title: Management of Hepatic Encephalopathy: A Primer.
abstract: To review the management of hepatic encephalopathy (HE), including lifestyle modifying strategies and pharmacological interventions.
  
  
  
  A literature search of PubMed through March 2016 was conducted utilizing the keywords hepatic encephalopathy, ammonia, and cirrhosis All published articles evaluating treatments for HE were considered.
  
  
  
  Available English-language data from reviews, abstracts, presentations, and clinical trials of the treatment of HE in humans were reviewed; relevant clinical data were selected and included.
  
  
  
  HE is a prevalent complication of portal hypertension and cirrhosis that results in altered mental status and neuropsychiatric impairment. Although the pathogenesis has not been elucidated, numerous treatment options exist. This review will explore the role of dietary interventions and supplements, including use of zinc, acetyl-l-carnitine, and probiotics, in the management of HE. Additionally, the use of various ammonia-lowering agents will be evaluated. The nonabsorbable disaccharides represent first-line therapies for the management and prophylaxis of HE; rifaximin use has been demonstrated to be effective for both treatment and prophylaxis of HE symptoms, with use relegated to those patients who fail to respond to or tolerate the nonabsorbable disaccharides. In light of toxicities associated with the use of neomycin and metronidazole, recent guidelines recommend both as alternatives for the treatment of HE, with the use of vancomycin discouraged.
  
  
  
  Although numerous treatment options are available, management of HE remains a clinical challenge. Additional research is needed to explore the pathogenesis and better understand the role of pharmacotherapy in managing this condition.
authors.affiliation: Pharmacy Department, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
authors.forename: Tara
authors.initials: T
authors.lastname: Jawaro
authors.affiliation: Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA.
authors.forename: Anna
authors.initials: A
authors.lastname: Yang
authors.affiliation: Pharmacy Department, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA.
authors.forename: Deepali
authors.initials: D
authors.lastname: Dixit
authors.affiliation: Pharmacy Department, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA Mary.bridgeman@pharmacy.rutgers.edu.
authors.forename: Mary Barna
authors.initials: MB
authors.lastname: Bridgeman
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004187:Disaccharides / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000178:diet therapy* / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D008103:Liver Cirrhosis / Q000209:etiology / Q000517:prevention & control; D008795:Metronidazole / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D009355:Neomycin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D019936:Probiotics / Q000627:therapeutic use*; D012294:Rifamycins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000078262:Rifaximin; D012720:Severity of Illness Index
chemical_list: D000900:Anti-Bacterial Agents; D004187:Disaccharides; D012294:Rifamycins; D008795:Metronidazole; D009355:Neomycin; D000078262:Rifaximin
keywords: alcoholism; hepatic encephalopathy; hepatitis; liver disease