A 60-year-old man with alcoholic cirrhosis recovers from an episode of overt hepatic encephalopathy. He is currently on lactulose 30 mL twice daily with normal mentation. To prevent recurrence, which medication should be added?
- A Oral neomycin 1 g three times daily
- B L-ornithine L-aspartate 18 g/day
- C Rifaximin 550 mg twice daily ✓
- D Flumazenil 1 mg intravenous bolus
Correct answer: C. Rifaximin 550 mg twice daily
Explanation
Rifaximin 550 mg twice daily is approved for secondary prophylaxis of hepatic encephalopathy in patients already on lactulose. It reduces ammonia-producing gut bacteria and lowers recurrence risk. LOLA is used for acute episodes but not for prevention. Neomycin is rarely used due to ototoxicity and nephrotoxicity. Flumazenil is used in benzodiazepine-induced sedation, not for chronic prophylaxis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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