title: A randomized, double-blind, controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of overt hepatic encephalopathy.
abstract: OBJECTIVE
  Hepatic encephalopathy (HE) is associated with poor prognosis in cirrhosis. Drugs used in the treatment of HE are primarily directed at the reduction of the blood ammonia levels. Rifaximin and lactulose have shown to be effective in HE. We evaluated the efficacy and safety of rifaximin plus lactulose vs. lactulose alone for treatment of overt HE.
  
  
  METHODS
  In this prospective double-blind randomized controlled trial, 120 patients with overt HE were randomized into two groups: (group A lactulose plus rifaximin 1,200 mg/day; n=63) and group B (lactulose (n=57) plus placebo). The primary end point was complete reversal of HE and the secondary end points were mortality and hospital stay.
  
  
  RESULTS
  A total of 120 patients (mean age 39.4±9.6 years; male/female ratio 89:31) were included in the study. 37 (30.8%) patients were in Child-Turcotte-Pugh (CTP) class B and 83 (69.2%) were in CTP class C. Mean CTP score was 9.7±2.8 and the MELD (model for end-stage liver disease) score was 24.6±4.2. At the time of admission, 22 patients (18.3%) had grade 2, 40 (33.3%) had grade 3, and 58 (48.3%) had grade 4 HE. Of the patients, 48 (76%) in group A compared with 29 (50.8%) in group B had complete reversal of HE (P<0.004). There was a significant decrease in mortality after treatment with lactulose plus rifaximin vs. lactulose and placebo (23.8% vs. 49.1%, P<0.05). There were significantly more deaths in group B because of sepsis (group A vs. group B: 7:17, P=0.01), whereas there were no differences because of gastrointestinal bleed (group A vs. group B: 4:4, P=nonsignificant (NS)) and hepatorenal syndrome (group A vs. group B: 4:7, P=NS). Patients in the lactulose plus rifaximin group had shorter hospital stay (5.8±3.4 vs. 8.2±4.6 days, P=0.001).
  
  
  CONCLUSIONS
  Combination of lactulose plus rifaximin is more effective than lactulose alone in the treatment of overt HE.
authors.affiliation: Department of Gastroenterology, GB Pant Hospital, New Delhi, India. drbcsharma@hotmail.com
authors.forename: Barjesh Chander
authors.initials: BC
authors.lastname: Sharma
authors.forename: Praveen
authors.initials: P
authors.lastname: Sharma
authors.forename: Manish Kumar
authors.initials: MK
authors.lastname: Lunia
authors.forename: Siddharth
authors.initials: S
authors.lastname: Srivastava
authors.forename: Rohit
authors.initials: R
authors.lastname: Goyal
authors.forename: S K
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D000328:Adult; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D005765:Gastrointestinal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007792:Lactulose / Q000008:administration & dosage / Q000627:therapeutic use*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012294:Rifamycins / Q000008:administration & dosage / Q000627:therapeutic use*; D000078262:Rifaximin; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin