Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: A randomized controlled study

ArticleinJournal of Hepatology 42(5):674-9 · May 2005with57 Reads
DOI: 10.1016/j.jhep.2004.12.028 · Source: PubMed
Hepatic encephalopathy is a frequent event after transjugular-intrahepatic-portosystemic-shunt (TIPS), especially during the first months. Aim of this study was to compare two different treatments (lactitol 60 g/day, rifaximin 1200 mg/day) with no-treatment in the prevention of post-TIPS hepatic encephalopathy. Seventy-five consecutive cirrhotics submitted to TIPS were randomized to receive either one of the above treatments or no-treatment. The main end-point was the occurrence of an episode of overt hepatic encephalopathy during the first month post-TIPS. Before the procedure and weekly thereafter the patients were evaluated by examining their mental status, asterixis, ammonia and trail-making-test Part-A (TMT-A). The three groups were comparable for age, sex, etiology, Child-Pugh-score, post-TIPS porto-systemic gradient, previous hepatic encephalopathy, basal values of ammonia and psychometric performance. Twenty-five patients developed hepatic encephalopathy (33%, CI 95%=22-45%). One-month incidence was similar in the three groups (P=0.97). Previous hepatic encephalopathy (Relative Hazard=3.79;1.27-11.31) and basal-TMT-A Z-score>1.5 (RH=3.55;1.24-10.2) were predictors of post-TIPS encephalopathy at multivariate analysis. A <5 mmHg porto-systemic gradient was also significantly related to the occurrence of encephalopathy. Our data show that treatment with lactitol or rifaximin is not effective in the prophylaxis of hepatic encephalopathy during the first month after a TIPS.
    • "(4)(5)(6)21,24,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)43,45,46,(48)(49)(50)(51)(52)(53)(54)(55)) Twenty-five RCTs measured blood ammonia in plasma, venous, or arterial blood, (5,6,(21)(22)(23)(25)(26)(27)(28)(29)31,35,36,(38)(39)(40)(41)44,(46)(47)(48)(49)52,54,55) while 22 assessed the electroencephalogram mean cycle fre- quency. (4)(5)(6)(21)(22)(23)25,26,(28)(29)(30)32,36,(38)(39)(40)(41)(42)48,49,52,54) "
    [Show abstract] [Hide abstract] ABSTRACT: Nonabsorbable disaccharides (NADs) have been used to treat hepatic encephalopathy (HE) since 1966. However, a Cochrane Review, published in 2004, found insufficient evidence to recommend their use in this context. This updated systematic review evaluates the effects of the NADs, lactulose and lactitol, for the treatment and prevention of HE in patients with cirrhosis. Thirty-eight randomized controlled trials, involving 1,828 patients, were identified through electronic and manual searches; 31 randomized controlled trials looked at the treatment of HE, while seven looked at its primary/secondary prevention. Random-effects meta-analyses showed that, compared to placebo/no intervention, NADs had a beneficial effect on HE (relative risk [RR] = 0.63, 95% confidence interval [CI] 0.53-0.74, number needed to treat [NNT] = 4) and serious liver-related adverse events such as liver failure, variceal bleeding, serious infections, spontaneous bacterial peritonitis, and hepatorenal syndrome (RR = 0.42, 95% CI 0.26-0.69, NNT = 50). Treatment was also associated with a reduction in mortality in patients with overt HE (RR = 0.36, 95% CI 0.14-0.94, NNT = 20), although not in patients with minimal HE. Meta-analyses of the prevention randomized controlled trials showed that NADs prevented the development of HE (RR = 0.47, 95% CI 0.33-0.68, NNT = 6), the risk of developing serious liver-related adverse events (RR = 0.48, 95% CI 0.33-0.70, NNT = 6), and reduced mortality (RR = 0.63, 95% CI 0.40-0.98, NNT = 20). Use of NADs was associated with nonserious gastrointestinal adverse events. There were no differences in the efficacy or safety of lactulose and lactitol. Conclusions: NADs have beneficial effects in the treatment and prevention of HE; their use, in this context, confers additional benefits including a reduction in serious liver-related morbidities and all-cause mortality. (Hepatology 2016) © 2016 by the American Association for the Study of Liver Diseases.
    Full-text · Article · Apr 2016
    • "To overcome these problems, computerized psychometric tests recently have been proposed as a simplified tool for MHE detection. A simplified PHES is as good as the PHES in diagnosing MHE and in predicting the occurrence of OHE [10]. The aims of the present study were to study the incidence of MHE in patients with liver cirrhosis, and to compare the sensitivity of the electroencephalography "
    Article · Jan 2016
    • "Initially, it was routine to use standard HE treatment to prevent post-TIPS HE. However, one study illustrated that neither rifaximin nor lactulose prevented post-TIPS HE any better than placebo [111]. Careful case selection has reduced the incidence of severe HE post-TIPS. "
    [Show abstract] [Hide abstract] ABSTRACT: The AASLD/EASL Practice Guideline Subcommittee on Hepatic Encephalopathy are: Jayant A. Talwalkar (Chair, AASLD), Hari S. Conjeevaram, Michael Porayko, Raphael B. Merriman, Peter L. M. Jansen, and Fabien Zoulim. This guideline has been approved by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver and represents the position of both associations.
    Full-text · Article · Aug 2014
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