LETTERS TO THE EDITOR

 

Lactulose enemas in the treatment of hepatic encephalopathy. Do we help or harm?

Enemas de lactulosa para el tratamiento de la encefalopatía hepática. ¿Ayudamos o empeoramos?

 

 

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Key words: Encephalopathy. Enema. Lactulose. Safety.

Palabras clave: Encefalopatía. Enema. Lactulosa. Seguridad.

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Dear Editor,

The administration of lactulose enemas instead of or in combination with oral lactulose is common practice in patients with hepatic encephalopathy.

Lactulose is a non-absorbable disaccharide that is catabolized by the bacterial flora to short chain fatty acids (e.g., lactic acid and acetic acid) which lower the colonic pH. This pH favors the formation of non-absorbable NH₄⁺ from NH₃, trapping NH₄⁺ in the colon and thus reducing plasma ammonia concentrations (1). Lactulose therapy is considered as a first-line treatment and can be administered both orally and rectally (2).

Several authors have highlighted that lactulose enemas can be prepared with 300 ml of lactulose diluted in 700 ml of water (3,4), and the patient should retain this mixture for one hour in the Trendelenburg position. However, once we explored how these enemas are prepared in real practice, we found that a widespread modus operandi is to add lactulose to a bottle of Enema Casen^® (= Fleet^® enema) (sodium dihydrogen phosphate dihydrate, disodium phosphate dodecahydrate). Thus, lactulose is co-administered with high levels of phosphate.

The reason that may justify this procedure is simple; the prescription does not usually indicate how the enema should be prepared. Moreover, Enema Casen^® is widely available in hospitals and one of the few presentations commercialized is in an enema format. Hence, this method of administering is easy and quick.

However, it is important to note that phosphate administration is not risk-free. Phosphate enemas are hypertonic solutions and their retention can lead to a massive absorption of sodium and phosphate in the colon, which can lead to severe electrolyte disturbances.

Therefore, developing strategies to ensure the proper administration of lactulose enemas without compromising patient safety is of paramount importance.

 

Ana de Lorenzo-Pinto¹, Raquel García-Sánchez¹ and Almudena Lorenzo-Salinas^2
1Pharmacy Service. Hospital General Universitario Gregorio Marañón. Madrid, Spain.
²Nursing Unit. Emergency Department. Hospital Clínico San Carlos. Madrid, Spain

 

References

1. Hepatic encephalopathy in adults: Treatment. UpToDate. Accessed on May 23 2017. Available at: http://uptodates.bvcscm.csinet.es/contents/hepatic-encephalopathy-in-adults-treatment?source=search_result&search =lactulosa%20encefalopatis&selectedTitle=1∼150H6.         [ Links ]

2. Vilstrup H, Amodio P, Bajaj J, et al. 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. Hepatology 2014;60(2):715-35. DOI: 10.1002/hep.27210.         [ Links ]

3. Al Sibae MR, McGuire BM. Current trends in the treatment of hepatic encephalopathy. Ther Clin Risk Manag 2009;5(3):617-26.         [ Links ]

4. Uribe M, Campollo O, Vargas F, et al. Acidifying enemas (lactitol and lactose) vs. nonacidifying enemas (tap water) to treat acute portal-systemic encephalopathy: A double-blind, randomized clinical trial. Hepatology 1987;7:639. DOI: 10.1002/hep.1840070404.         [ Links ]

5. Sharluyan A, Stanescu S, Pérez-Caballero Macarrón C. ¿Es prudente seguir utilizando los enemas fosfato? An Pediatr 2014;81(6):e72-3. DOI: 10.1016/j.anpedi.2014.03.003.         [ Links ]