Background: Hepatic encephalopathy (HE) is often treated with lactulose
as first-line therapy despite the lack of an evidence base. The GI adverse
effects of lactulose can limit compliance. Overuse of lactulose can also
result in diarrhea and dehydration. The aim was to define the association
between lactulose use and HE recurrence
Design: A retrospective review of patients evaluated for HE in a transplant
center was performed
Methods: Demographics, MELD score, HE therapy details, recurrent HE
episode details including hospitalizations were noted. Non-compliance was
inferred if a patient had _2 bowel movements/day and it was corroborated
from caregivers at the time of recurrence. Over-use was defined as _4
loose bowel movements/day with dehydration at the time of recurrence.
Recurrent HE was only considered to be associated with lactulose if no
other precipitants were identified.
Results: 119 cirrhotics (age 55�7 years, MELD17�5, 44% alcohol, 31%
HCV, 10% both) were included. 83(70%) had a recurrence 9�2 months
after the initial HE episode. Of the recurrent episodes, 43 (48%) were due
to GI adverse effects of lactulose; 36 (40%) were due to non-compliance
and 7 (8%) were due to severe diarrhea by lactulose overuse. Remaining
recurrent episodes were due to sepsis(n = 24), GI bleed(n = 4) or were
spontaneous(n = 12) while on lactulose.
Non-compliance to lactulose was predominantly due to GI adverse effects
(90%) or due to patient unwillingness to be treated(10%). There was a
significantly higher rate of further HE hospitalization if there was lactulose
over-use or non-compliance compared to other recurrence precipitating
factors. There was no significant difference in death or liver transplant
between the groups.
Conclusions: Recurrence of HE can be attributed to both overuse and
non-compliance with lactulose in as high as 48% of patients. This is
associated with a higher rate of recurrent hospitalization compared to other
precipitating factors. Alternatives which minimize GI adverse effects may