Lactulose recommended for secondary prophylaxis of hepatic encephalopathy in latest EASL guidelines
Europe: Lactulose is recommended as secondary prophylaxis following the first episode of overt hepatic encephalopathy recommends the European Association for the Study of the Liver (EASL) in just released clinical practice guidelines on the management of hepatic encephalopathy.
The guideline, published in the Journal of Hepatology, presents evidence-based answers to a set of questions on the diagnosis, definition, differential diagnosis, and treatment of hepatic encephalopathy. The guideline, however, does not cover the pathophysiology of HE and does not include all available treatment options. It also provides the methods through which it was developed and any information relevant to its interpretation.
In a response to the question of whether patients with hepatic encephalopathy, can pre-defined classification criteria improve diagnostic accuracy and the effects of treatment, the authors recommend, "HE should be qualified as type A in patients with acute liver failure, type B in those with portosystemic shunt, and type C in those with cirrhosis."
"Overt HE should be qualified as recurrent if ≥2 bouts occur within 6 months and persistent if the patient does not return to her/his baseline performance between bouts. The severity of mental alterations, any identified precipitants, and the presence of portosystemic shunts should also be recorded as these factors impact upon both diagnostic accuracy and treatment."
In response to the question that in patients with HE, are the West Haven criteria and Glasgow coma scale appropriate for grading?, the researchers recommend that the West Haven criteria should be used for HE grading when at least temporal disorientation is present (i.e. from West Haven grades ≥2). A neuropsychological/neurophysiological or therapeutic test should be used to diagnose covert HE In patients with no or mild neuropsychiatric abnormalities. In patients with grades III-IV West Haven criteria, the Glasgow coma scale should be added.
Addressing the question that whether the exclusion or identification of alternative or additional causes of neuropsychiatric impairment improves prognostic accuracy and the results of treatment in patients with suspected HE, the researchers recommend that in patients with suspected HE, alternative or additional causes of neuropsychiatric impairment should be identified to improve prognostic accuracy and the results of treatment.
They also recommend that plasma ammonia measurement should be performed, as a normal value brings the diagnosis of HE into question in patients with delirium/encephalopathy and liver disease.
Providing a recommendation on whether in cirrhosis patients covert HE should be screened for in the clinic and/or ward, and how, they added that in cirrhosis patients with no history of overt HE, screening for covert HE should be performed with tests for which experience/tools and local norms are available. As the only bedside test available to date, the Animal Naming Test is worthy of further study and validation.
Other recommendations are as follows:
- In patients with HE, all measures to control the progression of the underlying liver disease should be undertaken.
- In patients with HE, precipitating factors should be sought and managed.
- Following the first episode of overt HE, lactulose is recommended as secondary prophylaxis and should be titrated to obtain 2-3 bowel movements per day.
- Rifaximin as an adjunct to lactulose is recommended as secondary prophylaxis following ≥1 additional episode of overt HE within 6 months of the first one.
- In patients presenting with gastrointestinal bleeding, rapid removal of blood from the gastrointestinal tract (lactulose or mannitol by nasogastric tube or lactulose enemas) can be used to prevent HE.
- Routine zinc supplementation is not recommended.
- In HE patients who demonstrated or suspected vitamin/micronutrient deficiencies should be treated, as they can compound HE.
- Obliteration of accessible portal-systemic shunts in cirrhosis patients with recurrent or persistent HE can be considered in stable patients with a MELD score <11.
- In patients with recurrent/persistent HE, replacement of animal protein with vegetable and dairy protein can be considered, provided that overall protein intake is not compromised and that patient's tolerance is considered.
- Patients with end-stage liver disease and recurrent or persistent HE not responding to other treatments should be assessed for liver transplantation.
- Liver transplantation should be considered as soon as possible since there is no other therapeutic option in patients with hepatic myelopathy.
Reference:
European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. J Hepatol. 2022 Sep;77(3):807-824. doi: 10.1016/j.jhep.2022.06.001. Epub 2022 Jun 17. PMID: 35724930.
