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Lactulose and Xifaxan – Drugs for Advanced Hep C Management

Nicole Cutler L.Ac. June 19, 2012

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If chronic Hepatitis C escalates to advanced disease that includes hepatic encephalopathy, Lactulose and Xifaxan could be useful medications.

For many people living with advanced Hepatitis C infection, hepatic encephalopathy (HE) is one of the more challenging problems to manage. HE occurs frequently in those with cirrhosis as a result of end-stage liver disease, a potential consequence of chronic Hepatitis C infection. Causing disruptive emotional and physical symptoms, hepatic encephalopathy may be helped by several medications – the most popular of which are Lactulose and Xifaxan.

What Is Hepatic Encephalopathy?

A brain disorder caused by liver damage, hepatic encephalopathy occurs when the liver cannot remove toxic chemicals, such as ammonia, from the blood. These chemicals then enter the brain and interfere with its ability to function optimally.

Those with chronic Hepatitis C become susceptible to HE when a heavily damaged liver is unable to filter toxins from the blood or when blood flow through the liver is blocked. Although few individuals with Hepatitis C develop full-blown hepatic encephalopathy, some degree of brain impairment may occur in as many as three-quarters of those who have advanced liver cirrhosis.
The severity of hepatic encephalopathy is measured on a five-point scale:

  1. Grade 0 – indicates minimal changes in memory, concentration, intellectual function and coordination.
  2. Grade 1 – marked by increasing confusion and disorientation, forgetfulness, impaired intellectual function, decreased attention, agitation, lack of coordination and disturbed sleep patterns (often day-night reversal).
  3. Grade 2 – involves drowsiness, disorientation, loss of ability to perform mental tasks, personality and behavior changes and increased motor symptoms.
  4. Grade 3 – involves lethargy, somnolence (sleeping), loss of mental function, profound confusion, amnesia, aggression, abnormal tremors and hyperactive reflexes.
  5. Grade 4 – indicates coma. In this stage, respiratory or cardiovascular failure may occur.

A high level of ammonia in the blood is believed to be largely responsible for hepatic encephalopathy. As a byproduct of the digestion of proteins by bacteria in the intestines, ammonia is normally metabolized into urea by the liver and excreted by the kidneys as urine. High levels of ammonia appear to alter the balance of chemicals in the brain. Although not all patients with HE have elevated blood ammonia levels, this theory is supported by the fact that medications used to reduce ammonia levels usually improves encephalopathy symptoms.

HE Treatment

Because hepatic encephalopathy can be a medical emergency, those with chronic Hepatitis C with cirrhosis are typically guided towards keeping HE at bay. There is no question that the best way to reduce the risk of HE is to prevent, treat and manage liver disease. However, individuals with chronic hepatic encephalopathy need to minimize the level of toxins in their blood to prevent an emergency situation.

For chronic HE, doctors may recommend different combinations of the following:

  • Dietary changes focused on consuming specific amounts of protein.
  • Taking Lactulose and/or Xifaxan 550.
  • Preventing and treating constipation.
  • Prescribing other medications to remove blood from the intestines or treat infections.

Xifaxan and Lactulose

The primary goal of HE treatment is to eliminate or neutralize toxins such as ammonia in the intestines. The first line of treatment is Lactulose, a synthetic, non-digestible sugar that treats constipation. Lactulose is broken down in the intestines into products that pull water out from the body and into the colon. While this water softens stools, Lactulose also reduces blood ammonia levels by drawing ammonia out of the blood into the colon where it is removed from the body. While being fairly safe and effective, Lactulose causes diarrhea.

By reducing bacteria in the intestines that make toxins the liver can’t process, Xifaxan (rifaximin) 550 mg is an antibiotic that can help reduce the risk of HE recurrence in adults with liver failure and reduce someone’s chances of being hospitalized because of hepatic encephalopathy. According to the company’s website, Xifaxan 550 is often prescribed together with Lactulose for managing HE. Unfortunately, Xifaxan 550 is not always covered by health insurance companies, is extremely pricey and, like most drugs, is associated with side effects such as:

  • Bloating, gas and stomach pain
  • Defecation urgency
  • Feeling like the bowels are not empty
  • Nausea, vomiting and constipation
  • Headache, fatigue and dizziness
  • Swelling in the hands, feet or torso

HE is one of the more frustrating conditions that can result from chronic Hepatitis C infection. Because it can dramatically detract from quality of life and progress quickly to an emergency situation, physicians take hepatic encephalopathy seriously. Especially because there are helpful medications available – like Lactulose and Xifaxan 550 that can help manage HE – discussing any changes in mental status or intellectual functioning with a doctor is crucial for those with advanced liver disease. Taking these drugs may not eliminate fatigue, forgetfulness or confusion, but they are valuable to susceptible individuals for preventing hepatic encephalopathy from progressing to one of its later (and dangerous) stages.

References:, Xifaxan, Retrieved June 17, 2012,, 2012., FDA Approves XIFAXAN® 550 Mg Tablets For Reduction In Risk Of Overt Hepatic Encephalopathy (HE) Recurrence, Retrieved June 17, 2012, FierceMarkets, 2012., Hepatic Encephalopathy, Liz Highleyman, Retrieved June 17, 2012, Hepatitis C Support Project, 2012., Hepatic Encephalopathy, Retrieved June 17, 2012, American Liver Foundation, 2012.



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  • Elfekyss

    great thanks for goolden information

  • Gingern

    This is a very informative article, direct and to the point. My sister takes both these drugs for HE resulting from advanced hep C. The results are dramatic as the article states and she has not suffered from ammonia build-up and related problems for quite some time now. My only concern is about the possibly indefinite use of the antibiotic Xifaxan. Can you take an antibiotic (550 mg) every day for God knows how long? It just seems like it would wipe everything out after awhile – good AND bad bacteria – and that might create it’s own set of problems eventually???

    • Wowjanetmulvaney

      Could you tell me how you purchase the drug Zifaxa, my brother really bad with HE we need to get some for him

      • Ginger

        You have to have a doctor’s prescription for Xifaxin. That is the only way I know of and I’ve never heard of it being sold on the blackmarket either…

  • Carolyn Homs

    The xifaxen and not the lactulose work for my husband. His HE is horrible getting to level 3 at times and the xifaxen knocks it right out. his ammonia levels are not very high when he has these level 3 episodes after skipping medicine. his potassium levels are off and some vitamin deficiencies too, including too much protein. sometimes we need to look closer as one size does not fit all and the human brain can be more complex than one factor and one medicine.

  • menotq

    great.go from constipation to diarrhea..just what does that do for my depression.I’ll keep waiting for something better. Thanks but no thanks!

    • Oldcardude001

      I have been taking the Xifaxan50 for 2 tears. I never get disrrea and it does help. I also eat about 3 ounces of pitted prunes every night. I go t the toilet on a regular basis and feel completelt relieved. I have had Hep C for 35 years and cirrosis about 8 years. This is the first combination (prunes ans Xifaxan) that have made me feel better. I just came back from a 2 week H E episode and barely remember anything. My caregiver said I was mean and I managed to drive about 85 5 OF THE PEOPLE i KNOW OUT OF MY LIFE BECAUSE OF MY BAZAAR BEHAVIOR. i THINK i WILL BE OKAY NOE BECAUSE OF THE CORRECT COMBINATION.

      • Prodigal son anyone?

        We lost touch with a son who just doesn’t like his dad like this and doesn’t want to understand.

    • PatriceZZZZZZZZZZZZZ .

      Not everyone gets diarrhea.If already constipated it may just make one regular. On a very high dose I went 6 x a day,but no surprises. The ammonia build up makes depression worse. maintenance dose is lower than emergency dose. It cleared most of my neuropathy, I can wear shoes again and don’t have screaming burning pain in my feet. It is very sweet, chase it with water or juice. It clears up brain fog and eliminates tremors. at least in me.

  • HE is no fun

    One footnote – my husband recently took the car out and wrecked it while having an HE blackout. He remembered nothing and spent 5 days in hospital for an infection from ascites ( swelling & fluid). Consider asking your caregivers to hide the keys when you fall into this pattern. Taking meds consistently may save your life and others. HE can come on overnight so be careful.

  • Tassya

    I was in my garden playing with my dog, then I appeared to be in Hospital. It was the most scare experience in my life. It seems that I went into coma, and barking of my dog alarmed my next door neighbor who tried to revive me, but I did not respond, therefore ambulance was called. I spent a few days in hospital and now I am terrified that that episode so-called hepatic encephalopathy will return. I was prescribed to take 6 tablets of rifaximin which is 1 thousand and two hundred mg. per a day and lactulose. I feel that may be it is too much. I was not explained why so much and for how long. What shall I do?

  • Mom

    I just love how my mom’s insurance company and Medicare can decide that they don’t want to cover her Xifaxan. She’s been on lactulose, and in and out of the hospital due to high ammonia levels. Tell me that it wouldn’t be cheaper to cover the meds than cover than hospital bills. Or, maybe I should be angry at the pharmaceutical company for being more concerned for money than the lives being adversely affected by such a costly medicine.

    • Dawn

      I couldn’t agree more. My dad is willing to go on hospice for this same condition along with three other major organs failing. But the Xifaxan along with Lactulose is keeping the espisodes under control between episodes. Now hospice won’t cover the Xifaxan even though it treats his HE symptoms of cirrhosis of the liver. Medicare won’t cover this med if on Hospice. In between a rock and a hard place……

  • moe

    My son has this problem doesnt want to listen if we try to tell him his levels r goin up. I dont know what to do anymore

  • phyllis pousson

    MY HUSBAND WILL START HIS XIFIXAN TOMORROW, HIS LEVELS ARE NOT THAT HIGH LAST BLOOD WORK THEY WERE 42 BUT HIS SYMPTHONS ARE REALLY BAD, I think he has deminitia or alz but his dr said a naralogist will not c him till his levels are normal his levels have been high since 2015 HOW HIGH ARE YOUR LEVELS?????????????