Secondary prevention

Prophylactic treatment with lactulose has been shown to be effective for preventing recurrence of HE in patients with cirrhosis.[1][5] Lactulose should be given chronically to patients (who are tolerant to lactulose) with cirrhosis/portal hypertension and previous or recurrent episodes of HE.

Patients should be counselled on how to titrate lactulose to achieve their target number of bowel movements per day. One study reported that failure to adequately titrate lactulose was one of the most common reasons for preventable re-admissions to hospital.[64]

Rifaximin effectively prevents recurrence of HE and is a recommended add-on therapy to lactulose for secondary prophylaxis following ≥1 episode of overt HE within 6 months of the first one in patients with episodic HE.[1][2] In one randomised controlled trial, a 6-month course of rifaximin decreased the risk of relapse and hospitalisation due to HE in patients with recurrent HE.[39] One systematic review and meta-analysis found that rifaximin had a beneficial effect on secondary prevention of HE, full recovery from HE, and mortality.[32]

There is no strong evidence to guide the decision as to if, or when, prophylactic treatment for HE should be discontinued. Guidelines recommend that if liver and nutritional status have improved, and precipitating factors have been controlled, discontinuation of HE treatment can be considered on an individual basis.[2]

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