A Crossover Retrospective Chart Review Evaluating Hospitalizations Associated with the Use of Rifaximin vs Lactulose in the Management of Patients with Hepatic Encephalopathy

Abstract

Purpose: Hepatic encephalopathy (HE) is a common condition among patients with liver disease, leading to repeated hospitalizations at an average daily cost of $6,230. This chart review compared the number and duration of hospitalizations associated with a discharge diagnosis of HE among patients treated first with lactulose and then rifaximin. Methods: This study was a single-center, crossover, retrospective chart review of 145 patients diagnosed with HE. All patients received lactulose (30 cc bid) for ≥6 months then rifaximin (400 mg tid) for ≥6 months. Charts were reviewed to compare patients' last 6 months on lactulose therapy and first 6 months on rifaximin therapy. The primary endpoint was the number of hospitalizations a patient had during each 6-month therapy period. Hospitalizations were assigned 2005 dollar value based on inflation-adjusted Healthcare Cost Utilization Project (H-CUP) 2002 data for HE. Secondary endpoints were length of hospitalization, HE grade, presence of asterixis, patient reported medication compliance, and side effects severity during each therapy period. Results: The number of hospitalizations was significantly lower during the period of rifaximin therapy compared with lactulose (mean 0.5 vs 1.6, respectively, P < 0.001). During the rifaximin therapy period, patients spent significantly less time in the hospital (mean time 3.14 days) than during the lactulose period (mean time 12.52 days, P < 0.001). Compared with the lactulose therapy period, HE grade was significantly lowered following rifaximin therapy (P < 0.001). Significantly fewer patients had asterixis at the end of the rifaximin therapy period compared with the end of the lactulose period (P < 0.001), as well as fewer diarrhea, flatulence, and abdominal pain side effects (P < 0.001). Medication compliance was significantly higher with rifaximin therapy compared with lactulose (P < 0.001). Using H-CUP data, the reductions in occurrences and duration of hospitalizations realized with rifaximin therapy resulted in an average cost savings of $67,559 per patient. Conclusions: After 6 months of rifaximin therapy, HE grade was significantly lowered compared with the prior 6 months of lactulose therapy. Subsequently, hospitalizations were fewer and shorter during the rifaximin therapy period compared lactulose, resulting in substantially lower costs. Based on these results rifaximin should be considered as first-line therapy for HE.