Prevention of Post-TIPS Hepatic Encephalopathy by Administration of Rifaximin and Lactulose

Официальное название

Prevention of Hepatic Encephalopathy by Administration of Rifaximin and Lactulose in Patients With Liver Cirrhosis Undergoing TIPS Placement: a Multi-centre Randomized, Double Blind, Placebo Controlled Trial.

Обзор

Rationale: Hepatic encephalopathy (HE) is a major and common complication in patients with liver cirrhosis. HE can be classified in the extensive range of neurocognitive deterioration as minimal HE (MHE), covert HE (grade I), or overt HE (OHE, grade II-IV). Liver cirrhosis is the most common cause of portal hypertension (PH). Patients who develop complications of PH, like variceal bleeding or refractory ascites, can benefit from a Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement. Unfortunately, post-TIPS HE is a common and often severe complication. Incidence of new onset or worsening of HE after TIPS is approximately 20-45%. Currently there is no strategy to prevent post-TIPS HE.

Подробное описание

Objective: To assess the incidence of post-TIPS OHE within the first three months after prophylactic administration of lactulose and rifaximin versus placebo in patients who undergo Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement.

Study design: A multicentre, randomized, placebo-controlled, double blind study.

Study population: Adult consecutive patients undergoing elective TIPS placement (for refractory ascites or secondary prophylaxis in variceal bleeding) in all Dutch academic centres where TIPS procedures are performed: Amsterdam UMC, location Academic Medical Centre (AMC), Erasmus MC, Leiden University Medical Centre (LUMC), Maastricht University Medical Centre+ (MUMC+), Radboud University Medical Centre (Radboudumc), University Medical Centre Groningen (UMCG), and University Hospitals Leuven (UZ Leuven) in Belgium.

Intervention: Rifaximin 550 milligram (mg) b.i.d. will be prescribed, in combination with a starting dose of 25 milliliter (mL) lactulose b.i.d. and further dependent on the amount of daily bowel movements, with the objective not to exceed more than two soft stools per day. Intervention will start 72 hours before TIPS placement, and will last till three months after TIPS placement. The control group will receive placebo in combination with lactulose (as described above).

Main study parameters/endpoints: Primary endpoint is the development of OHE within three months after TIPS placement determined by the West Haven criteria. Secondary endpoints are 90 day mortality; development of a second episode of OHE within the first three months; development of OHE in the period between three and twelve months after TIPS placement; development of MHE between TIPS placement and twelve months after placement; the increase of the psychometric hepatic encephalopathy score (PHES) and simplified one minute animal naming test (S-ANT1) compared to baseline. Differences in molecular composition of peripheral / portal blood samples at TIPS placement. Furthermore, quality of life will be assessed.

Вмешательства

• Препарат Rifaximin 550 milligram Oral Tablet [XIFAXAN]
  Rifaximin 550 milligram b.i.d. 72 hours before TIPS placement till 3 months post-TIPS
• Препарат Placebo oral tablet
  Placebo b.i.d. 72 hours before TIPS placement till 3 months post-TIPS
• Препарат Lactulose 667 milligram/milliliter Oral Solution
  Lactulose based on soft stool frequency, 72 hours before TIPS placement till 3 months post-TIPS

Первичные конечные точки

• post-TIPS Hepatic Encephalopathy [Срок оценки: First 3 months after TIPS placement]

Вторичные конечные точки (9)

• Mortality [Срок оценки: 90 days]
• Transplant free survival [Срок оценки: One year]
• time to development of post-TIPS HE episode(s) [Срок оценки: One year]
• development of a second episode of post-TIPS HE [Срок оценки: 3 months]
• development of post-TIPS HE between 3-12 months after TIPS placement [Срок оценки: 3-12 months]
• change in Psychometric Hepatic Encephalopathy Score (PHES) compared to baseline [Срок оценки: One year]
• change in one-minute animal naming test compared to baseline [Срок оценки: One year]
• differences in molecular composition of peripheral / portal blood samples [Срок оценки: One year]
• differences in molecular composition of peripheral blood samples [Срок оценки: One year]

Критерии участия

Критерии включения

• Elective TIPS placement for refractory ascites or recurrent variceal bleeding:

Recurrent tense ascites and one or more of the following criteria:

i. Not responding to the maximal dose of diuretics (400 milligram spironolactone and 160 milligram furosemide).

ii. Kidney insufficiency (Creatinine > 135 umol/L) induced by diuretics. iii. Electrolyte disturbances (Sodium < 125 mmol/L, Potassium > 5.5 mmol/L) induced by diuretics.

iv. Not tolerating higher dose of diuretics (e.g. because of subjective side effects like muscle cramps).

Recurrent variceal bleeding, not responsive to treatment with endoscopic band ligation and beta-blockers, with a high risk of failure of endoscopic treatment:

i. Patients with a variceal bleeding and Child-Pugh C (10-13 points) cirrhosis or ii. Patients with a variceal bleeding, Child-Pugh B and an active bleeding during endoscopy

• Age ≥18 years
• Confirmed liver cirrhosis as documented by liver biopsy, elastography (e.g. Fibroscan) or combination of usual radiological and biochemical criteria.
• Signed informed consent

Критерии исключения

• Any absolute contraindications for TIPS placement
• Use of ciclosporin
• Life-threatening variceal bleeding with emergency TIPS placement which can not be delayed 72 hours
• Age > 80 years
• Non-cirrhotic portal hypertension
• Portal vein thrombosis (main trunk)
• HIV
• Current or recent (<3 months) use of rifaximin
• Overt neurologic diseases such as Alzheimer's disease, Parkinson's disease
• Pregnant or breastfeeding women
• Patients refusing or unable to sign informed consent

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Рандомизированное

Модель

Параллельные группы

Маскирование

Тройное слепое

Основная цель

Профилактика

Центры проведения

Нидерланды · 5 центров

• Academic Medical Centre — Amsterdam
• University Medical Center Groningen — Groningen
• Leiden University Medical Center — Leiden
• Radboud University — Nijmegen
• Erasmus Medical Center — Rotterdam

Бельгия · 1 центр

• Universitaire Ziekenhuizen Leuven — Leuven

Публикации

• Zacharias HD, Kamel F, Tan J, Kimer N, Gluud LL, Morgan MY. Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev. 2023 Jul 19;7(7):CD011585. doi: 10.1002/14651858.CD011585.pub2. PMID 37467180
• de Wit K, Schaapman JJ, Nevens F, Verbeek J, Coenen S, Cuperus FJC, Kramer M, Tjwa ETTL, Mostafavi N, Dijkgraaf MGW, van Delden OM, Beuers UHW, Coenraad MJ, Takkenberg RB. Prevention of hepatic encephalopathy by administration of rifaximin and lactulose in patients with liver cirrhosis undergoing placement of a transjugular intrahepatic portosystemic shunt (TIPS): a multicentre randomised, double PMID 33372103

Идентификаторы

NCT: NCT04073290 · PEARL trial · 2018-004323-37 · 848017009

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

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