Table 1.
Available treatments (other than general principles, non-absorbable disaccharides/antibiotics) with some commentary on the evidence for them and/or tips for use.
| Treatment Category | Treatment | Evidence or Tips for Use |
|---|---|---|
| Laxative | Polyethylene glycol | In the acute setting, when administration is safe by mouth or by naso-gastric tube |
| L-Ornithine L-Aspartate | ||
| Non ureic nitrogen scavengers | Sodium benzoate | Particularly useful when hyponatremia is also present |
| Non ureic nitrogen scavengers | Sodium phenylbutyrate | |
| Non ureic nitrogen scavengers | Glycerol phenylbutyrate | |
| Non ureic nitrogen scavengers | Ornithine phenylacetate | |
| Nutritional measures | Vegetarian/dairy diets | In patients with highly recurrent/persistent HE or those who are truly intolerant to animal protein Under tight monitoring to avoid lowering overall calorie/protein intake |
| Nutritional measures | Food intake distribution over the 24 h | 3 snacks to top up the 3 main meals can be suggested to malnourished/sarcopenic patients If not tolerated, please insist on the late-evening snack, which is the most important |
| Nutritional measures | Branched-chain amino acids | Useful also as a late-evening snack and in association with vegetarian/dairy diets, to ensure adequate protein intake |
| Nutritional measures | Prebiotics, probiotics and symbiotics | Ecological approaches, such as increased soluble fibre intake (albeit not necessarily easy to obtain) most likely useful and free of side effects |
| Albumin | In patients with ascites Possibly also acting as a nutritional measure |
|
| Acetyl L-carnitine | ||
| Fecal Microbiota Transplantation | ||
| Direct vigilance modulation | Golexanolone | |
| Direct vigilance modulation | Caffeine | With attention to timing (max effect for 60–90 min after intake) |
| Miscellanea | Minocycline, ibuprofen, indomethacin, phosphodiesterase-5 inhibitors, benzodiazepine inverse agonists, AST-120, liposome-supported peritoneal dialysis | Experimental |
| Education | Limited evidence but reasonable approach, especially if slim and structured, for both patients and caregivers | |
| Tertiary referral centre experience | Needs to be better and more formally described, published where possible and disseminated in a structured fashion |