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Dr. Rahimi: 
Hi, I'm Dr. Robert Rahimi, a Transplant Hepatologist at Baylor University Medical Center. And I'm here to talk about HElp! The AASLD Guidelines Related to Diagnosis of HE. So, the important part is we're going to talk about grade I, A, 1 guidelines. And what that means is randomized controlled trials that are high quality and evidence-based medicine that will likely change in the future based on the current research that we already know.

Now, looking at hepatic encephalopathy, overall it's a reversible neuropsychiatric abnormality in patients with chronic liver disease, usually that have portal hypertension after you have excluded neurologic or metabolic ideologies. And there is a covert versus overt entity.

The first part of the guidelines that is secondary prophylaxis after an episode of overt HE is recommended. Now, to get into this, you have to know that HE is a clinical diagnosis. It's based on asterixis and disorientation in patients that have underlying chronic liver disease or portal hypertension, specifically cirrhosis. If you look at the secondary prophylaxis, lactulose is what is the standard of care. And we use this specifically to titrate to 2 to 4 bowel movements a day. It causes the osmotic diarrhea, and it catabolizes bacterial flora to short chain fatty acids as a non-absorbable disaccharide. And this is what secondary prophylaxis is for the first AASLD guideline.

Now, when you look at the next grade I, A, 1, we look at rifaximin as an effective add-on therapy to lactulose in prevention of overt HE recurrence. And the founding study for this was by Bass et al and colleagues where the New England Journal study looked at overall rifaximin, an add-on therapy to lactulose after a patient has failed lactulose. And this overall decreased hospital readmissions. In this slide, you can see that the breakthrough episodes of HE in patients that had rifaximin as added on therapy showed a 22.1% versus those that got placebo at 45.9% breakthrough episodes. And HE-related hospitalizations were significantly decreased at 13.6% versus 22.6%.

Looking at the third guideline for grade I, A is rifaximin is add-on to lactose is recommended for prevention of recurrent episodes of HE after the second episode that has occurred. And the initial study that was done to look at placebo lactulose, looked at patients that got lactulose versus placebo, they had a decrease in HE overall.

Going back to the Bass et al study, lactulose with additive rifaximin therapy resulted in decreased hospital readmission.

If you look at further HE grades, and you look at overall nutritional status, two other topics are very important. The daily energy intake should be 35 to 40 kcal/kg ideal body weight, and daily protein intake should be considered specifically for this catabolic state, and it should be 1.2 to 1.5 g/kg per day. And a small meal or liquid nutrition supplements should be distributed throughout the day, and late night snack should be offered for these patients.

And the takeaway points for the AASLD guidelines that we reviewed today from the grade I, A, 1, is that secondary prophylaxis after an episode for overt HE is recommended. Rifaximin is an effective add-on therapy to lactulose for prevention of overt HE recurrence. And rifaximin, as an add-on to lactulose is recommended for prevention of recurrent episodes of HE after a second episode.

Thank you, everyone, for joining me, and I hope this has been educational.

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