A 60-year-old man with cirrhosis had two episodes of overt hepatic encephalopathy in the past year, both controlled with lactulose. He remains on lactulose titrated to 2 to 3 soft stools daily. Which addition reduces the risk of further breakthrough episodes?

• A Neomycin 500 mg twice daily
• B Protein restriction to less than 40 g per day
• C Flumazenil infusion for 48 hours monthly
• D Rifaximin 550 mg twice daily ✓

Explanation

Rifaximin 550 mg twice daily added to lactulose significantly reduces recurrence of overt hepatic encephalopathy and rehospitalization, with minimal systemic absorption. Neomycin carries ototoxic and nephrotoxic risk with long-term use. Protein restriction worsens sarcopenia and is no longer recommended, since normal to higher protein intake improves outcomes in cirrhosis.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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