98 These mechanisms may be additive or synergistic in
treating MHE. Probiotics may represent a safe, effective, long-term therapy for MHE and may be an alternative to lactulose. Clinical studies evaluating the role of LOLA in the treatment of MHE did not show its effectiveness; however, these studies were small and underpowered. A recent study that compared lactulose, a probiotic and LOLA with no treatment, however, showed that LOLA is as effective as lactulose MAPK inhibitor or a probiotic preparation in improving psychometric performance and HRQOL.67 Larger prospective studies are warranted to evaluate the role of LOLA before it can be recommended for the treatment of MHE. The role of antibiotics in
MHE has not been evaluated. Prospective studies with poorly absorbed antibiotics are required to evaluate their efficacy in improving MHE. 45 Lactulose is effective in reducing blood ammonia levels and improving psychometric performance in cirrhotic patients with MHE. (1b) The INASL Working Party recommends that all patients with cirrhosis be screened for the presence of MHE using a standard battery of psychometric tests, PHES, CFF or ICT, depending upon the availability of tests and BMN 673 their validation for local populations from different parts of the world (Fig. 1). Patients whose index psychometric or computerized test results do not indicate pathology should be screened every 6–12 months. Treatment for MHE may be initiated with lactulose; patients should receive 30–60 mL of lactulose in two or three divided doses so that
they pass two to three semi-soft stools per day. Although the appropriate duration of therapy for MHE is unsettled, at least three studies suggest that treatment may be advised for 3–6 months.3,67,95 “
“We read with interest the article by Hongthanakorn et al. published in a recent issue of HEPATOLOGY.1 The authors reported a very high incidence of virological breakthrough (VBT) in patients receiving five different nucleos(t)ide analogues (NUCs) Forskolin mw in clinical practice: 26% (39 patients). They reported that 7% of NUC-naïve patients receiving entecavir (ETV) experienced VBT, and that the cumulative probability of experiencing VBT at 3 years was 13%. The VBT rates reported by Hongthanakorn et al. are higher than described previously. In our population of 69 NUC-naïve chronic HBV patients treated in routine clinical practice with ETV, we found that 100% achieved undetectable HBV DNA after 96 weeks of treatment.2 We did not perform tests to evaluate genetic resistance, but we found no evidence of clinical resistance to treatment or VBT. Other studies in clinical practice have shown high efficacy of treatment with low rates of VBT, around 1%.3-5 In phase 3 randomized clinical trials, VBT rates with ETV treatment were 1.6%.6, 7 Hongthanakorn et al.