A 48-year-old man with hepatitis B cirrhosis (Child-Pugh A) presents with confusion and asterixis. He has no GI bleed, infection, or electrolyte abnormality identified. Lactulose is started. Which agent should be added as secondary prophylaxis against further episodes of hepatic encephalopathy?
- A Neomycin
- B Metronidazole
- C Rifaximin ✓
- D Ciprofloxacin
Correct answer: C. Rifaximin
Explanation
Rifaximin, a non-absorbable rifamycin derivative, is approved as add-on therapy to lactulose for secondary prevention of hepatic encephalopathy recurrence. A landmark trial showed rifaximin plus lactulose significantly reduced encephalopathy hospitalizations compared to lactulose alone. Neomycin and metronidazole are not used for long-term prophylaxis due to toxicity (ototoxicity, nephrotoxicity, peripheral neuropathy). Ciprofloxacin is used for SBP prophylaxis, not encephalopathy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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