Rifaximin for prevention and treatment of hepatic encephalop | Figure 1

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Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis

Key messages

The prevention and treatment of hepatic encephalopathy, in people with cirrhosis, largely depends on use of the compound lactulose. Rifaximin is not used to treat hepatic encephalopathy, at present, but it is used as an add‐on to lactulose to help prevent hepatic encephalopathy in people whose response to lactulose is inadequate.

What did we find?

We identified 41 clinical studies involving 4545 people, who were randomly allocated to treatment groups. All participants had cirrhosis mainly due to excessive alcohol intake or chronic viral hepatitis. Participants were classed as having acute (13 studies), chronic (7 studies), or minimal (8 studies) hepatic encephalopathy, or were considered to be at risk for its development (13 studies). The studies compared rifaximin with a placebo (12 studies), no intervention (1 study), or lactulose/lactitol (14 studies). In 18 studies, rifaximin was given together with lactulose/lactitol and the results compared to the effect of giving lactulose/lactitol alone.

The analyses found that giving rifaximin alone may help improve health‐related quality of life and the performance of tests used to assess mental function in people with minimal hepatic encephalopathy. However, lactulose is probably as effective and is considerably cheaper. There were no differences in the benefits and side effects of rifaximin when directly compared with lactulose/lactitol. However, when rifaximin was given together with lactulose/lactitol, it reduced the risk of death (from 14.8% to 10.1%), reduced the risk of unwanted side effects (from 34.4% to 17.6%), and resulted in improvement in hepatic encephalopathy (from 86.9% to 33.8%) when compared to use of lactulose alone.

What are the limitations of the evidence?

We are uncertain about or have only moderate confidence in our findings, meaning we cannot make more certain conclusions about the effects of rifaximin. This was mainly because people in the studies might have been aware of which treatment they were getting and not all the studies provided data about the outcomes we were interested in. Also, many studies were too small for us to be certain about their results. More high‐quality studies are needed.

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