Implications and benefits of the use of rifaximin for preventing episodes of hepatic encephalopathy

Abstract

108 British Journal of Healthcare Management 2016 Vol 22 No 3 © 2 01 6 M A H ea lth ca re L td Encephalopathy has a wide manifestation of signs and symptoms, from non-specific personality changes to unresponsiveness and coma. Recurrences are frequent after an overt episode of encephalopathy, with a 40% recurrence rate within 6 months. In the USA, encephalopathy is the main reason for 110,000 hospitalizations annually (Stepanova et al, 2009), while there are no such figures available in the UK. The most widely used treatment for encephalopathy is lactulose, which is a laxative in liquid form. The efficacy of lactulose, however, is not universal, and many patients develop recurrent episodes of encephalopathy requiring hospitalisation on this drug. Moreover, increasing doses to control encephalopathy symptoms are associated with diarrhoea. Therefore, the treatment of patients with recurrent hepatic encephalopathy despite the use of lactulose remains an unmet clinical need. A randomised, double-blind, placebo-controlled trial has shown that rifaximin significantly reduces the episodes of recurrent encephalopathy in adult patients with two or more previous episodes of overt encephalopathy in the last 6 months as compared with placebo (Bass et al, 2010). Rifaximin, although effective, is costly with the estimated cost of a 6-month treatment being £1689.65. Recently, the National Institute for Health and Care Excellence (NICE) (2015) technology appraisal guidance TA337 addressed the use of rifaximin for preventing episodes of overt hepatic encephalopathy in patients with cirrhosis. The guidance followed 4 evidence submissions by the manufacturing company, each of which provided alternative modeling for costEmmanuel A Tsochatzis, Senior Clinical Lecturer and Honorary Consultant, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK Implications and benefits of the use of rifaximin for preventing episodes of hepatic encephalopathy