title: Lactulose, rifaximin or branched chain amino acids for hepatic encephalopathy: what is the evidence?
abstract: Hepatic encephalopathy (HE) is a serious complication of acute and chronic liver disease associated with severe morbidity and mortality. We performed updated random effects meta-analyses to evaluate the evidence for non-absorbable disaccharides (lactulose and lactitol), rifaximin and branched chain amino acids (BCAA). A meta-analysis of randomized trials showed that, compared with placebo or no intervention, non-absorbable disaccharides have beneficial effects on HE manifestations and prevention of HE episodes. The addition of rifaximin to non-absorbable disaccharides versus rifaximin alone was more beneficial than non-absorbable disaccharides used alone on both outcome measures. Likewise, a meta-analysis of randomised controlled trials found that oral BCAA supplements have beneficial effects on manifestations of HE compared with control supplements. The effect was found in a variety of clinical settings. No convincing effects of intravenous BCAA for episodic HE were identified. In conclusion, evidence-based treatment recommendations for patients with HE should include non-absorbable disaccharides combined with rifaximin or BCAA. Additional evidence is needed to evaluate the effect of combining all three interventions.
authors.affiliation: Department of Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark. liselottegluud@yahoo.dk
authors.forename: Lise Lotte
authors.initials: LL
authors.lastname: Gluud
authors.forename: Gitte
authors.initials: G
authors.lastname: Dam
authors.forename: Mette
authors.initials: M
authors.lastname: Borre
authors.forename: Iñigo
authors.initials: I
authors.lastname: Les
authors.forename: Juan
authors.initials: J
authors.lastname: Cordoba
authors.forename: Giulio
authors.initials: G
authors.lastname: Marchesini
authors.forename: Niels Kristian
authors.initials: NK
authors.lastname: Aagaard
authors.forename: Hendrik
authors.initials: H
authors.lastname: Vilstrup
mesh_terms: D000597:Amino Acids, Branched-Chain / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D004187:Disaccharides / Q000378:metabolism / Q000627:therapeutic use; D019317:Evidence-Based Medicine; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000188:drug therapy*; D006801:Humans; D007792:Lactulose / Q000627:therapeutic use*; D012294:Rifamycins / Q000627:therapeutic use*; D000078262:Rifaximin
chemical_list: D000597:Amino Acids, Branched-Chain; D000900:Anti-Bacterial Agents; D004187:Disaccharides; D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin