Is Rifaximin effective for my overt hepatic encephalopathy?

Question

Hello doctor,

I am 52 years old and have been living with primary biliary cholangitis and cirrhosis for about eight years. I had my first episode of overt hepatic encephalopathy three weeks ago, and it was terrifying. I could not remember my own address, and my daughter found me wandering outside. After hospitalization and stabilization, I was discharged on Lactulose alone and told to follow up. However, I have been reading about Rifaximin as a maintenance therapy and wondering why I was not prescribed it. Is it only given after multiple episodes, or can it be started after the first one?

I am also on Ursodeoxycholic acid and Obeticholic acid for my PBC. Will there be any drug interactions? My job involves a lot of cognitive work. I am a school principal, and I am really concerned about how this will affect my ability to function. What long-term management plan would you suggest for someone in my situation?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your episode was overt hepatic encephalopathy (HE) due to cirrhosis from primary biliary cholangitis (PBC). HE occurs when toxins like ammonia affect brain function. The good news is that with proper prevention, many patients regain stable cognitive function.

Lactulose is first-line and essential after the first episode. Rifaximin is strongly recommended after a second episode, but many hepatologists now add it earlier, especially in patients with high cognitive demands, like your profession. It is reasonable to discuss starting Rifaximin now for added protection. Rifaximin is minimally absorbed and is safe with Ursodeoxycholic acid and Obeticholic acid. There are no significant interactions.

Continue Lactulose lifelong (two to three soft stools daily). Consider adding Rifaximin for secondary prevention. Maintain normal protein intake and avoid starvation. Prevent constipation, dehydration, and infections. Avoid sedatives and alcohol. Monitor sodium, kidney function, and liver status regularly.

Most patients recover well enough for cognitive work once overt hepatic encephalopathy (HE) is controlled. Return gradually and monitor concentration. Early warning signs include sleep reversal, forgetfulness, and slowed thinking. Seek care early.

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

Thank you.