In Reply

The Diagnosis and Treatment of Minimal Hepatic Encephalopathy by Dr. med. Tianzuo Zhan, Prof. Dr. med. Dr. h.c. med. Wolfgang Stremmel in volume 10/2012

We thank our correspondents for their comments on our article. Our response is shown below:

• The recommendation for a restriction of protein intake is indeed the subject of diverging opinion. Phongsamran et al (1) have also regarded that protein restriction is not substantiated by any evidence. We concede that the listing of excessive protein as item 2 in the box of precipitating factors equates to over-rating the effects of protein.
• Upon reading the article written by Plauth et al (2), one is indeed led to conclude that “the effect of lactulose on ammonia generation from glutamine through the mucosa of the small intestine has been shown only for the evacuation of the intestinal lumen and not for a specific effect on glutamine uptake .”
• The mention of Egberts and Schomerus and their study findings on improved driving performance as a result of branched-chain amino acids is fully justified.
• The therapeutic option of rifaximin 550 mg twice daily was derived from published studies and its use as approved therapy in the US.
• Our article did not focus on cost speculation. The theoretical calculation of treatment costs is specious because until rifaximin is, as expected, licensed for the treatment of hepatic encephalopathy in the German market, the price for a required dosage has yet to be decided.
• In addition to lactulose, Phongsamran et al in their article suggested other options for antibiotic treatment of hepatic encephalopathy, such as vancomycin, metronidazole, and neomycin. Because of poor clinical effectiveness, high costs (vancomycin), and potential adverse effects (neomycin), their use as prophylaxis is at the very least controversial.
• In certain circumstances, we consider the use of rifaximin to treat our patients.

DOI: 10.3238/arztebl.2012.0503c

Prof. Dr. med. Dr. h.c. med Wolfgang Stremmel

Abteilung Innere Medizin IV (Gastroenterologie, Infektionskrankheiten,

Vergiftungen), Heidelberg

Conflict of interest statement

The authors holds shares in Gilead and has received travel expenses and lecture honoraria from Falk-Symposium.

References

1. Phongsamran PV, Kim JW, Cupo Abbott J, Rosenblatt A: Pharmacotherapy for hepatic encephalopathy. Drugs 2010; 70: 1131–48.

2. Plauth M, Raible A, Graser TA, et al.: Lactulose or paromomycin do not affect ammonia generation in the isolated perfused rat small intestine. Z Gastroenterol 1994; 32: 141–5.

3. Zhan T, Stremmel W: The diagnosis and treatment of minimal hepatic encephalopathy. Dtsch Arztebl Int 2012; 109(10): 180–7.