Can medications and diet changes help manage my OHE?

Question

Hello doctor,

I am a 47-year-old male with hepatitis C-related cirrhosis, and I have had two episodes of OHE in the past six months. I was recently started on Rifaximin and Lactulose after my second hospitalization. My hepatologist mentioned secondary prophylaxis, but I travel a lot for work, and managing the medications on the road is difficult. I have also been reading that zinc deficiency can make OHE worse, and my levels have never been tested.

I also started taking some herbal supplements from a wellness store, and now I am wondering if they might be interfering with Rifaximin or making the encephalopathy worse. My last ammonia level was 112 µmol/L, even though I feel okay right now. I also have mild ascites managed with Spironolactone. Should I be worried about protein intake? I have been told to limit protein intake, but I am losing a lot of muscle mass and do not know how to balance it properly. What should I do?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

You are correctly on secondary prophylaxis, which means lifelong prevention after two or more overt hepatic encephalopathy (HE) episodes. Lactulose and Rifaximin together are the standard and most effective regimen, reducing recurrence risk by over 50 percent. Consistency is critical, even during travel. Missing doses increases relapse risk, even if you feel well.

Ammonia level alone is not decisive. Clinical symptoms matter more. Many patients feel normal despite elevated ammonia if treatment is maintained.

Do not restrict protein excessively.
This worsens muscle loss, and muscle helps remove ammonia.
Aim for 1.2 to 1.5 grams per kilogram per day, preferably from plant sources, dairy, and lean protein.
Avoid starvation or skipping meals.

Zinc deficiency is common in cirrhosis and can worsen overt hepatic encephalopathy (HE) by impairing ammonia metabolism. Testing zinc levels is reasonable, and supplementation may help if low.

Be careful while using herbal supplements:

Use with extreme caution.
Many herbal products are unregulated and may worsen liver function or interfere indirectly.
Avoid unknown supplements unless approved by your hepatologist.
Continue Rifaximin, Lactulose, ascites control, hydration, and regular meals.

A few early signs of relapse include:

Sleep disturbance.
Poor focus.
Irritability.
Slowed thinking.

Seek care immediately if any of these signs appear.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.