Introduction Rifaximin is a non-absorbable, broad spectrum antibiotic that is used for the treatment and prevention of overt hepatic encephalopathy (HE). It acts locally in the gut to reduce intestinal flora, including ammonia-producing species, with hyperammonaemia considered to play a central role in the pathogenesis of HE. Our aim was to assess the tolerability and efficacy of rifaximin at preventing HE-related hospital admissions at our transplant unit.
Method Medical records for all patients who were commenced on rifaximin for recurrant HE at our transplant unit between March 2012 and August 2014 were evaluated. Patient demographics, concurrent therapy, MELD, UKELD and number of hospital admissions were collected 6 months prior to initiation of rifaximin therapy and then 6 months following treatment. Continuous variables are presented as median (interquartile range).
Results 23 patients with HE (median age 64 (53–68) years; 14 males) were commenced on Rifaximin. Nine had ALD, 8 had NASH, 2 had PBC, and one each had alpha-1 antitrypsin deficiency, PSC, Hepatitis C and secondary biliary cirrhosis. MELD and UKLED at commencement were 13 (11–21) and 55 (50–58) respectively. All were prescribed lactulose and 6 had tried neomycin and 1 metronidazole. Of the 23 patients, six died and one was transplanted within six months of starting treatment, one was discharged back to the local hospital. Treatment was withdrawn in one patient due to diarrhoea (non-infective). Thus, 14 patients were included in the final analysis. The number of hospital admissions for overt HE fell significantly between the six months prior to and the six months after commencing rifaximin, from 2 (1–3) to 0(0–1.25), p = 0.003. There was no observed change in the MELD or UKELD scores during the six months of treatment (12.5 vs 12, p = 0.9 and 51 vs 51, p = 0.2 respectively). In one patient, the HE improved to the extent that she was able to be removed from the transplant waiting list. Three of the 14 patients were being treated for recurrent HE post TIPSS insertion. In this subgroup of patients, there was no reduction in the number of hospital admissions with HE (2 vs 2, p = 0.4). None of the patients developed C difficile infection.
Conclusion Rifaximin is effective at reducing the number of hospital admissions in patients with recurrent HE. We would recommend a trial of treatment with rifaximin in patients who are being considered for liver transplant because of recurrent HE, with otherwise well preserved hepatic synthetic function. We did not observe a benefit of rifaximin at preventing hospital admissions in patients with post-TIPSS recurrent HE. Rifaximin is well tolerated and proved to be safe.
Disclosure of interest None Declared.