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Abstract Details
The Use of Rifaximin in the Prevention of Overt Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt : A Randomized Controlled Trial
Ann Intern Med. 2021 Feb 2. doi: 10.7326/M20-0202. Online ahead of print.
1University Hospital of Toulouse and Toulouse III Paul Sabatier University, Toulouse, France (C.B., J.M.P., J.P.V.).
2Groupe Hospitalier Pitié-Salpêtrière, Paris, France (D.T.).
3Centre d'Investigation Clinique de Rennes, Rennes, France (C.J.).
4Centre Hospitalier Universitaire de Nantes, Nantes, France (I.A.).
5Trousseau University Hospital of Tours, Tours, France (L.D.M.).
6Centre Hospitalier Universitaire de Lille, Lille, France (S.D.).
7Centre Hospitalo-Universitaire Timone, Marseille, France (P.B.).
8Centre Hospitalier Universitaire d'Angers, Angers, France (F.O.).
9Beaujon Hospital, Clichy, France (A.P.).
10Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France (V.D.).
11Hôpitaux Universitaires Paris Seine-Saint-Denis, Bondy, and Université Paris 13, Sorbonne Paris Cité et INSERM UMR 1162, Paris, France (N.G.).
12Hôpital Saint-Antoine, Paris, France (N.C.).
13and Toulouse University Hospital, Toulouse, France (V.R., A.S.).
Abstract
Background: The efficacy of rifaximin in the secondary prevention of overt hepatic encephalopathy (HE) is well documented, but its effectiveness in preventing a first episode in patients after transjugular intrahepatic portosystemic shunt (TIPS) has not been established.
Objective: To determine whether rifaximin prevents overt HE after TIPS compared with placebo.
Participants: 197 patients with cirrhosis undergoing TIPS for intractable ascites or prevention of variceal rebleeding.
Intervention: Patients were randomly assigned to receive rifaximin (600 mg twice daily) or placebo, beginning 14 days before TIPS and continuing for 168 days after the procedure.
Measurements: The primary efficacy end point was incidence of overt HE within 168 days after the TIPS procedure.
Results: An episode of overt HE occurred in 34% (95% CI, 25% to 44%) of patients in the rifaximin group (n = 93) and 53% (CI, 43% to 63%) in the placebo group (n = 93) during the postprocedure period (odds ratio, 0.48 [CI, 0.27 to 0.87]). Neither the incidence of adverse events nor transplant-free survival was significantly different between the 2 groups.
Limitations: The study's conclusion applies mainly to patients with alcoholic cirrhosis, who made up the study population. The potential benefit of rifaximin 6 months after TIPS and beyond remains to be investigated.
Conclusion: In patients with cirrhosis treated with TIPS, rifaximin was well tolerated and reduced the risk for overt HE. Rifaximin should therefore be considered for prophylaxis of post-TIPS HE.
Primary funding source: French Public Health Ministry.