- Drug Levels (based on history or med list)
- RUQ sono with Doppler
- Consider lumbar puncture
- Consider diagnosis paracentesis to evaluation for spontaneous bacterial peritonitis (SBP); as many as 10% of patients with overt hepatic encephalopathy also have SBP.
- PEG-3350 4 liters can be administered via NGT as adjunctive therapy
- Addition of rifaximin to lactulose increases efficacy of therapy and decreases mortality and lowers readmission rates for hepatic encephalopathy at 180 days6,7
- Rifaximin added to placebo has been shown to maintain remission
- Lactulose contains galactose; contraindicated in those who cannot take galactose in diet
- Adverse effects:
- Bloating, epigastric pain, flatulence, nausea, vomiting
- Hypernatremia, hypokalemia
- Safety Considerations:
- Pregnancy: Although lactulose does not cross the placenta, there have not been adequate and well-controlled studies of lactulose in pregnant women conducted. Administer lactulose to pregnant women only if clearly indicated.
- Breastfeeding: Evidence is inconclusive for determining infant risk when used in breastfeeding mother. Exercise caution when administering lactulose to a nursing woman.
- Give with or without food.
- Avoid in patients with hypersensitivity to rifaximin or any component of the drug or to other rifamycin antibiotics e.g., rifampin, rifabutin.
- Avoid use in diarrhea complicated by fever or blood in stool or due to pathogens other than Escherichia coli.
- Adverse effects
- Peripheral edema
- Abdominal pain, nausea, dizziness, headache, fatigue
- Safety Considerations:
- Pregnancy: It is unknown whether rifaximin crosses the placenta. Thus, administer during pregnancy only if the benefit justifies the risk to the fetus and inform the patient of the potential for harm. Breastfeeding: Evidence is inconclusive for determining infant risk when used in breastfeeding mother. Exercise caution when administering rifaximin to a nursing woman.
- Cost Considerations:
- May require prior authorization.
- Consider enrolling the patient in a Patient Assistance Program.
Developed by the ACP Expert Panel on Hepatic Encephalopathy.
Reviewed by the ACEP Clinical Resource Review Committee.
Arun B. Jesudian, MD, co-chair Stanley C. Thompson, MD, co-chair Christopher W. Baugh, MD, MBA William Ford, MD Christi Anne Jen, PharmD, BCPS, FAzPA James Neuenschwander, MD, FACEP Edgar Ordonez, MD, FACEP Rebecca A. Perez, RN, BSN, CCM
Jerry Anderson Riane V. Gay, MPA, CAE Liz Muth Lillian Renner
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