Combined PEG3350 Plus Lactulose Results in Early Resolution of Hepatic Encephalopathy and Improved 28-Day Survival in Acute-on-Chronic Liver Failure. Issue 1 (13th January 2022)

• Record Type: Journal Article
• Authors: Ahmed, Syed; Premkumar, Madhumita; Dhiman, Radha K.; Kulkarni, Anand V.; Imran, Rather; Duseja, Ajay; Kaur, Prabhdeep; Taneja, Sunil; Singh, Virendra; Mishra, Saurabh; Roy, Akash; Mehtani, Rohit
• Is Part Of: Journal of clinical gastroenterology. Volume 56:Issue 1(2022)
• Page Start: e11
• Page End: e19
• Publication Date: 2022-01-13
• Subjects: acute-on-chronic liver failure -- hepatic encephalopathy -- polyethylene glycol -- lactulose -- cirrhosis -- acute decompensation; Gastroenterology -- Periodicals; Digestive organs -- Diseases -- Periodicals; Gastroenterology -- Periodicals; Digestive organs -- Diseases; Gastroenterology; Periodicals; Periodicals; 616.33005
• DOI: 10.1097/MCG.0000000000001450
• Languages: English
• ISSNs: 0192-0790

Abstract

Abstract : Supplemental Digital Content is available in the text. Abstract : Background and Aims: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality in those with hepatic encephalopathy (HE). Polyethylene glycol (PEG) 3350 electrolyte solution can ensure rapid gut catharsis, which may resolve HE more effectively than lactulose. In this open-label–randomized trial, we compared PEG+lactulose versus lactulose alone in ACLF with HE grade ≥2 for efficacy and outcome. Patients and Methods: Patients were randomized to receive PEG (2 L q12 h) followed by lactulose (30 mL q8 h) or standard medical treatment [SMT, lactulose (titrated 30 mL q8 h)]. Endpoints were HE grade improvement at 24 hours, 48 hours, and 7 days using hepatic encephalopathy scoring algorithm (HESA), ammonia reduction, HE resolution, and survival benefit. Results: Of 60 patients, 29 were randomized to PEG+lactulose arm and 31 to SMT. In the PEG arm, early reduction in HESA score was noted in more persons [18 (62.1%) vs. 10 (32.2%); P =0.021] with a shorter median time to HE resolution [4.5 (3 to 9) d vs. 9 (8 to 11) d; P =0.023]. On multivariate analysis, age [hazard ratio (HR), 1.06 (1.00 to 1.13); P =0.03], HESA score [HR, 6.01 (1.27 to 28.5); P =0.024], and model for end-stage liver disease [HR, 1.26 (1.01 to 1.53); P =0.022] were predictors of mortality at 28 days. Ammonia level or reduction did not correlate with HE grades. Adverse events included excessive diarrhea (20.6% vs. 9.6%) in the PEG and SMT arms, albeit without dyselectrolytemia or worsened renal function. In the PEG versus SMT arm, survival at 28 days were 93.1% versus 67.7% ( P =0.010) and at 90 days was 68.9% versus 48.3% ( P =0.940), respectively, with fewer persons relapsing with HE in the PEG arm. Conclusions: PEG resulted in early and sustained HE resolution with improved short-term survival making, it a suitable and safe drug in patients with acute HE in ACLF.