Rifaximin for hepatic encephalopathy may improve liver transplant waitlist outcomes
Treatment with rifaximin for overt hepatic encephalopathy (HE) recurrence in patients on liver transplantation waitlist appears to significantly lessen hospital admissions associated with spontaneous bacterial peritonitis (SBP), ascites and variceal bleeding, a recent study has found. Furthermore, it helps reduce requirement for transplant prioritization and prolong time to hospital readmission.
“Patients with advanced cirrhosis are susceptible to unplanned emergency hospitalizations for a variety of reasons... These patients frequently progress to requiring high dependency or intensive care support and may at any time progress to developing acute-on-chronic liver failure,” the investigators said.
“This study provides real‐world data that demonstrate the potential value of rifaximin in reducing hospital admissions and length of stay within the advanced cirrhotic population awaiting liver transplantation,” they added.
The retrospective analysis included 101 HE patients listed for liver transplantation over a 2‐year period, among whom 66 were given rifaximin (mean age, 55 years; 73 percent male) and 35 were naïve (mean age, 49 years; 63 percent male) at listing. Concurrent use of lactulose was similar in the two groups and so was the median MELD score.
Compared with drug-naïve patients, those treated with rifaximin had significantly lower all‐cause admissions (elective admissions excluded; mean, 2.75 vs 6.30 per year; difference, −3.55; p=0.021), admissions related to complications of large volume ascites including SBP (mean, 0.77 vs 2.47 per year; difference, −1.70; p=0.010), and admissions with acute variceal bleeding (mean, 0.14 vs 1.03 per year; difference −0.89; p=0.014). [Aliment Pharmacol Ther 2019;doi:10.1111/apt.15326]
On multivariate regression analysis, rifaximin was independently associated with an increase in average days to readmission (adjusted effect estimate, 71 days, 95 percent CI, 3–139; p=0.040) and reduced likelihood of requirement for prioritization on the waiting list (odds ratio, 0.29, 0.09–0.93; p=0.037).
“Surprisingly, patients treated with rifaximin did not have a reduction in emergency encephalopathy‐related admissions per se. However, overall the absolute mean number of admissions attributed specifically to HE per year was low (1.00 per year in the rifaximin group vs 0.98 per year in the naïve group), and patients listed for liver transplantation for HE invariably had severe and treatment‐refractory encephalopathy,” the investigators noted.
“It is also important to say that patients with admissions for falls, sepsis and bleeding often developed HE during that admission so a reduction in all‐cause admissions on rifaximin indirectly reduced the likelihood of developing HE,” they continued.
However, the reduced rate of variceal bleeding, complications of ascites and all‐cause hospitalization in the rifaximin‐treated cohort did not impact mortality, which was low at 13.89 percent. This means that more patients would need to have been analysed in order to detect a mortality difference, as the investigators pointed out.
Despite the strengths of the current study, including active alcohol intake not being a confounder since patients had been abstinent for ≥6 months prior to listing, the “data should not be interpreted as a reason to change clinical practice but should act as a catalyst for further prospective studies in this patient group,” they said.