A 58-year-old man with known cirrhosis (NASH-related, Child-Pugh B) presents with grade 2 hepatic encephalopathy. Ammonia is elevated. Lactulose is started. Which additional therapy has been shown in randomized trials to reduce recurrence of overt hepatic encephalopathy when added to lactulose?
- A Rifaximin ✓
- B Oral branched-chain amino acids
- C Metronidazole
- D Neomycin
Correct answer: A. Rifaximin
Explanation
Rifaximin, a non-absorbable rifamycin derivative, added to lactulose significantly reduces recurrence of overt hepatic encephalopathy and related hospitalizations, as shown in a landmark randomized controlled trial. Metronidazole and neomycin are older antibiotics with toxicity concerns (neuropathy, nephrotoxicity) and are not preferred for long-term prophylaxis. Branched-chain amino acids have a limited role and are not first-line for recurrence prevention.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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