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Dr. Bloom: 
Hi, I'm Dr. Patty Bloom. I'm an Assistant Professor and Transplant Hepatologist at the University of Michigan. And today I'll be talking about how do I prevent future hospitalizations from hepatic encephalopathy, or HE?

So, here are the key strategies. The first is to do our best to prevent the progression of liver disease. So, if a patient has viral hepatitis, that means treating with antivirals. If our patient has alcohol use disorder, it means connecting them with resources to treat their alcohol use disorder, including medications like naltrexone, acamprosate, baclofen, gabapentin. And really treating the underlying cause of the liver disease will prevent hepatic encephalopathy.

Seek out and correct underlying triggers is another key strategy. So, some of those underlying triggers include dehydration; that's a really common one, especially for our patients who are on diuretics or are restricting their fluid intake. The dehydration is a really, really common trigger for hepatic encephalopathy. And oftentimes, people will improve even just with a liter of saline or colloid solution.

Another trigger is constipation, so making sure that patients are having regular bowel movements. Of course, certain medications, opiates, benzodiazepines can trigger hepatic encephalopathy, so try to avoid those as much as possible.

We should certainly be prescribing lactulose after the first overt HE episode and ask patients to titrate to 2 to 4 bowel movements a day. We don't go over that because again, if someone is having more frequent bowel movements, they might develop dehydration, which then can actually trigger encephalopathy.

And rifaximin is recommended after the second episode of overt hepatic encephalopathy. And when used in conjunction with lactulose, it definitely prevents future HE episodes.

So, to dig into some of the details more, lactulose really helps. Don't just feel like it's what we've been doing for decades, we have to give it a try. It really helps to treat hepatic encephalopathy. In this large meta-analysis with some high-quality evidence, they found that the number needed to treat of patients getting lactulose to treat their hepatic encephalopathy was only 5. And then the number needed to treat to save a life to prevent mortality was 20. So, lactulose really is this incredible and helpful medication for hepatic encephalopathy.

The goal is not to induce diarrhea. Okay? I think, you know, a lot of us think maybe if you're having more bowel movements and you're getting rid of more ammonia and more toxins, but actually several studies have now shown that the number of bowel movements actually didn't predict readmission and didn't correlate with cognitive tests and that when people are having too many bowel movements, it can actually dehydrate them and lead to more encephalopathy.

So, when to start rifaximin? The large phase 3 multicenter trial that proved the efficacy of rifaximin, they started the medication after the second overt HE episode. So, that is what the, you know, the technical drug indication is for, after the second episode. Although, I will just say there is some benefit to starting it after even one overt HE episode. And this is what many people are doing, especially if they can get it covered for their patients.

Finally, I do recommend a high protein diet. The body's muscles play a huge role in detoxifying the blood, especially from ammonia. And if people are avoiding protein, they're more likely to become sarcopenic and their muscles atrophy. So, actually eating a high protein diet is very beneficial for patients with encephalopathy. And I know that's a change in the guidelines from decades ago, we used to restrict people's protein because ultimately protein does get broken down into ammonia. But we now have really solid evidence that protein is important for our patients with cirrhosis and HE.

So, very few patients with HE are consistently taking lactulose and rifaximin. These studies here are showing that the numbers of patients actually using their lactulose and rifaximin appropriately, may be somewhere around 5%, which is just incredibly low. And many of them are using benzodiazepines and opiates. So, a key here is medication counseling, make sure you know what your patients are actually taking, and trying to increase their use of lactulose or rifaximin, and decrease their use of sedating medications as possible.

And finally, I'll just mention that continuity of care is key for patients with HE, especially in terms of preventing readmissions. Having close follow-up after discharge, using patient navigators, using perhaps apps, pharmacists, telephone calls, to really stay connected to patients after discharge can be incredibly helpful to their overall management.

So, I hope that gave you some useful strategies. Thank you for listening.

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