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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.


http://www.drugs.com/xifaxan.html, Xifaxan, Retrieved June 17, 2012, Drugs.com, 2012.

http://www.fiercebiotech.com/press-releases/fda-approves-xifaxan-550-mg-tablets-reduction-risk-overt-hepatic-encephalopathy-he-re, FDA Approves XIFAXAN® 550 Mg Tablets For Reduction In Risk Of Overt Hepatic Encephalopathy (HE) Recurrence, Retrieved June 17, 2012, FierceMarkets, 2012.

http://www.hcvadvocate.org/hepatitis/hepC/hepatic_encephalopathy.html, Hepatic Encephalopathy, Liz Highleyman, Retrieved June 17, 2012, Hepatitis C Support Project, 2012.

http://www.liverfoundation.org/abouttheliver/info/hepaticencephalopathy/, Hepatic Encephalopathy, Retrieved June 17, 2012, American Liver Foundation, 2012.

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Posted by Nicole Cutler L.Ac. on June 19, 2012

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  • 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.

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