Stuart Pope
Critical Care Pharmacy Specialist
Emory Healthcare
Atlanta, Georgia
Disclosure information not submitted.
Alley Killian, BCCCP, PharmD
Clinical Pharmacist, Surgical / Transplant ICU
Emory University Hospital
Atlanta, Georgia
Disclosure information not submitted.
.jpg "Ram Subramanian, MBA, MD, FCCM photo")
Ram Subramanian, MBA, MD, FCCM
Professor of Medicine & Surgery
Emory University
Atlanta, Georgia
Disclosure information not submitted.
Title: Safety of Lactulose for the Treatment of Hepatic Encephalopathy in Decompensated Cirrhosis
Introduction/Hypothesis: Hepatic encephalopathy (HE) is a common complication seen in end stage liver disease, characterized by a variety of neurological abnormalities, and associated with poor prognosis. Lactulose is commonly used as first line treatment for symptomatic HE in cirrhotic patients. However, a paucity of data exists regarding the safety of lactulose for the treatment of HE in decompensated cirrhosis, including patients with acute-on-chronic liver failure (ACLF). Lactulose poses several risks to critically ill patients, including ileus formation, metabolic and electrolyte derangements, and hypovolemia. Thus, this retrospective cohort analysis compared the safety of lactulose-containing versus non-lactulose-containing medication regimens for the treatment of HE in patients admitted with decompensated cirrhosis.
Methodology: A retrospective cohort analysis was performed for adult patients who were admitted to the surgical/transplant ICU at Emory University Hospital with decompensated cirrhosis and received treatment for HE. The primary objective for this study is the incidence of gastrointestinal (GI) complications, which included ileus formation and bowel perforation. Secondary objectives include metabolic disturbances, incidence of diarrhea, and both ICU and hospital length of stay.
Results: A total of 239 patients were included in this analysis. Of these, 156 (65%) patients met criteria for ACLF. The lactulose-containing group experienced a statistically significant higher incidence of GI complications (34% vs. 20%, Χ2=4.6999, p-value=0.03), primarily driven by an increased incidence of ileus formation (96% vs. 88%, Χ2=5.7059, p-value=0.017). Metabolic disturbances were more likely to occur in the non-lactulose-containing group while diarrhea was statistically more common in the lactulose-containing group. Patient-specific outcomes such as length of stay and mortality did not differ between groups.
Conclusion: Our study demonstrates that lactulose is associated with a higher incidence of GI complications in patients who are admitted to an ICU with decompensated cirrhosis. This finding may contribute to practice changes at our institution; however, prospective trials are needed to investigate the causative relationship between lactulose and GI complications in this patient population.