title: Efficacy and tolerability of rifaximin in combination with lactulose in end-stage liver disease patients with MELD greater than 20: a single center experience.
abstract: BACKGROUND
  Rifaximin is a non-absorbable antibiotic which is approved for the treatment of hepatic encephalopathy (HE) in the United States. Our goal was to retrospectively assess this in patients with very advanced liver disease with our center data.
  
  
  METHODS
  Between 2003 and 2010, we examined a total of 286 consecutive patients from our center who were on a combination of rifaximin and lactulose, who had been evaluated or listed as eligible for a liver transplant. Patients who received less than 3 months of rifaximin and lactulose were excluded. Patients who had incomplete data; specifically, a lack of MELD score upon hospital admission were excluded from this analysis. The retrospective chart review was approved by the institutional review board.
  
  
  RESULTS
  We observed a total of 723 hospitalizations among the patients. Of the 723 hospitalizations, 218 were due to portosystemic encephalopathy (PSE), whereas 505 were due to other causes. We observed that patients with a MELD < 20 had an average of 2.5 hospitalizations per 6 month period, and that those with a MELD > 20 had an average of 1.6 hospitalizations per 6 month period for HE. At the same time, patients who had a MELD score < 20 had 3.29 hospitalizations for HE unrelated causes and those whose MELD was >20 had 3.73 hospitalizations for causes not related to HE. In this cohort 65% of all hospitalizations from HE were in patients whose MELD was < 20, and 35% of all hospitalizations were for patients with a MELD > 20.
  
  
  CONCLUSIONS
  In our experience, HE related hospitalizations were lower in patients whose MELD > 20 who were on a combination of rifaximin and lactulose compared to patients with MELD < 20. In contrast, patients whose MELD > 20 had greater hospitalizations for non HE events which may be an expected result owing to the overall increased severity of their liver disease. The limitation of this study is its retrospective nature and single center experience. In conclusion, administration of rifaximin appears to significantly reduce hospitalizations from HE in patients with MELD > 20 and therefore is advocated in maintenance of remission of HE in patients with very advanced liver disease.
authors.affiliation: Hepatobiliary Tumor Program, The Liver Institute at Methodist Dallas Medical Center, Dallas, Texas. Electronic address: parvezmantry@mhd.com.
authors.forename: P S
authors.initials: PS
authors.lastname: Mantry
authors.affiliation: Hepatobiliary Tumor Program, The Liver Institute at Methodist Dallas Medical Center, Dallas, Texas.
authors.forename: A
authors.initials: A
authors.lastname: Mehta
authors.affiliation: Hepatobiliary Tumor Program, The Liver Institute at Methodist Dallas Medical Center, Dallas, Texas.
authors.forename: R
authors.initials: R
authors.lastname: Graydon
mesh_terms: D004359:Drug Therapy, Combination; D004361:Drug Tolerance; D058625:End Stage Liver Disease / Q000188:drug therapy* / Q000601:surgery; D005260:Female; D005765:Gastrointestinal Agents / Q000494:pharmacology; D006801:Humans; D007792:Lactulose / Q000494:pharmacology*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012294:Rifamycins / Q000494:pharmacology*; D000078262:Rifaximin
chemical_list: D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin