ISHEN Releases Consensus Statement on Unanswered Questions in Hepatic Encephalopathy Management

The International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) has published consensus statements on the management of hepatic encephalopathy (HE), namely regarding fitness to drive, testing strategies for covert or minimal HE, therapeutic options for HE, and recommendations on nutrition and patient-reported outcomes. These statements were published in the American Journal of Gastroenterology.

Members of the ISHEN Executive Committee, Organizing Committee and other researchers developed key clinical questions regarding the day-to-day management of HE. They discussed these questions in relation to existing information present in current medical literature. Concerning patients with HE and their fitness to drive, ISHEN members agreed that each clinic visit should include a short, non-judgmental discussion about the patient’s driving history. Patients with HE who are active drivers and have cirrhosis and/or have had an episode of overt HE (OHE) in the past 3 months should be cognitively evaluated. Patients and caregivers should be given oral and written advice to avoid driving if they have had a recent OHE episode. A formal driving reassessment should be scheduled for any affected patients who wish to resume driving.

The ISHEN members also made consensus statements on minimal HE (MHE) and covert HE (CHE) testing. According to the consensus, a patient’s performance on nationally and culturally validated neuropsychological tests should be used to guide the diagnosis of MHE/CHE. The ISHEN members discouraged the combination of ≥2 diagnostic tests, as clinical evidence has yet to substantiate this practice in improving the accuracy of diagnosis. Ideally, patients with cirrhosis should be offered MHE/CHE screening, but screening for MHE can be restricted to patients who have potential issues related to their fitness to work or drive.

Treatment and prophylactic strategies for HE and OHE were also discussed in the consensus statement. According to the committee members, therapy should be considered on a case-by-case basis once CHE/MHE is diagnosed, as patients with these conditions are at risk of OHE. They recommend lactulose for the treatment of MHE “as a trial run” for patients who test positive. ISHEN members also came to a consensus that precipitating factors for HE should be identified and treated in acute OHE episodes.

The ISHEN also recommends lactulose as the first treatment of choice, which can be administered orally or via enema, depending on the severity of HE. An alternative or additional treatment for patients who are nonresponsive to lactulose could include intravenously administered L‐ornithine‐L‐aspartate. Lactulose is also recommended as a prophylactic therapy for recurrence of OHE following an initial episode. After the second episode, the ISHEN members agreed that rifaximin can be used as an add-on to lactulose for the prevention of recurrent OHE episodes.

In terms of nutrition, the ISHEN recommends supplementation with branched-chain amino acids for the prevention of HE recurrence. They recommended personalized and practical nutrition counseling, and that clinicians should work with patients on how best to achieve caloric and protein targets. Patients with HE should avoid protein restriction.

The ISHEN members noted that additional efforts should be made by the clinician to obtain patient- “and caregiver-reported outcomes at diagnosis and intermittently over time to determine when optimization of therapy or additional supports may be required.”

Reference

Bajaj JS, Lauridsen M, Tapper EB, et al. Important unresolved questions in the management of hepatic encephalopathy: An ISHEN consensus [published online March 30, 2020]. Am J Gastroenterol. doi: 10.14309/ajg.0000000000000603