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Probiotics Good Second Option for Preventing Recurrence of Hepatic Encephalopathy

 

According to the current done in INDIA, hepatic encephalopathy (HE) develops in 50% to 70% of patients with cirrhosis. Its occurrence is an indicator of a poor prognosis, with projected 1- and 3-year survival rates of 42% and 23%, respectively, without liver transplantation. Increases in the frequency and severity of HE episodes predict an increased risk for death.


Lactulose has been shown to be useful in the treatment of acute, chronic, recurrent portosystemic HE and in the secondary prophylaxis of HE. Studies have shown improvement in minimal HE (MHE) with the use of probiotics and reduction of overt low-grade HE during follow-up. There is also a high prevalence of cognitive abnormalities assessed by psychometry tests after clinical recovery of HE. No definitive recommendation or consensus on secondary prophylaxis of HE is yet available; therefore, the use of lactulose or probiotics for the prevention of HE is not yet routine practice.
This open-label trial compares the use of lactulose, probiotics, and no treatment on the recurrence of HE among patients with cirrhosis and a past episode of HE.


Lactulose is known to be effective for secondary prophylaxis of HE, but it has side effects, particularly diarrhea, that some patients can't tolerate. Rifaximin is also an option, but it poses a risk of gastrointestinal infection with Clostridium difficile when taken long term.
This study evaluated 235 cirrhotic patients who had recovered from HE and were randomly assigned to no therapy (n=78); lactulose 30 mL three times daily (n=80); or three capsules daily of the commercially available high-potency probiotic mixture (n=77). Each probiotic capsule contains 112.5 billion viable lyophilized bacteria — specifically, four strains of Lactobacillus, three strains of Bifidobacterium and one strain of Streptococcus salivariussubsp. thermophilus (i.e., S. thermophiles).


There was a significant difference between lactulose and no treatment (p=0.001) and between probiotics and no treatment (p=0.02) but no difference between lactulose and probiotics (p=0.349), according to the investigators. There were no between group differences in rates of readmission for causes other than HE (p=0.134) or deaths (p=0.56).


Ammonia is been regarded as the key precipitating factor in HE, and lower ammonia levels have been shown to improve HE. In the current study, there was a significant decrease in ammonia levels (from baseline to three months) with lactulose (p=0.03) and probiotics (p=0.04) but not in the control group (p=0.597).
The researchers acknowledge that the precise mechanisms of action of probiotics in liver disease or HE are uncertain.

 

Link:
http://www.medscape.org/viewarticle/766955?src=cmemp