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Maharshi S, Sharma BC. Prophylaxis of hepatic encephalopathy: current and future drug targets. Hepatol Int 2024; 18:1096-1109. [PMID: 38492132 DOI: 10.1007/s12072-024-10647-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G.B. Pant Hospital, Room No. 201, Academic Block, New Delhi, 110002, India.
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Jhajharia A, Singh S, Jana S, Ashdhir P, Nijhawan S. Intravenous versus oral 'L-ornithine-L-aspartate' in overt hepatic encephalopathy: a randomized comparative study. Sci Rep 2024; 14:11862. [PMID: 38789596 PMCID: PMC11126676 DOI: 10.1038/s41598-024-62293-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Hepatic encephalopathy (HE), a morbid ordeal affecting chronic liver disease patients always insists for the search of a rational, superior & infallible agent beyond the time-proven standards i.e., Lactulose & Rifaximin. In this RCT, we compared the efficacy of intravenous (IV) L-ornithine-L-aspartate(LOLA) versus Oral LOLA in patients with chronic liver disease(CLD) enduring overt Hepatic Encephalopathy(OHE). 40 CLD patients with OHE were randomly assigned IV or oral LOLA in a 1:1 ratio. Patients were graded for HE and monitored for serum ammonia levels from day 1 to day 5. The aim was to compare IV versus oral LOLA efficacy in HE grades improvement and its correlation with ammonia levels. The study was registered with clinical trials registry-India, CTRI/2020/12/029943. Baseline characteristics of patients in both groups were similar. The mean difference in ammonia levels from day 1 to day 5 was 55.4 ± 32.58 µmol/L in the IV LOLA group and 60.75 ± 13.82 µmol/L in the oral LOLA group (p = 0.511). Significant reductions in ammonia levels were observed from day 1 to day 5 within each group (p < 0.001). HE grade & ammonia correlated positively in both groups. LOLA, regardless of administration route, has demonstrated efficacy in OHE.
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Affiliation(s)
- Ashok Jhajharia
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India.
- , House No. 109, Shiv Vihar, VKI, Infront of road number 5, Sikar Road, Jaipur, 302039, India.
| | - Shashank Singh
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Sangeeta Jana
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Prachis Ashdhir
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
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He Q, Mao C, Chen Z, Zeng Y, Deng Y, Hu R. Efficacy of L-ornithine L-aspartate for minimal hepatic encephalopathy in patients with cirrhosis: A meta-analysis of randomized controlled trials. Arab J Gastroenterol 2024; 25:84-92. [PMID: 38403493 DOI: 10.1016/j.ajg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/12/2023] [Accepted: 01/06/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) is an early stage of hepatic encephalopathy (HE) and is highly prevalent. The efficacy of L-ornithine L-aspartate (LOLA) for the treatment of HE is well known but its role in MHE remains uncertain. The objectives of the current study were to evaluate the efficacy of LOLA for the treatment of MHE in patients with cirrhosis. METHODS The Cochrane Library, PubMed, EMBASE, Web of Science and Ovid databases were searched. Only randomized controlled trials (RCTs) that compared the efficacy of LOLA with placebo or no intervention for the treatment of MHE in patients with cirrhosis were included from inception to January 2023. The primary outcomes were reversal of MHE and development of overt hepatic encephalopathy (OHE). RESULTS Overall, six RCTs comprising 292 patients were included. Compared with placebo or no intervention, LOLA was more effective in reversing MHE (RR = 2.264, 95 % CI = 1.528, 3.352, P = 0.000, I2 = 0.0 %) and preventing progression of OHE (RR = 0.220, 95 % CI = 0.076, 0.637, P = 0.005, I2 = 0.0 %). Based on subgroup analyses, oral LOLA treatment appeared more likely to reverse MHE (RR = 2.648, 95 % CI = 1.593, 4.402, P = 0.000, I2 = 0.0 %), intravenous LOLA treatment yielded a similar probability of reversing MHE (RR = 1.669, 95 % CI = 0.904, 3.084, P = 0.102, I2 = 0.0 %). LOLA did not show a superior possibility in reducing mortality (RR = 0.422, 95 % CI = 0.064, 2.768, P = 0.368, I2 = 0.0 %) and ammonia levels (SMD = 0.044, 95 % CI = -0.290, 0.379, P = 0.795, I2 = 0.0 %) compared with placebo or no intervention. CONCLUSIONS LOLA has significant beneficial effects on reversal of MHE and prevention of OHE in patients with cirrhosis compared with placebo or no intervention.
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Affiliation(s)
- Qiufeng He
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Chuangjie Mao
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Zhili Chen
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yilan Zeng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yang Deng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Rong Hu
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China.
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Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution. J Clin Med 2023; 12:jcm12031187. [PMID: 36769836 PMCID: PMC9917479 DOI: 10.3390/jcm12031187] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common complication in patients with advanced liver disease. It is a brain dysfunction characterized by neurological and psychiatric symptoms that significantly affects quality of life, morbidity and mortality of patients. HE has various precipitants that can potentially promote its onset, alone or in combination. Among the historically well-known precipitants, such as infections, gastrointestinal bleeding, dehydration, electrolyte disorders and constipation, recent studies have highlighted the role of malnutrition and portosystemic shunts as new precipitating factors of HE. The identification, management and correction of these factors are fundamental for effective HE treatment, in addition to pharmacological therapy with non-absorbable disaccharides and/or antibiotics.
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A Simple Algorithm for Semiquantitative Analysis of Scored Histology Data in the R Environment, on the Example of Murine Non-Alcoholic Steatohepatitis Pharmacotherapy. LIVERS 2022. [DOI: 10.3390/livers2040031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Despite the high medical and socioeconomic burden of non-alcoholic fatty liver disease (NAFLD), treatments that could effectively reduce histological liver damage in this condition are lacking. As providing only qualitative data is a major limitation of most histological scoring systems, we aimed to develop a simple and straightforward algorithm for semiquantitative analysis of scored histology data using the extended Fisher’s exact test in the R environment. As an illustrative example, we used the effects of L-ornithine L-aspartate (LOLA) and empagliflozin (EMPA) in a 3-month chemical/dietary murine model of NAFLD. 100 C57Bl/6 mice were randomized into 4 groups: Intact (n = 10), Control (NAFLD; n = 30), LOLA (NAFLD + 1.5 g·kg−1 b.w./d LOLA orally; n = 30), and EMPA (NAFLD + 10 mg·kg−1 b.w./d EMPA orally; n = 30). LOLA reduced hepatitis activity (p < 0.05), cholestasis, necrosis, and fibrosis severity (p < 0.01), and EMPA prevented necrosis (p < 0.05) and reduced fibrosis severity (p < 0.01). The statistical approach we suggest can be used as a simple complementary tool for exploratory analysis of scored histology data.
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Wong YJ, Loo JH. Albumin therapy for hepatic encephalopathy: current evidence and controversies. Metab Brain Dis 2022; 38:1759-1763. [PMID: 35616800 DOI: 10.1007/s11011-022-01002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/07/2022] [Indexed: 12/01/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication that occurs in 16-21% of end-stage cirrhosis patients. Emerging evidence suggests that systemic inflammation and oxidative stress may play a role in the development of HE. Recent understanding on the anti-inflammatory properties of human albumin has led to growing interest of using human albumin for the treatment and prevention of HE among decompensated patients. In this review, we aim to discuss the current evidence and controversies of using human albumin for the treatment and prevention of HE in advanced cirrhosis patients.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore, Singapore.
- Duke-NUS Medicine Academic Clinical Program, SingHealth, Singapore, Singapore.
| | - Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore, Singapore
- Duke-NUS Medicine Academic Clinical Program, SingHealth, Singapore, Singapore
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Jain A, Sharma BC, Mahajan B, Srivastava S, Kumar A, Sachdeva S, Sonika U, Dalal A. L-ornithine L-aspartate in acute treatment of severe hepatic encephalopathy: A double-blind randomized controlled trial. Hepatology 2022; 75:1194-1203. [PMID: 34822189 DOI: 10.1002/hep.32255] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Data on the use of intravenous L-ornithine L-aspartate (LOLA) in the treatment of overt HE (OHE) is limited. We evaluated the role of intravenous LOLA in patients of cirrhosis with OHE grade III-IV. APPROACH AND RESULTS In a double-blind randomized placebo-controlled trial, 140 patients were randomized to a combination of LOLA, lactulose, and rifaximin (n = 70) or placebo, lactulose, and rifaximin (n = 70). LOLA was given as continuous intravenous infusion at a dose of 30 g over 24 h for 5 days. Ammonia levels, TNF-α, ILs, and endotoxins were measured on days 0 and 5. The primary outcome was the improvement in the grade of HE at day 5. Higher rates of improvement in grade of HE (92.5% vs. 66%, p < 0.001), lower time to recovery (2.70 ± 0.46 vs. 3.00 ± 0.87 days, p = 0.03), and lower 28-day mortality (16.4% vs. 41.8%, p = 0.001) were seen in the LOLA group as compared with placebo. Levels of inflammatory markers were reduced in both groups. Significantly higher reductions in levels of blood ammonia, IL-6, and TNF-α were seen in the LOLA group. CONCLUSIONS Combination of LOLA with lactulose and rifaximin was more effective than only lactulose and rifaximin in improving grades of HE, recovery time from encephalopathy, with lower 28-day mortality.
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Affiliation(s)
- Arpan Jain
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | | | - Bhawna Mahajan
- Department of BiochemistryGB Pant HospitalNew DelhiIndia
| | | | - Ajay Kumar
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | | | - Ujjwal Sonika
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
| | - Ashok Dalal
- Department of GastroenterologyGB Pant HospitalNew DelhiIndia
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Zhang G, Ren X, Liang X, Wang Y, Feng D, Zhang Y, Xian M, Zou H. Improving the Microbial Production of Amino Acids: From Conventional Approaches to Recent Trends. BIOTECHNOL BIOPROC E 2021. [DOI: 10.1007/s12257-020-0390-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Butterworth RF. Ammonia Removal by Metabolic Scavengers for the Prevention and Treatment of Hepatic Encephalopathy in Cirrhosis. Drugs R D 2021; 21:123-132. [PMID: 33890246 PMCID: PMC8206241 DOI: 10.1007/s40268-021-00345-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/18/2022] Open
Abstract
Effective lowering of circulating ammonia is the mainstay strategy in the prevention and treatment of hepatic encephalopathy in cirrhosis and there is increasing interest in agents with the metabolic potential for the active removal of ammonia by the liver and skeletal muscle by agents including L-ornithine L-aspartate, branched-chain amino acids, as well as the re-purposing of benzoate and phenylacetate currently employed for the control of hyperammonaemia in congenital urea-cycle enzymopathies. Based upon results of multiple systematic reviews with meta-analyses, L-ornithine L-aspartate demonstrably lowers circulating ammonia in patients with cirrhosis with concomitantly improved mental status. Distinct mechanisms responsible include optimisation of hepatic metabolic pathways for ammonia removal as well as direct hepatoprotective effects involving the release of glutathione and of nitric oxide with beneficial effects on hepatic microcirculation. L-ornithine L-aspartate also prevents cirrhosis-related sarcopenia, leading to increased capacity for ammonia removal by skeletal muscle. Branched-chain amino acids continue to be prescribed as nutritional supplements with the potential to result in improvements in liver function. Sodium benzoate, glycerol phenylbutyrate and an analogous compound L-ornithine phenylacetate were also evaluated. Glycerol phenylbutyrate was the only agent with a beneficial effect on both hyperammonaemia and hepatic encephalopathy. None were superior to lactulose for the lowering of blood ammonia.
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Affiliation(s)
- Roger F Butterworth
- Department of Medicine, University of Montreal, 45143 Cabot Trail, Englishtown, NS, B0C 1H0, Canada.
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Das A, Fröhlich D, Achanta LB, Rowlands BD, Housley GD, Klugmann M, Rae CD. L-Aspartate, L-Ornithine and L-Ornithine-L-Aspartate (LOLA) and Their Impact on Brain Energy Metabolism. Neurochem Res 2020; 45:1438-1450. [PMID: 32424601 DOI: 10.1007/s11064-020-03044-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022]
Abstract
L-Ornithine-L-aspartate (LOLA), a crystalline salt, is used primarily in the management of hepatic encephalopathy. The degree to which it might penetrate the brain, and the effects it might have on metabolism in brain are poorly understood. Here, to investigate the effects of LOLA on brain energy metabolism we incubated brain cortical tissue slices from guinea pig (Cavea porcellus) with the constituent amino acids of LOLA, L-ornithine or L-aspartate, as well as LOLA, in the presence of [1-13C]D-glucose and [1,2-13C]acetate; these labelled substrates are useful indicators of brain metabolic activity. L-Ornithine produced significant "sedative" effects on brain slice metabolism, most likely via conversion of ornithine to GABA via the ornithine aminotransferase pathway, while L-aspartate showed concentration-dependent excitatory effects. The metabolic effects of LOLA reflected a mix of these two different processes and were concentration-dependent. We also investigated the effect of an intraperitoneal bolus injection of L-ornithine, L-aspartate or LOLA on levels of metabolites in kidney, liver and brain cortex and brain stem in mice (C57Bl6J) 1 h later. No significant changes in metabolite levels were seen following the bolus injection of L-aspartate, most likely due to rapid metabolism of aspartate before reaching the target tissue. Brain cortex glutamate was decreased by L-ornithine but no other brain effects were observed with any other compound. Kidney levels of aspartate were increased after injection of L-ornithine and LOLA which may be due to interference by ornithine with the kidney urea cycle. It is likely that without optimising chronic intravenous infusion, LOLA has minimal impact on healthy brain energy metabolism due to systemic clearance and the blood - brain barrier.
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Affiliation(s)
- Abhijit Das
- Neuroscience Research Australia, Barker St, Randwick, NSW, 2031, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia
| | - Dominik Fröhlich
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Kensington, 2052, Australia
| | - Lavanya B Achanta
- Neuroscience Research Australia, Barker St, Randwick, NSW, 2031, Australia.,Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Kensington, 2052, Australia
| | - Benjamin D Rowlands
- Neuroscience Research Australia, Barker St, Randwick, NSW, 2031, Australia.,Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Kensington, 2052, Australia
| | - Gary D Housley
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Kensington, 2052, Australia
| | - Matthias Klugmann
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Kensington, 2052, Australia
| | - Caroline D Rae
- Neuroscience Research Australia, Barker St, Randwick, NSW, 2031, Australia. .,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia.
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