Portal-Systemic Encephalopathy Medication

  • Author: Gagan K Sood, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 25, 2010
 

Medication Summary

The mainstay of therapy is lactulose, a nonabsorbed disaccharide. The actions of this agent are multiple and culminate in reduced delivery of ammonia to the brain. Lactitol, another disaccharide, may be better tolerated, but this agent is used relatively infrequently. Oral antibiotics are not used as frequently, but they do have a role in patients who are intolerant of lactulose. Flumazenil, bromocriptine, BCAAs, and L-ornithine have been investigated but cannot be considered first-line therapy.

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Nonabsorbed disaccharides

Class Summary

Promote acidification, sterilization, and ammonium ion trapping in colon lumen. Increased stool frequency occurs, and all mechanisms likely reduce ammonia delivery to systemic circulation and the brain. Inexpensive and generally well tolerated.

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Lactulose (Cephulac, Cholac, Constulose)

 

DOC; inhibits diffusion of NH3 into blood by producing an acidic pH that causes conversion of NH3 to NH4.

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Nonabsorbed antibiotics

Class Summary

Used for gut sterilization.

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Neomycin PO (Neo-Tabs)

 

Second-choice drug. Small percentage of neomycin may be absorbed with each dose. Chronic administration may lead to nephrotoxicity or ototoxicity.

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Rifaximin (Xifaxan)

 

Oral antibiotic that reduces ammonia-producing enteric bacteria in patients with hepatic encephalopathy. In vitro, elicits broad-spectrum activity against gram-positive and gram-negative aerobic and anaerobic enteric bacteria. Minimal systemic absorption (< 0.4%); concentrated in GI tract; low risk for inducing bacterial resistance. Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis.

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Contributor Information and Disclosures
Author

Gagan K Sood, MD  Associate Professor, Department of Medicine and Surgery, Baylor College of Medicine

Gagan K Sood, MD is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Ann Ouyang, MBBS  Professor, Department of Internal Medicine, Pennsylvania State University College of Medicine; Attending Physician, Division of Gastroenterology and Hepatology, Milton S Hershey Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Blake A Jones, MD, to the development and writing of this article.

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