1Department of Internal Medicine, University of Toledo, Toledo, Ohio, USA. firstname.lastname@example.org.
2Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, USA. email@example.com.
3University of Toledo Medical Center, Toledo, Ohio, USA. firstname.lastname@example.org.
4Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, USA. email@example.com.
5Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, USA. firstname.lastname@example.org.
6Division of Internal Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA. email@example.com.
7Department of Internal Medicine, Loyola Medicine/MacNeal Hospital, Chicago, Illinois, USA. firstname.lastname@example.org.
8University of Toledo Libraries, University of Toledo, Toledo, Ohio, USA. email@example.com.
9University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA. firstname.lastname@example.org.
10Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, USA. email@example.com.
11Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, USA. firstname.lastname@example.org.
12Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, USA. email@example.com.
13Dept. of Medicine and Surgery at the David Geffen School of Medicine at UCLA (University of California Los Angeles), Los Angeles, California, USA. firstname.lastname@example.org.
Background and aims: Transjugular intrahepatic portosystemic shunt (TIPS) is often used in patients with cirrhosis to manage portal hypertension-related complications. Unfortunately, 35-50% of patients develop overt hepatic encephalopathy (HE) after TIPS. However, data on lactulose and rifaximin to prevent post-TIPS HE is limited. Therefore, we aimed to perform a network meta-analysis to investigate the efficacy of multiple pharmacological regimens in the prevention of post-TIPS HE.
Methods: A comprehensive search strategy to identify reports of studies of rifaximin use on post-TIPS hepatic encephalopathy was constructed using truncated keywords, phrases, and subject headings developed in Embase. This strategy was translated to MEDLINE, Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection, with all searches performed on 10 February 2022. No publication date or language limits were used.
Results: The initial search identified 72 studies, and 56 studies were screened after removing duplicates. Five studies, two randomized controlled trials (RCTs) and three retrospective studies, met our inclusion criteria and were included in the final analysis. A total of 840 patients were included, with 65% male. Our meta- analysis did not find a statistically significant difference between lactulose vs placebo/no prophylaxis, nor rifaximin vs placebo/no prophylaxis, nor rifaximin plus lactulose vs placebo/no prophylaxis in the reduction of post-TIPS HE.
Conclusions: Rifaximin alone, lactulose alone, and rifaximin plus lactulose did not significantly reduce the development of post-TIPS HE. Based on the P-scores of the three treatment groups, the combination of rifaximin plus lactulose showed the most promising trend towards preventing post-TIPS HE. More studies, especially large RCTs, are warranted.