title: Primary prophylaxis of overt hepatic encephalopathy in patients with cirrhosis: an open labeled randomized controlled trial of lactulose versus no lactulose.
abstract: OBJECTIVE
  Development of overt hepatic encephalopathy (HE) is associated with poor prognosis in patients with cirrhosis. Lactulose is used for the treatment of HE. There is no study on the prevention of overt HE using lactulose in patients who never had HE earlier.
  
  
  METHODS
  Consecutive cirrhotic patients who never had an episode of overt HE were randomized to receive lactulose (Gp-L) or no lactulose (Gp-NL). All patients were assessed by psychometry (number connection test [NCT-A and B], figure connection test if illiterate [FCT-A and B], digit symbol test [DST], serial dot test [SDT], line tracing test [LTT]) and critical flicker frequency test (CFF) at inclusion and after 3 months. These patients were followed every month for 12 months for development of overt HE.
  
  
  RESULTS
  Of 250 patients screened, 120 (48%) meeting the inclusion criteria were randomized to Gp-L (n = 60) and Gp-NL (n = 60). Twenty (19%) of 105 patients followed for 12 months developed an episode of overt HE. Six (11%) of 55 in the lactulose (Gp-L) group and 14 (28%) of 50 in the Gp-NL (P = 0.02) developed overt HE. Ten (20%) of 50 patients in Gp-NL and five (9%) of 55 patients in the Gp-L group died, P = 0.16. Number of patients with minimal hepatic encephalopathy (MHE) were comparable in two groups at baseline (Gp-L vs Gp-NL, 32:36, P = 0.29). Lactulose improved MHE in 66% of patients in Gp-L. Taking a cutoff < 38 Hz sensitivity and specificity of CFF in predicting HE were 52% and 77% at baseline and 52% and 82% at 3 months of treatment. On multivariate analysis, Child's score and presence of MHE at baseline were significantly associated with development of overt HE.
  
  
  CONCLUSIONS
  Lactulose is effective for primary prevention of overt hepatic encephalopathy in patients with cirrhosis.
authors.affiliation: Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
authors.forename: Praveen
authors.initials: P
authors.lastname: Sharma
authors.forename: Barjesh Chander
authors.initials: BC
authors.lastname: Sharma
authors.forename: Amit
authors.initials: A
authors.lastname: Agrawal
authors.forename: Shiv Kumar
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D005260:Female; D005765:Gastrointestinal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000517:prevention & control* / Q000523:psychology; D006760:Hospitalization; D006801:Humans; D007194:India; D007792:Lactulose / Q000009:adverse effects / Q000627:therapeutic use*; D016014:Linear Models; D008103:Liver Cirrhosis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D011322:Primary Prevention; D011594:Psychometrics; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005765:Gastrointestinal Agents; D007792:Lactulose