- Current Standard of Care: Two major medications for HE treatment are lactulose and rifaximin. Lactulose is a non-absorbable disaccharide that reduces ammonia production in the gastrointestinal system. Rifaximin is a non-absorbable antibiotic that is typically used as an add-on to lactulose.
- Challenges in Treatment: Prescription drug coverage, especially for rifaximin, can be costly for patients without coverage. Maintaining effective dosing of lactulose can also be challenging due to adherence and effective dosing issues. Agitation in patients with altered mentation poses risks, and selecting agents for control requires consideration of underlying liver dysfunction.
- Challenges in the Transition of Care: Prescription drug coverage remains a challenge during the transition from inpatient to outpatient care. Identification of barriers, navigating prior authorization, and ensuring documentation support for medication indications are crucial. Education for patients and caregivers on medication purpose, administration, and when to contact health care teams is important.
- Impact of Lack of Outpatient Access to Rifaximin: Lack of access to rifaximin can hinder effective HE treatment, leading to recurrence, readmissions, and complications. Patients unable to maintain prescription drug access may be at risk for complications like falls.
- Challenges With Lactulose Acceptance and Titration: Lactulose is given as a liquid, which may pose a barrier for some patients. Titration is essential to achieve therapeutic effects, but it requires careful dosing to avoid under or overdosing.
- Inappropriate Use of Ammonia Levels in Treatment: Ammonia levels may not always guide treatment decisions, as clinical improvement is prioritized over specific lab values. The initiation and titration of therapy are not solely based on ammonia levels.
- Alternative Rifaximin Dosing Strategy: An evaluation of alternative rifaximin dosing strategies for cost savings considered lower doses but maintained the current dosing due to operational concerns.
- Duration of Therapy Considerations: Consideration of the duration of therapy, especially for patients listed for transplant. Interdisciplinary discussions and notifications are essential when discontinuing therapy.
- Pharmacist's Role in Patient Care: Pharmacists play a crucial role in patient education, medication evaluation, and addressing changes in mentation. They are well-positioned to identify deprescribing opportunities and contribute to interdisciplinary discussions.