Q000187:drug effects / Q000382:microbiology; D008103:Liver Cirrhosis / Q000150:complications / Q000473:pathology / Q000628:therapy*; D018529:Nutritional Support; D011170:Portasystemic Shunt, Surgical; D019936:Probiotics / Q000008:administration & dosage; D012294:Rifamycins / Q000627:therapeutic use; D000078262:Rifaximin
D000900:Anti-Bacterial Agents; D012294:Rifamycins; D005442:Flumazenil; D000641:Ammonia; D000078262:Rifaximin