Effects of rifaximin versus nonabsorbable disaccharides in hepatic encephalopathy

Abstract

Background: Lactulose is recommended as secondary prophylaxis after the initial episode and rifaximin as an add-on to lactulose for preventing recurrent episodes of hepatic encephalopathy (HE) after the second episode. However, the relative merits of rifaximin vs nonabsorbable disaccharides (NADs) on overt and minimal HE (MHE) are debated.Aim: This study aimed to perform a meta-analysis of randomised controlled trials (RCTs) on rifaximin vs NADs in HE.Methods: Electronic and manual searches were performed. The results presented as risk ratios or standardised mean difference with 95% confidence intervals. Sensitivity analyses were performed to evaluate the risk of bias and sources of heterogeneity. Results:In total, 8 RCTs were included, and only 7 RCTs with 386 patients were merged for meta-analysis. Meta-analyses showed that rifaximin appears better at reducing the blood ammonia levels compared with NADs, and that both rifaximin and NADs were well tolerated with few adverse effects. There were however, no significant differences in clinical efficacy or ability to reverse MHE between the two treatments. Most of the included studies were of low quality with a high risk of bias, leading to a low statistical power. Conclusions:Rifaximin had a beneficial effect on blood ammonia levels compared with NADs, and both rifaximin and NADs have good tolerance. However, no difference in the clinical efficacy and MHE reversal was observed between them.

Efficacy and Safety of Rifaximin Versus Placebo or Other Active Drugs in Critical ill Patients With Hepatic Encephalopathy

“…To date, several meta-analyses have assessed the therapeutic effects of rifaximin vs. control interventions on patients with HE (Jiang et al, 2008;Eltawil et al, 2012;Hu and Tang, 2013;Wu et al, 2013;Kimer et al, 2014;Wang, 2015;Zhuo et al, 2019). These systematic reviews included 3-19 trials (n 264-1,370 patients) that were published between 1985 and 2017.…”

“…To date, 10 meta-analyses including seven systematic reviews (Jiang et al, 2008;Eltawil et al, 2012;Hu and Tang, 2013;Wu et al, 2013;Kimer et al, 2014;Wang, 2015;Zhuo et al, 2019) and three network meta-analyses (Zhu et al, 2015;Cai et al, 2018;Dhiman et al, 2020), have been published on efficacy or safety of rifaximin for HE treatment. Most of these meta-analyses focused on one control arm or one type of HE, and their results seem equivocal and inconsistent.…”

Is rifaximin better than nonabsorbable disaccharides in hepatic encephalopathy?

“…Two previous meta-analyses were not strict enough in the review of included articles. [ 12 , 13 ] Articles in which rifaximin was in combination with other drugs, andconference publications with only abstracts were also included in their studies, which could not accurately evaluate the efficacy of rifaximin. The present study strictly reviewed the included studies, which ensured the credibility of this study, and the effects of rifaximin and NADs in HE were analyzed using appropriate statistical methods.…”

“…The present meta-analysis was conducted to compare the efficacy of rifaximin and NADs in the treatment of HE. Two previous meta-analyses were not strict enough in the review of included articles [12,13] . Articles in which rifaximin was in combination with other drugs, andconference publications with only abstracts were also included in their studies, which could not accurately evaluate the efficacy of rifaximin.…”