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Drugs used in Hepatic encephalopathy

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prabin kumar bam, introduction of hepatic encephalopathy, treatment measures, drugs used in hepatic encephalopathy, management of hepatic encephalopathy, role of lactulose, role of antibiotics (Rifaximin), nutrition, liver transplantation, prophylaxis,

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Drugs used in Hepatic encephalopathy

  1. 1. DRUGS USED IN HEPATIC ENCEPHALOPATHY Prabin Kumar Bam Chitwan Medical College Bharatpur, Nepal 2/1/2019 1
  2. 2. Hepatic Encephalopathy • Hepatic encephalopathy is a brain dysfunction caused by liver insufficiency and/or portosystemic shunt. • In this disorder, nitrogenous waste products (chiefly ammonia) accumulates in systemic circulation. Then they cross blood-brain barrier, enter brain and affect it. • Symptoms: Personality changes, intellectual impairment, decresed consciousness and coma in the advanced stage. 2/1/2019 2
  3. 3. Treatment measures Hospitalization Maintain ABC Remove the cause and precipitating factor. IV dextrose, saline and Inj. Thiamine. Reduce ammonia load. Proper nutrition Inj. Vitamin K Liver transplantation. 2/1/2019 3
  4. 4. Non absorbable disaccharides • Lactulose • Lactilol • First line drug therapy. 2/1/2019 4
  5. 5. • Mechanism of Action: Disaccharides → monosaccharides → volatile fatty acid (VFA) + H ions. VFA : promotes bacterial growth, which form bulk. H ions: decrease pH which causes; 1. ↓ synthesis & absorption of ammonia. 2. ↑movement of ammonia from blood to GIT. 2/1/2019 5
  6. 6. • Dose: 15- 30 ml given twice a day to induce 2-3 soft bowel movements daily. Can be given as rectal enema. • Adverse effects: Bloating, hypokalemia, aspiration and dehydration. 2/1/2019 6
  7. 7. Antibiotics - Rifaximin • MOA: Selectively eliminates urease producing bacteria. • It is given in combination with lactulose. • Dose: 550mg/ 12hr. • AE: abdominal pain, flatulence, headache and constipation. • Other antibiotics like Metronidazole and Neomycin can also be used. 2/1/2019 7
  8. 8. Oral branched-chain amino acids (BCCAs) • Increase the manifestations of episodic HE. • Leucine → stimulate liver regeneration. • They increase albumin synthesis and improve immunity. 2/1/2019 8
  9. 9. L- ornithine L- aspartate (LOLA) • Can be given IV (preferred) or oral. • They help in detoxification of ammonia by promoting metabolic pathways and urea cycle. 2/1/2019 9
  10. 10. Zinc supplementation • Zn deficiency is common in patients with liver cirrhosis. • Zinc increases the activity of an enzyme in the urea cycle (ornithine transcarbamylase). And hence helps in improvement of HE. 2/1/2019 10
  11. 11. Other ammonia lowering agents • Probiotics • Sodium benzoate • Glycerol phenyl butyrate 2/1/2019 11
  12. 12. • Approximately 75% of patients with HE suffer moderate to severe protein-calorie malnutrition. • So, vegetable proteins should be given (60- 80g/day). They are well tolerated than animal proteins. • High glucose diet (35-40kcal/kg wght.). 2/1/2019 12 Nutrition
  13. 13. Liver transplantation • Recommended in recurrent HE and treatment resistant cases. • It results in complete resolution of HE. 2/1/2019 13
  14. 14. Prophylaxis  Combined Lactulose and Rifaximin should be used. 2/1/2019 14
  15. 15. References • Harrison’s Principles of Internal Medicine. • Davidson’s Principles and Practice of Medicine. 2/1/2019 15
  16. 16. 2/1/2019 16

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