What therapies help to manage hepatic encephalopathy?

Question

Hello doctor,

I am writing about my mother, who is 58 and has liver cirrhosis due to NASH. She was diabetic and obese for many years before we knew about the liver damage. She had her first overt hepatic encephalopathy episode three months ago, and it was terrifying. She was speaking nonsense and trying to leave the house at midnight. She was admitted and treated with lactulose enemas and IV fluids.

Since then, she has been on oral lactulose, but she struggles to take it because it causes so much gas and bloating, and she often skips doses. She is also on Spironolactone 100 mg and Furosemide 40 mg for her ascites, which has been tapped twice in the last month. They drained seven liters the last time. Her hepatologist is talking about TIPS, but her cardiologist has concerns because of her mild hypertrophic cardiomyopathy.

She is still diabetic with an HbA1c of 8.9, and her endocrinologist recently adjusted her insulin. We have noticed that even between overt hepatic encephalopathy episodes, she is not herself. She is slow, forgetful, and cannot manage her own medications anymore. Her latest ammonia level was 112 µmol/L even while taking lactulose. We asked about Rifaximin, and the hepatologist said it is indicated, but cost is an issue for us. Is there a way to improve lactulose compliance, and are there any alternative, more affordable options to Rifaximin for preventing another overt hepatic encephalopathy episode?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your mother’s symptoms are consistent with recurrent hepatic encephalopathy occurring in the setting of advanced liver cirrhosis related to nonalcoholic steatohepatitis (NASH). In cirrhosis, the liver cannot effectively clear toxins such as ammonia. These toxins then affect brain function and lead to confusion, sleep disturbance, and behavioral changes. The cornerstone treatment is Lactulose, which reduces ammonia absorption by increasing bowel movements. The usual target is two to three soft stools daily. Gas and bloating are common side effects, which often lead patients to skip doses.

Compliance can sometimes improve by splitting the dose into smaller, more frequent amounts, mixing it with water or juice, or taking it after meals. Adjusting the dose gradually may also reduce discomfort while maintaining the desired stool frequency. Adding Rifaximin is recommended in patients who have had recurrent encephalopathy because it decreases ammonia-producing gut bacteria and significantly reduces the risk of relapse. If cost is a concern, you may ask your doctor about generic versions, insurance coverage programs, or hospital assistance schemes, as these are sometimes available.

Other important preventive steps include avoiding constipation, ensuring adequate hydration, promptly treating infections, and maintaining a balanced diet with moderate protein intake rather than severe restriction. Because she also has ascites requiring diuretics such as Spironolactone and Furosemide, careful monitoring of fluid balance and electrolytes is important. Regarding transjugular intrahepatic portosystemic shunt (TIPS), cardiology evaluation is essential because certain heart conditions may increase risk. With consistent medication, management of triggers, and close follow-up with the hepatology team, many patients can reduce the frequency of encephalopathy episodes and maintain better cognitive function.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.