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Branched-chain Amino Acids for Patients with Hepatic Encephalopathy

 

Am Fam Physician. 2020 Jan 1;101(1):online.

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BRANCHED-CHAIN AMINO ACIDS FOR TREATMENT OF HEPATIC ENCEPHALOPATHY

BenefitsHarms

1 in 6 had improvement in signs and symptoms of hepatic encephalopathy

1 in 20 were harmed by adverse effects (e.g., nausea, diarrhea)

BRANCHED-CHAIN AMINO ACIDS FOR TREATMENT OF HEPATIC ENCEPHALOPATHY

BenefitsHarms

1 in 6 had improvement in signs and symptoms of hepatic encephalopathy

1 in 20 were harmed by adverse effects (e.g., nausea, diarrhea)

Details for This Review

Study Population: Adults with hepatic encephalopathy and cirrhosis, mostly caused by alcoholic liver disease or viral hepatitis

Efficacy End Points: Mortality, hepatic encephalopathy (number with improvement)

Harm End Points: Gastrointestinal symptoms, including nausea and diarrhea; other reported adverse events

Narrative: Hepatic encephalopathy 1 is a brain dysfunction that can be mild with minimal confusion, or overt and severe with coma.13 Cirrhosis, where scar tissue replaces normal hepatic tissue, is the most common cause of hepatic encephalopathy. Branched-chain amino acids (BCAAs) may reduce hepatic encephalopathy by helping skeletal muscle detoxify blood46 and are, therefore, recommended by some as routine treatment.2,3

The systematic review summarized here identified 16 randomized trials of 827 patients with hepatic encephalopathy (97% with cirrhosis). Primary outcomes were mortality, hepatic encephalopathy (number with improvement), and harms. Patients were followed for varying time periods ranging from one to 104 weeks.1

BCAAs had benefits in improving signs and symptoms of hepatic encephalopathy assessed mainly by the West Haven Criteria (relative risk [RR] = 0.7; 95% CI, 0.6 to 0.9; 17% absolute risk difference [ARD]; number needed to treat = 6 [for every six patients treated, one measurably improved]). However, no effect was found on mortality (RR = 0.9; 95% CI, 0.7 to 1.1). BCAAs also increased nausea and diarrhea (RR = 3.4; 95% CI, 0.7 to 16.5; 5% ARD; number needed to harm = 20), but no serious adverse events were reported.1

The West Haven Criteria (https://www.mdcalc.com/hepatic-encephalopathy-grades-stages) classifies the degree of mental status disturbance in encephalopathy using a 4-point scoring system ranging from reversal of sleep patterns and mild alteration in cognition to deep coma.2 The portal-systemic encephalopathy (PSE) index may also o

Author disclosure: No relevant financial affiliations.


Copyright © 2020 MD Aware, LLC (theNNT.com). Used with permission.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP assistant medical editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at https://www.aafp.org/afp/mbtn.

References

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1. Gluud LL, Dam G, Les I, et al. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2017;(5):CD001939....

2. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715–735.

3. American Association for the Study of Liver Diseases, European Association for the Study of the Liver. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol. 2014;61(3):642–659.

4. Córdoba J, López-Hellín J, Planas M, et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol. 2004;41(1):38–43.

5. Kachaamy T, Bajaj JS. Diet and cognition in chronic liver disease. Curr Opin Gastroenterol. 2011;27(2):174–179.

6. Olde Damink SW, Jalan R, Redhead DN, et al. Interorgan ammonia and amino acid metabolism in metabolically stable patients with cirrhosis and a TIPSS. Hepatology. 2002;36(5):1163–1171.

7. Conn HO, Leevy CM, Vlahcevic ZR, et al. Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology. 1977;72(4 pt 1):573–583.

8. Sanaka MR, Ong JP, Mullen KD. Challenges of designing hepatic encephalopathy treatment trials. Hepatology. 2003;38(2):527–528.

9. Stahl J. Studies of the blood ammonia in liver disease. Its diagnostic, prognostic, and therapeutic significance. Ann Intern Med. 1963;581–24.

10. Bleibel W, Al-Osaimi AM. Hepatic encephalopathy. Saudi J Gastroenterol. 2012;18(5):301–309.

 

 

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