Rifaximin is Efficacious in the Treatment of Chronic Overt Hepatic Encephalopathy: A UK LIVER MULTI-CENTRE EXPERIENCE

TY - JOUR

T1 - Rifaximin is Efficacious in the Treatment of Chronic Overt Hepatic Encephalopathy: A UK LIVER MULTI-CENTRE EXPERIENCE

AU - Patel, Vishal C.

AU - Orr, James

AU - Sturgeon, John

AU - Habtemariam, Z

AU - Preedy, H

AU - Richardson, P

AU - Aspinall, R

AU - Hudson, Mark

AU - Shawcross, Debbie

PY - 2014

Y1 - 2014

N2 - Introduction Rifaximin-a is a non-absorbable antibiotic increas- ingly being used for the secondary prevention of recurrent overt hepatic encephalopathy (HE) in the UK. The therapeutic mecha- nism of rifaximin has yet to be elucidated, with reduction in gut ammonia production postulated. We undertook a UK multi- centre retrospective audit of patients receiving rifaximin therapy for HE in 4 hospitals, two of which are liver transplant units, with the aim of assessing tolerability, impact on HE/liver disease severity and hospitalisation rates. Methods Patient demographics, concurrent therapy, Child Pugh, MELD, UKELD and number of hospital admissions were col- lected 3 months prior to initiation of rifaximin therapy and then 3 months following treatment. Results 170 patients were identified (mean age 57yrs±12; 68% male) over the period 05/2010–03/2013. Three month post treatment outcome data were available for 73 patients (43%); 53 patients (31%) died during the 3 month follow up period. Aver- age duration of treatment was 79 ± 121 days, with therapy well tolerated in 97.6% of patients. 74% were taking concomitant lactulose with 23.5% on rifaximin monotherapy. No cases of Clostridium difficile infection were reported. The most common aetiology was alcohol 90/170 (53%) with 25 (28%) actively drinking . 36 patients (21%) were trans- planted during the audit period. The predominant HE pheno- type was episodic overt (67%), with persistent overt featuring in 20% and the Parkinsonian phenotype in 6%. Admission data were available for 143/170 (84%) patients with a total of 444 admissions in the 3 months prior to therapy (average admission length 23 ± 25 days). The hospitalisation rate per patient fell significantly from 2.7 ± 3.2 to 1.0 ± 1.8 admissions in the 3 months following initiation of therapy (p < 0.0001) [Figure i]. HE grade improved significantly following therapy (p < 0.0001) [Figure ii]. Child Pugh score fell significantly following therapy (p < 0.0001) [Figure iii], as did MELD and UKELD scores: 15 ± 7 vs. 13 ± 5 (p < 0.03) and 55 ± 6 vs. 51 ± 5 (p < 0.02), respectively. This is noteworthy as the MELD score does not include HE as a parameter and is based on bilirubin, INR and creatinine. Conclusion Our UK multi-centre experience is that rifaximin is well-tolerated and an efficacious treatment for the secondary prevention of HE. Rifaximin significantly reduced both hospital re-admission rates after 3 months treatment, impacting signifi- cantly on the NHS resource burden of HE, and reduced overall liver disease severity raising the possibility that its therapeutic effect may extend beyond reducing gut ammonia production.

AB - Introduction Rifaximin-a is a non-absorbable antibiotic increas- ingly being used for the secondary prevention of recurrent overt hepatic encephalopathy (HE) in the UK. The therapeutic mecha- nism of rifaximin has yet to be elucidated, with reduction in gut ammonia production postulated. We undertook a UK multi- centre retrospective audit of patients receiving rifaximin therapy for HE in 4 hospitals, two of which are liver transplant units, with the aim of assessing tolerability, impact on HE/liver disease severity and hospitalisation rates. Methods Patient demographics, concurrent therapy, Child Pugh, MELD, UKELD and number of hospital admissions were col- lected 3 months prior to initiation of rifaximin therapy and then 3 months following treatment. Results 170 patients were identified (mean age 57yrs±12; 68% male) over the period 05/2010–03/2013. Three month post treatment outcome data were available for 73 patients (43%); 53 patients (31%) died during the 3 month follow up period. Aver- age duration of treatment was 79 ± 121 days, with therapy well tolerated in 97.6% of patients. 74% were taking concomitant lactulose with 23.5% on rifaximin monotherapy. No cases of Clostridium difficile infection were reported. The most common aetiology was alcohol 90/170 (53%) with 25 (28%) actively drinking . 36 patients (21%) were trans- planted during the audit period. The predominant HE pheno- type was episodic overt (67%), with persistent overt featuring in 20% and the Parkinsonian phenotype in 6%. Admission data were available for 143/170 (84%) patients with a total of 444 admissions in the 3 months prior to therapy (average admission length 23 ± 25 days). The hospitalisation rate per patient fell significantly from 2.7 ± 3.2 to 1.0 ± 1.8 admissions in the 3 months following initiation of therapy (p < 0.0001) [Figure i]. HE grade improved significantly following therapy (p < 0.0001) [Figure ii]. Child Pugh score fell significantly following therapy (p < 0.0001) [Figure iii], as did MELD and UKELD scores: 15 ± 7 vs. 13 ± 5 (p < 0.03) and 55 ± 6 vs. 51 ± 5 (p < 0.02), respectively. This is noteworthy as the MELD score does not include HE as a parameter and is based on bilirubin, INR and creatinine. Conclusion Our UK multi-centre experience is that rifaximin is well-tolerated and an efficacious treatment for the secondary prevention of HE. Rifaximin significantly reduced both hospital re-admission rates after 3 months treatment, impacting signifi- cantly on the NHS resource burden of HE, and reduced overall liver disease severity raising the possibility that its therapeutic effect may extend beyond reducing gut ammonia production.

KW - Rifaximin

KW - Hepatic Encephalopathy

KW - Cirrhosis

M3 - Meeting abstract

SN - 0017-5749

VL - 63

SP - A14

JO - Gut

JF - Gut

IS - Supplement 1

M1 - OC-029

T2 - British Society of Gastroenterology 2014 Liver Section Free Papers Oral Presentation

Y2 - 16 June 2014 through 19 June 2014

ER -