Published online Jan 27, 2020. doi: 10.4254/wjh.v12.i1.10
Peer-review started: July 1, 2019
First decision: August 7, 2019
Revised: September 30, 2019
Accepted: December 8, 2019
Article in press: December 8, 2019
Published online: January 27, 2020
Hepatic encephalopathy (HE) is a major complication of cirrhosis with independant prognostic significance. The clinical and economic burdens of HE is tremendous and growing worldwide. Therapies are needed to improve the quality of life of patients and to decrease the rate of hospitalizations and the economic consequences.
The current management of HE is mainly based on lactulose. Rifaximin has been shown to decrease the risk of HE recurrence in patients with episodic forms. HE can also be persistent. However, there is no drug support recommendation for rifaximin use in this setting.
The study aimed at assessing the effectiveness of rifaximin in the management of recurrent episodes of HE and recurrent acute exacerbations on persistent HE, in “real life conditions”.
This is a retrospective study using a within-subjects design. The data of patients treated with rifaximin for HE is collected in two liver diseases centers, during the six-month period before and during the six-month period after the initiation of rifaximin. The primary effectiveness endpoint was the total number of HE events involving hospitalization.
In the case of patients presenting recurrent episodes of HE, we observed a significantly reduction of the total number of HE-events by up to 50%. Conversely, in the prevention of acute exacerbations in patients with persistent HE, an off-label use which has been found in more than half of the studied population, there was no significant difference in the number of HE-events.
The effectiveness of rifaximin was confirmed in the prevention of HE episodes recurrence but was not proved in the prevention of acute exacerbations recurrence on persistent HE.
We noticed some encouraging results with a certain probability of persistent HE cessation. Randomized controlled trials are needed to assess rifaximin efficacy in this type of HE. It seems necessary to develop standardized and reproducible tools to improve the patients’ selection in clinical trials and allow results comparison among studies. It seems to be an essential step to achieve further progress in the management of HE in clinical practice.