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Dr. Jesudian:
This is CE on ReachMD, and I'm Dr. Arun Jesudian. Why do we need better treatment for hepatic encephalopathy?

Hepatic encephalopathy is a very burdensome condition in patients with cirrhosis, and it can lead to frequent hospitalizations and even rehospitalizations in patients who have been discharged following treatment for hepatic encephalopathy.

What this leads to is poor outcomes among this population. Patients who have a readmission within 30 days following an admission for overt hepatic encephalopathy have much worse short-term survival than those who are able to stay home and not be readmitted within that month. And also, each hospitalization is usually long and costly, so we end up spending quite a bit of money taking care of patients with overt hepatic encephalopathy in terms of these frequent hospitalizations. Healthcare utilization is increased considerably in the patient who has overt hepatic encephalopathy, particularly if they continue to have recurrent episodes, which is the nature of this condition.

And the first-line treatment that we use for overt hepatic encephalopathy is lactulose. And lactulose, although it is effective, is not perfect. Many patients are at risk of having a recurrent episode of hepatic encephalopathy while taking lactulose therapy.

Lactulose is difficult for patients to take in that there's no one fixed dose. We're usually telling our patients take as much as you need to have 2 to 4 soft bowel movements a day. So instead of having a prescription that tells you exactly how much to take, they need to titrate this themselves. And this is a patient who, again, is impaired in terms of their mental status, so they usually need someone to help them with that or to keep some track of how many bowel movements they've had.

Lactulose is also difficult to tolerate in that it is very sweet tasting. It causes bloating, and it, by design, causes diarrhea, which many patients find difficult to deal with, especially if they need to leave their home and be in a car, on a train, or transiting between places.

So we do need better therapies than lactulose to help prevent recurrent episodes of hepatic encephalopathy. We need better-tolerated therapies that patients can take reliably at a fixed dose and not skip doses because they're having some type of adverse event. That's an area for future research but also where we can use existing FDA-approved therapies like rifaximin, which has been shown to prevent recurrent episodes of overt hepatic encephalopathy in patients who have failed lactulose therapy, who have had a recurrent episode while taking lactulose.

Rifaximin has been shown to prevent both recurrent episodes of overt hepatic encephalopathy and hepatic encephalopathy-related hospitalizations in this population. And that's so important, again, because that improves patient outcomes but also decreases our healthcare utilization, as these hospitalizations are long and costly.

If you take one thing away, educate patients and caregivers on the goal of lactulose therapy, the goal number of bowel movements that that patient should be having every day, how to take it, and the importance to staying adherent to their lactulose and their rifaximin therapy.

Our time is up—short, sweet, and ready for practice. Thank you for listening.

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