Medications for hepatic encephalopathy: Nursing pharmacology

Hepatic encephalopathy refers to a life-threatening condition characterized by liver dysfunction, so the liver is unable to metabolize toxic substances, like ammonia, which is mainly produced in the gastrointestinal tract by the bacterial flora.

As a result, these toxic substances can build up and travel to the brain, ultimately causing brain dysfunction. These clients can present with symptoms like insomnia or hypersomnia, mood changes, asterixis or flapping tremor, confusion, and even coma.The two medications most commonly used to treat hepatic encephalopathy include lactulose, which is an osmotic laxative; and rifaximin, which is an antibiotic.Okay, so lactulose is an indigestible and non-absorbable synthetic sugar that can be given orally or rectally.

Once administered, lactulose gets broken down by the intestinal bacterial flora into lactic acid and short-chain fatty acids like acetic acid.

These acidic metabolites partially dissociate to release hydrogen ions, which convert the ammonia generated into ammonium ions that get excreted in the stools.Additionally, since lactulose is indigestible and non-absorbable, it stays in the lumen and pulls out water from the intestinal cells via osmosis.

This lubricates the stool and helps it move faster through the gastrointestinal tract, leaving less time for the ammonia to be produced or absorbed.Now, common side effects of lactulose include abdominal cramps, bloating, and flatulence, due to the production of methane by the intestinal bacteria that break down lactulose.

In addition, lactulose can cause diarrhea, which can further lead to dehydration and electrolyte disturbances, such as hypernatremia and hypokalemia; and severe cases may result in arrhythmias.

Finally, lactulose should be used with caution in clients with intestinal obstruction. Additional precautions should be taken during pregnancy and breastfeeding, as well as in elderly or debilitated clients, and in those with diabetes mellitus, as it may affect their blood glucose levels.Next, rifaximin is administered orally, and since it is a poorly absorbable antibiotic, it primarily acts on the ammonia-producing bacteria in the gastrointestinal tract, stopping their growth.

As a result, the production of ammonia in the colon is reduced.Common side effects of rifaximin include abdominal pain, nausea, constipation, and flatulence.

In addition, rifaximin may allow certain bacteria like Clostridioides difficile to survive and invade the gastrointestinal tract, rarely but potentially leading to diarrhea and Clostridioides difficile infection or CDI for short.

Often, clients taking rifaximin may also experience dizziness, headaches, insomnia, and pyrexia, while some may also develop a skin rash, photosensitivity, and exfoliative dermatitis.

Some additional side effects include proteinuria and polyuria, as well as hypotension, peripheral edema, and ascites. Finally, rifaximin should be used with caution during pregnancy and breastfeeding, as well as in children and elderly clients.All right, when caring for a client with hepatic encephalopathy, first perform a focused assessment of your client’s neurological and mental status, including the degree of confusion or lethargy, and if asterixis is present.

Then, review their most recent laboratory test results, including electrolytes, especially sodium and potassium, as well as their blood ammonia level.

Lastly, review their EEG test results.Now, if your client is prescribed lactulose, explain how the medication will decrease their symptoms by helping eliminate ammonia through bowel movements.

Let them know that you will administer the medication three times each day in order to produce two to three soft bowel movements daily, and review common side effects, including flatulence, diarrhea, and abdominal cramping.

As you prepare to administer lactulose, confirm your client has easy access to a bathroom or bedside commode and ensure fall precautions are in place.

If your client is immobile, be sure to check them frequently for the production of bowel movements and provide scrupulous skin and perineal care.

Before administering lactulose orally, first ensure that your client can safely take oral medications. When administering lactulose syrup, administer 15 to 30 mL, as ordered.

If you’re administering lactulose crystals, prepare it by stirring into 15 to 30 mL of water or juice. When administering lactulose via nasogastric tube, be sure to flush the tube with water before and after the dose.

If lactulose is ordered per rectum, dilute 300 mL of lactulose in 700 mL of water or normal saline and administer the solution through a rectal balloon catheter; encourage them to retain the liquid for 30 minutes, and if the lactulose is retained for less than 30 minutes, repeat the administration.

Lastly, closely monitor your client’s fluid intake and output to prevent dehydration due to fluid loss from increased bowel movements.Now, if your client is prescribed rifaximin, explain how this antibiotic helps decrease their symptoms by reducing the growth of ammonia-producing bacteria in the gastrointestinal tract.

Administer the medication orally three times each day, as ordered, and let them know that some side effects of the medication include flatulence, abdominal pain, constipation, and peripheral edema.

Monitor your client closely for these side effects and for symptoms of Clostridioides difficile infection, such as abdominal cramping, as well as loose, watery, and bloody stools.After administration of lactulose or rifaximin, keep a close eye on your client’s ammonia, fluid and electrolyte balance, and intervene as needed to decrease the severity of side effects.

Finally, watch for the desired therapeutic effect of decreased blood ammonia levels and improved neurological and mental status.All right, as a quick recap… Lactulose and rifaximin are medications that are used to treat hepatic encephalopathy by helping to reduce the amount of ammonia in blood.

When caring for clients who are taking lactulose or rifaximin, nursing considerations include performing a focused client assessment, administering the medications as ordered, close monitoring for side effects, and evaluating for the desired therapeutic effect.

Client teaching focuses on the purpose of the medications, as well as learning what to expect as far as