P5821 - Clinical Efficacy of Combined Rifaximin and Lactulose vs Lactulose Monotherapy in the Treatment of Hepatic Encephalopathy: A Systematic Review and Meta-Analysis

Trisha Chandra Mohan, ¹, Omar Oudit, DO², Ananya Prasad, ³, Vibhav MS, ⁴, Rishikesh R. Magaji, ¹, Vinay Chandramouli Bellur, ⁵, Keerthi Balaji Babu Naidu, ⁵, Anusha Giri, ³, Deepak Bhat, MBBS⁶, Drumadala I. Gajbhiye, MBBS⁷, Allama Prabhu N S, ⁸, Adithya Sathya narayana, MBBS⁹, Vikram Chandramouli Bellur, MBBS¹⁰
1BGS Global Institute of Medical Sciences, Bangalore, Karnataka, India; 2Brookdale University Hospital Medical Center, Brooklyn, NY; 3ramaiah medical college, Bangalore, Karnataka, India; 4bangalore medical college and research institute, Bangalore, Karnataka, India; 5Ramaiah medical college, Bangalore, Karnataka, India; 6M. S Ramaiah Medical College, Bangalore North, Karnataka, India; 7Government Medical College and Hospital, Philadelphia, PA; 8Bangalore Medical College and Research Institute, Bangalore, Karnataka, India; 9M S Ramaiah Medical College, Bangalore, Karnataka, India; 10Kasturba Medical College, Bengaluru, Karnataka, India

Introduction: Hepatic encephalopathy (HE) is a debilitating neuropsychiatric complication of advanced liver disease, with lactulose being the long-term standard of care for management. However, recurrent episodes and incomplete response rates persist. Rifaximin, a gut-selective antibiotic, has been shown to reduce ammonia-producing gut flora, thereby lowering recurrence risk. Recent trials and guidelines suggest that combining rifaximin with lactulose may offer superior efficacy compared to lactulose alone, particularly in preventing recurrent overt HE episodes. This meta-analysis evaluates the comparative effectiveness of combination therapy versus lactulose monotherapy in improving clinical outcomes in the patients.

Methods: The review conducted follows the PRISMA guidelines. PUBMED, Google Scholar and Science-Direct, were searched using a comprehensive search term to retrieve available articles. The articles that included the assessment of the detection of adenoma and polyp by AI-assisted colonoscopy and traditional colonoscopy were included in the final analysis.

The data was analysed using the Meta, Metadata and the Metafor packages of R Studio. The Odds Ratio (OR) of improvement of Hepatic Encephalopathy in Rifaximin and Lactulose combination therapy in comparison to Lactulose monotherapy was assessed as the primary outcome. Secondary outcomes included Mortality rates and the mean difference in hospital stay. The Mantel-Haenszel method and the Inverse variance method were utilised to analyse the odds ratio.

Results: The conducted meta-analysis included a total of 7 articles where 583 patients with hepatic encephalopathy received Rifaximin and Lactulose as combination therapy and 508 patients received Lactulose-only therapy. The clinical efficacy of both the groups were similar in terms of all the outcomes ie; improvement/Reversal of Hepatic Encephalopathy (OR=1.62(0.76 ; 3.48 , I^2 = 86.4% , p< 0.0001) , Mean difference in hospital stay (MDS=-1.15(-12.67;10.36) ,I^2=0%, p = 0.793) and relative risk of morality. (RR=0.82(0.45 ; 1.50), I^2 =77.6% ,p = 0.0039).

Discussion: Our study suggests that Lactulose monotherapy in comparison with Rifaxmin and Lactulose combination therapy for hepatic encephalopathy show similar clinical efficacy in terms of Reversal of Hepatic Encephalopathy, difference in hospital stay and relative risk of mortality, This suggests that Lactulose and Rifaximin combination therapy do not confer any additional benefits in comparison with Lactulose Monotherapy.


Figure: Odds Ratio of Improvement of Hepatic Encephalopathy and Mean Difference in Hospital Stay in Lactulose Therapy vs Combined Therapy


Figure: Relative Risk of Mortality in Lactulose Therapy vs Combined Therapy

Disclosures:
Trisha Chandra Mohan indicated no relevant financial relationships.
Omar Oudit indicated no relevant financial relationships.
Ananya Prasad indicated no relevant financial relationships.
Vibhav MS indicated no relevant financial relationships.
Rishikesh R. Magaji indicated no relevant financial relationships.
Vinay Chandramouli Bellur indicated no relevant financial relationships.
Keerthi Balaji Babu Naidu indicated no relevant financial relationships.
Anusha Giri indicated no relevant financial relationships.
Deepak Bhat indicated no relevant financial relationships.
Drumadala Gajbhiye indicated no relevant financial relationships.
Allama Prabhu N S indicated no relevant financial relationships.
Adithya Sathya narayana indicated no relevant financial relationships.
Vikram Chandramouli Bellur indicated no relevant financial relationships.

Trisha Chandra Mohan, ¹, Omar Oudit, DO², Ananya Prasad, ³, Vibhav MS, ⁴, Rishikesh R. Magaji, ¹, Vinay Chandramouli Bellur, ⁵, Keerthi Balaji Babu Naidu, ⁵, Anusha Giri, ³, Deepak Bhat, MBBS⁶, Drumadala I. Gajbhiye, MBBS⁷, Allama Prabhu N S, ⁸, Adithya Sathya narayana, MBBS⁹, Vikram Chandramouli Bellur, MBBS¹⁰. P5821 - Clinical Efficacy of Combined Rifaximin and Lactulose vs Lactulose Monotherapy in the Treatment of Hepatic Encephalopathy: A Systematic Review and Meta-Analysis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.