Hepatic encephalopathy, a consequence of bacterial overgrowth and impaired ammonia metabolism, contributes to (as these authors say) nearly $2B in healthcare costs due to hospitalization in the United States alone. Typical, goal-oriented, modern therapy? Lactulose, a non-digestible sugar, resulting in increased bowel movement frequency.
These authors, appropriately, challenge established dogma – noting, perhaps, there are more effective strategies for clearing the bowels. As anyone who has undergone colonoscopy is aware, 4 liters of polyethylene glycol solution is the preferred – and highly-effective – bowel-cleansing method. These authors, therefore, compare standard lactulose therapy with a forced high-volume intake of PEG solution.
With 50 patients randomized in generally similar distribution to either lactulose or PEG, the PEG solution group more rapidly cleared mentation within 24 hours – with 21 of 25 randomized to PEG making at least 1 point improvement on the hepatic encephalopathy scoring algorithm, compared with 13 of 25 in the lactulose cohort. Victory! Of course, this sample is too small to truly account for any adverse effects. 8 serious adverse events occurred, include 3 deaths, although the authors feel none were related to the differences between treatment strategies. And, oddly, diarrhea was noted to be a more frequent adverse event in the PEG group.
Why is this odd? Because increased frequency of bowel movements is critical to treatment success in HES – and, frankly, if they’re not seeing enough stool output in the lactulose group, they might be doing it wrong. There’s no specific mention of outputs in the lactulose group, but, ideally, treatment of HES involves a rapid titration of lactulose to adequate stool volume, not a rigid treatment dose. As such, I might suggest this is a bit of a straw-man comparator between PEG and lactulose, with regard to tests of superiority.
But, I applaud simply thinking outside the box. Lactulose use has become somewhat dogmatic for the treatment of HES, when, clearly, the answer is just – poop, it doesn’t matter how.
Thanks to Rick Pescatore for forwarding this along.
“Lactulose vs Polyethylene Glycol 3350-Electrolyte Solution for Treatment of Overt Hepatic Encephalopathy”
http://www.ncbi.nlm.nih.gov/pubmed/25243839