Multistrain probiotics and lactulose in the treatment of minimal hepatic encephalopathy

Ahmad Shavakhi, Huriyeh Hashemi, Elham Tabesh, Zhaleh Derakhshan, Somaye Farzamnia, Shirin Meshkinfar, Sara Shavakhi, Mohammad Minakari, Ali Gholamrezaei


Background: Some evidence has shown benefits of probiotics in the management of minimal hepatic encephalopathy (MHE). We evaluated the efficacy of a multistrain probiotic compound, alone and in combination with lactulose, in the treatment of MHE. Materials and Methods: h   is study has two parts. First, consecutive adult patients with MHE were randomized to receive lactulose (30–60 mL/day) + probiotic (200 million colony forming units of seven bacteria species/day) (Gp-LPr) or lactulose + placebo (GpL). In second part, a non-randomized group of patients received probiotic alone (Gp-Pr). Medication duration was for 2 weeks and patients were followed-up for another 8 weeks. Improvement in MHE status was assessed by psychometric hepatic encephalopathy  score (PHES). Development of overt encephalopathy, hospitalization, and death were considered as secondary outcomes. Results: Sixty patients (80% male, mean age 38.4 ± 9.6 years) completed the intervention. PHES signi?cantly improved after medication in all the three groups (Gp-LPr: ?3.8 ± 3.9 to ?1.6 ± 3.0; Gp-L: ?4.8 ± 4.1 to ?1.6 ± 2.9; and Gp-Pr: ?4.9 ± 3.7 to ?2.1 ± 2.5, P < 0.001). After 8 weeks follow-up, improvement was maintained in Gp-LPr and Gp-Pr, but there was deterioration in those who did not receive probiotics (Gp-L: PHES score reversed to ?4.8 ± 4.2). Two patients (one each in Gp-L and Gp-Pr) experienced overt encephalopathy. One patient was hospitalized due to worsening of ascites (Gp-LPr) and one due to spontaneous bacterial peritonitis (Gp-L). Side effects were mild and not signi?cantly di?erent among the groups. Conclusions: Lactulose and probiotics are e?ective for the treatment of MHE; however, probiotics, but not lactulose, have long-term e?ects. More studies are required before suggesting probiotics for the standard treatment of MHE.


Key words: Hepatic encephalopathy, lactulose, prebiotics, probiotics, synbiotics


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